Health inspection·March 22, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 1 and Resident 2) when on 3/10/2024 Certified Nurse Assistant 2 (CNA 2) witnessed Resident 2 punch Resident 1 in the stomach area; and then Resident 1 punch Resident 2's right side of the face. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. Resident 2 sustained skin abrasions (when the surface layers of the skin have been broken) to the right side of the forehead (the part of the face above the eyes), the nose bridge (upper part of the nose) and right side of the nose crease (the part of the nose directly under the bridge) that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 4/4/2023 and readmitted the resident on 2/23/2024 with diagnoses that included schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/29/2024 indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 required supervision from staff with toileting hygiene, upper and lower body dressing, personal hygiene and with mobility (movement). A review of Resident 1's Change of Condition (COC - when there is a sudden change in a resident's health) Form dated 3/10/2024 timed at 7:05 a.m., indicated that on 3/10/2024 at 7:05 a.m., Resident 1 initiated physical aggression towards Resident 2 while in the hallway (in front of Resident 1's room). A review of Resident 1's Care Plan (untitled) dated 3/10/2024 indicated that Resident 1 was at risk for emotional distress due to Resident 1 being involved in a physical aggression with Resident 2. The goal was for Resident 1 not to have any negative outcome related to the altercation. A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 12/29/2023 with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs [mania or manic episode] to lows (depression or depressive episode]), (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555519 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)