Health inspection·June 13, 2025

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 ensure one of four sampled residents, who had a history of wandering into other residents' rooms, was free from physical abuse for one of four sampled residents (Resident 233). The facility failed to: 1. Provide Resident 233 with 1:1 (staff member provides dedicated, individualized attention to a single resident) monitoring to prevent him from wandering into Resident 23's room per untitled Care Plan dated 5/12/2025. 2. Implement the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, that indicated the facility would protect a resident's right to be free from abuse. As a result of these deficient practices Resident 23 struck Resident 233 on the face. Resident 233 sustained a right cheek abrasion (injury to the skin's surface resulting from friction or impact), orbital (socket of eye that protects the eyeball) discoloration, and a nosebleed. Findings: During a review of Resident 23's admission record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and was readmitted from a general acute care hospital (GACH 1) on 5/20/2025 with diagnoses including schizoaffective disorder (a mental illness that can negatively affect thoughts, mood, and behavior), antisocial personality (mental health condition characterized by a persistent pattern of disregard for the rights of others often leading to reckless or criminal behavior), and amnestic disorder (significant memory loss affecting the ability to recall past events and form new memories that result from substance abuse and brain injury) due to known alcohol dependence and traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). During a review of Resident 23's Social Service Discharge Summary and Recommendations, for Aftercare note from GACH 1 dated 5/20/2025, the Social Service Discharge Summary and Recommendations for Aftercare indicated Resident 23 had a history of severely physically assaulting a peer because the peer refused to share a lighter (facility unspecified). The Social Service Discharge Summary and Recommendations for Aftercare note indicated Resident 23 stated he suffered from memory loss and remained isolated and guarded (cautious, reserved and untrusting), and exhibited limited ability to tolerate conflict as seen by him striking a peer for bumping into him (facility unspecified). The Social Service Discharge Summary and Recommendations for Aftercare dated 5/20/2025 indicated despite Resident 23 verbalizing a motivation for change, Resident 23 continued to exhibit poor impulse control and Page 1 of 6 555565 555565 06/13/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0600 minimal responses to provided interventions. The Social Service Discharge Summary and Recommendations for Aftercare note indicated Resident 23 took advantage of his lower functioning peers. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 23's History and Physical (H&P), dated 5/21/2025, the H&P indicated Resident 23 was unable to make medical decisions. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025, the MDS indicated Resident 23's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were moderately impaired. The MDS indicated Resident 23 required moderate assistance (staff provide less than half the effort) for shower transfer, bathing, dressing the lower body, personal hygiene, required supervision for toileting hygiene, dressing upper body (above waist), chair/bed-to-chair transfer, required set up for oral hygiene, and was independent in eating. The MDS indicated Resident 23 did not have any impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. The MDS indicated Resident 23 always felt lonely or isolated and was feeling down, depressed, or hopeless for several days (two to six days). The MDS indicated Resident 23 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) as a behavior. During a review of Resident 23's Physician's Order Summary Report dated 5/20/2025 - 5/31/2025, the Physician's Order Summary Report indicated the following orders: 1. Hydroxyzine Pamoate (antihistamine [medication used to treat allergies] medication used to treat anxiety) capsule 50 milligram (mg- unit of mass) one tablet by mouth every 12 hours as needed for anxiety disorder for 14 days manifested by (m/b) inability to relax as evidenced by restlessness, dated 5/20/2025 to 6/3/2025. 2. Monitor behavior episodes of anxiety disorder m/b inability to relax as evidenced by restlessness dated 5/20/2025. 3. Olanzapine (medication used to treat mental health condition characterized by severe and persistent disruptions in thought, perception, emotion, and behavior) give 30 mg by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025 (discontinued on 5/28/2025). 4. Olanzapine 15 mg tablet to give two tablets by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/28/2025. 5. Monitor behavior of schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025. During a review of Resident 23's Medication Administration Record (MAR- record of medications administered to the resident) from 5/1/2025 to 5/31/2025, the MAR indicated the following: 1. Resident 23 had an episode of mood swing on 5/30/2025 and another episode on 5/31/2025 during the day shift (7:00 a.m. to 3:00 p.m.). 2. Resident 23 had two episodes of anxiety disorder m/b inability to relax as evidenced by restlessness on 5/31/2025 during the day shift. 555565 Page 2 of 6 555565 06/13/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0600 3. Resident 23 had two episodes of depression m/b inability to sleep during the evening shift (3:00 p.m. to 11:00 p.m.). Level of Harm - Actual harm Residents Affected - Few During a review of Resident 233's admission Record, the admission Record indicated Resident 233 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought involving a break with reality, feelings of suspicion and distrust towards others), unspecified dementia (a progressive state of decline in mental abilities) with other behavioral disturbances (pattern of actions that disrupt a person's ability to function), and cognitive communication deficit (trouble participating in conversations). During a review of Resident 233's Physician's Order Summary Report the Physician's Order Summary Report indicated an order for Risperidone (medication use to treat schizophrenia) 3 mg tablet by mouth two times a day for paranoid schizophrenia m/b irritability dated 5/9/2025. During a review of Resident 233's MAR from 5/1/2025 to 5/31/2025, the MAR indicated to monitor Resident 233's episodes of wandering and to document the resident's location every two hours starting 5/12/2025 with a discontinued date of 5/21/2025. During a review of Resident 233's H&P, dated 5/12/2025, the H&P indicated Resident 233 was not capable of making medical decisions. During a review of Resident 233' untitled Care Plan (CP) dated 5/12/2025, the CP indicated Resident 233 was identified at risk for wandering related to communication deficits, dementia, psychotropic and mood-altering medications. The CP indicated the resident wanders aimlessly. The CP interventions included to provide 1:1 supervision, encourage activity participation, encourage social interaction, and redirect resident as needed, initiated on 5/21/2025. During a review of Resident 233's MDS, dated [DATE], the MDS indicated Resident 233's cognitive skills were moderately impaired. The MDS indicated Resident 233 required moderate assistance with activities of daily living (ADLs- toilet transfer, bathing, toileting hygiene, personal hygiene, chair/bed-to-chair transfer) and required supervision for eating and oral hygiene. The MDS indicated Resident 233 did not have any impairments on the upper and lower extremities. The MDS indicated Resident 233 was feeling down, depressed, or hopeless and had little interest or pleasure in doing things for several days. During a record review of Resident 233's Elopement and Wandering Risk Observation/assessment dated [DATE] at 10:50 p.m., the Elopement and Wandering Risk Assessment indicated Resident 233 was disoriented or had periods of confusion and/or impaired attention span. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited unsafe wandering or elopement attempts but was easily redirected. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited behaviors of agitation leading to noncompliance to care and mood swings. During a review of Resident 23's Change of Condition (COC) dated 5/31/2025 at 7:46 p.m., the COC indicated Resident 23 had behavioral symptoms (e.g. agitation, psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) and was physically aggressive towards a peer (Resident 233), in Resident 23's room. The COC indicated Resident 23 stated he was attacked by another resident (Resident 233) and retaliated by striking the resident back. Resident 23 was sent out to the hospital for further evaluation and treatment. The COC indicated Resident 23's left palm and right hand were noted with redness. 555565 Page 3 of 6 555565 06/13/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0600 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 23's Physician's Order Summary Report, the Physician's Oder Summary Report indicated an order dated 5/31/2-25 for Resident 23 to have a 1:1 observation until transferred to the hospital. During a review of Resident 23's Progress Note dated 5/31/2025 at 10:14 p.m., the Progress Note indicated Resident 23 was transferred to GACH 3 at approximately 9:00 p.m., for a psychological (related to mental or emotional) evaluation as a perpetrator of physical aggression towards peer (Resident 233). During a review of a follow up Progress Note dated 6/3/2025 at 9:00 p.m., the Progress Note indicated Resident 23 was admitted to a behavioral unit at GACH 3 for psychosis and aggressive behavior. During a review of Resident 23's Interdisciplinary Team (IDT- resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) note, dated 6/2/2025 at 10:34 a.m., the IDT noted indicated on 6/2/2025 (date of incident indicated was an error, incident occurred on 5/31/2025) at 6:35p.m., there was an unwitnessed resident-to-resident altercation involving Resident 233. The IDT note indicated Licensed Vocational Nurse (LVN) 7 heard arguing in Resident 23's room, and upon entering the room, LVN 7 observed Resident 23 standing by the footboard of his bed, and Resident 233 was on the floor, leaning on the neighboring nightstand. The IDT note indicated Resident 23 stated Resident 233 went through his door and punched him, so he (Resident 23) punched him (Resident 233) back with a closed fist. During a review of Resident 233's COC dated 5/31/2025 at 10:01p.m., the COC indicated Resident 233 stated he was attacked by another resident in his (Resident 23's) room. The COC indicated the nursing staff arrived and immediately separated the residents to separate rooms and both residents were assessed for injuries. The COC indicated Resident 233 was noted with edema (swelling) on the lip, nose and right cheek and a contusion (bruise, collection of blood outside of the blood vessels, under the skin due to blunt impact) to the right cheek. Resident 233 was offered Tylenol (used to relieve mild to moderate pain) and cold compress for pain. The COC indicated Resident 233 occasionally moaned or groaned, had facial grimacing, was tense, distressed pacing, fidgeting, and had a headache. The COC indicated Resident 233 had a pain level rated 6 out of 10 on a pain rating scale (0- no pain, 3-4 -moderate pain, 5-7 severe pain and 8-10-excruciating pain) on the top of the scalp (skin covering the head) on the side of the head. The COC indicated Resident 233 was sent to the hospital for further evaluation and treatment. During a review of a late entry Progress Note dated 5/31/2025 at 6:35 p.m., the Progress Note indicated Resident 233 had an unwitnessed Resident-to-Resident altercation. The Progress Note indicated Resident 233 had swelling to the face (lip, forehead and check) and bleeding from the nose. The Progress Note indicated Resident 233 was transferred to GACH 3 via 911 at 6:45 p.m. per physician's order. During a review of Resident 233's IDT note dated 6/2/2025 at 8:31a.m., the IDT note indicated on 5/31/2025 at 6:35 p.m., there was an unwitnessed resident-to-resident altercation in Resident 23's room. The IDT note indicated LVN 7 discovered Resident 23 lying on the floor against a nightside and Resident 23 standing by the foot of the bed. The IDT note indicated Resident 233 was observed with swelling to the face (lip, forehead, and cheek), with scant (minimal) bleeding noted. The IDT note indicated LVN 7 applied a cold compress to Resident 233 and placed on 1:1 for monitoring and safety precautions. The COC indicated Resident 233 had a right cheek abrasion 5.0 centimeter (cm- unit of 555565 Page 4 of 6 555565 06/13/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0600 length) in length by 3.0 cm in width orbital discoloration. Level of Harm - Actual harm During a review of a Progress Note dated 5/31/2025 at 9:16 p.m. the Progress Note indicated Resident 233 was bleeding from his nose profusely but was able to stop the bleeding with first aid. Residents Affected - Few During a review of Resident 233's GACH 3 record dated 6/4/2025, GACH 3 record indicated the Computed tomography (CT- medical imagining technique to obtain internal images of the body) of the head without contrast (substance taken by mouth or injection into the vein to help visualize the brain and surrounding area) indicated Resident 233 had a left frontal scalp (front area of head located behind the forehead) hematoma (bruise). During an interview on 6/11/2025 at 4:47 p.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 233 was always walking around. CNA 4 stated while he (CNA 4) was walking in the hallway (date unspecified), he observed Resident 233 go into another resident's room and redirected him to the patio. CNA 4 stated on 5/31/2025 when he was tending to a different resident in another room, he heard Resident 23 screaming for help and observed CNA 9 and LVN 7 run to Resident 23's room. CNA 4 stated when he got to Resident 23's room he observed Resident 233 on the floor sitting down in the middle of the door against the cabinet with a bloody nose that was dripping over his mouth, chin, and on one side of the cheek. During an interview on 6/11/2025 at 5:14 p.m., with LVN 7, LVN 7 stated he was in the Nursing Station (West side) charting when he suddenly heard Resident 23 yelling. LVN 7 stated the door to Resident 23's room was closed when he heard the yelling, and he opened the door. LVN 7 stated Resident 23 said get out of my room to Resident 233. LVN 7 stated Resident 23 was standing at the foot of the bed and Resident 233 was close to the bedside table sitting on the floor. LVN 7 stated Resident 233 had blood dripping from his nose. LVN 7 stated he called for assistance, and CNA 4 and CNA 9 arrived to assist, separated the residents, and attended to Resident 233 to stop the bleeding. LVN 7 stated CNA 7 arrived to assist, and indicated he called the Registered Nurse Supervisor 3 (RNS 3). LVN 7 stated while RNS 3 was interviewing the residents, Resident 23 said, What are you doing? What are you doing? LVN 7 stated he asked Resident 23 why he punched Resident 233 and Resident 23 replied Resident 233 was in his home, and he punched him. LVN 7 stated he brought the crash cart (a medical cart equipped with medical equipment and supplies used during emergencies) and grabbed a stack of gauze to stop Resident 233's bleeding from the nose. LVN 7 stated Resident 233 continued to bleed until the paramedics (emergency response team that provide medical care and transport people to hospitals) arrived. LVN 7 stated Resident 23 did not have 1:1 supervision that day (5/31/2025). LVN 7 stated staff need to walk around to check on the residents as anything can happen anytime, so staff have to monitor the residents. During an interview on 6/12/2025 at 9:32 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 233 wanders. CNA 6 stated he has witnessed him go into other residents' rooms more than once. CNA 6 stated he has told an LVN (unknown) regarding Resident 233 going into other residents' rooms but does not recall who he told. During an interview on 6/12/2025 at 12:19 p.m., with CNA 9, CNA 9 stated Resident 233 is confused, wanders, and goes in and out of rooms. CNA 9 stated Resident 233 had 1:1 supervision before because he went into someone's room. CNA 9 stated Resident 23 is mostly to himself, would wave, but could not communicate with staff due to a language barrier. CNA 9 stated Resident 23 came from GACH 1 and had a history of being in jail for violence. CNA 9 stated when he (Resident 23) did not get his way (like wanting multiple packs or sugar but not giving him so much), he (Resident 23) would get 555565 Page 5 of 6 555565 06/13/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0600 aggressive. Level of Harm - Actual harm During an interview on 6/12/2025 at 12:44 p.m., with Resident 233's Family Member 2 (FM 2) FM2 stated she went to visit him (Resident 233) the day after the incident on 6/1/2025, she stated Resident 233 had a black eye, cut up face, and a busted lip. FM 2 stated she did not directly see Resident 233, but did see him through a video call. FM 2 stated she saw his eyes, face, and lips. FM 2 stated the staff did not provide them any information regarding how it happened. FM 2 stated Resident 233 had no recollection of the incident. FM 2 stated Resident 233 was not a fighter and would not say something to provoke you to get mad as that is not his character. FM 2 stated Resident 233 tends to wander when he's restless or when he does not want to be in that place. FM 2 stated if someone is showing him something or he is watching animals on screens, robots, dinosaurs, dominos, it would distract him for a long time. Residents Affected - Few During a concurrent interview and record review on 6/12/2025 at 4:42 p.m., with the Regional Administrator (RADM), the RADM stated once Resident 233 returned to the facility from GACH 3, Resident 233 was placed on 1:1 for precaution because he wandered into residents' rooms. The RADM stated when he spoke to the staff, the staff indicated Resident 233 tended to roam the halls and to the smoking patio. The RADM stated he believed the incident between Resident 23 and Resident 233 was preventable as both residents were on monitoring every two hours. The RADM stated during the time of the incident, they did not have staff walking around the unit, but had designated people to monitor the residents every two hours and indicated the CNAs and LVNs were monitoring the residents in the facility at that time. During an interview on 6/13/2025 at 10:13 a.m., with the Administrator (ADM), the ADM stated residents have the right to wander safely and freely and indicated he does not know if a resident would be placed on 1:1 if a resident goes into another resident's room once, but they would address the behavior from the beginning and discuss it during the IDT meeting. The ADM stated regarding the abuse allegation of resident striking another resident; the statement received from Resident 23 was that Resident 233 was going through his belongings, and that may have been what upset Resident 23, and not so much that Resident 233 was in the room. The ADM stated going into another resident's room would be a behavior that would be care planned if it happened repeatedly but is not sure if it would be care planned if it was an incident that occurred for the first time. During an interview on 6/13/2025 at 3:46 p.m., with the Director of Nursing (DON), the DON stated the residents in the secured unit (unit where Resident's 23 and 233 were housed) are psychologically complex and require closer behavioral monitoring and management. The DON stated residents that have had multiple falls or having behaviors such as wandering or aggression need to be monitored closely, and they would require a 1:1 monitoring. The DON stated in this resident-to-resident altercation; Resident 233 was redirectable. The DON stated Resident 23 had a history of aggression and came from a prison. The DON stated anyone, even dementia residents have the potential for aggression. During a review of the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse. 555565 Page 6 of 6