Health inspection·November 12, 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 protect the resident's right to be free from physical abuse by one of three sampled residents (Resident 1), when Resident 1 punched Resident 2 in the face on 10/31/2025. This deficient practice resulted in Resident 2 sustaining a left periorbital (area around the eye socket) discoloration, discoloration on the bridge (bony, elevated area between the eyebrows and the tip of the nose) of his nose, a left eyebrow skin tear, and a left dorsal (backside) fifth digit (finger) skin tear. Resident 2 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment and was assessed with a mildly depressed nasal bone fracture (a facial injury where the nasal [nose] bones are broken and pushed inward or backward, often causing a noticeable indentation or deformity of the nose) and a left periorbital hematoma (a collection of blood outside of a blood vessel, typically caused by an injury that ruptures the vessel). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), paranoid schizophrenia (the presence of intense paranoid delusions [having false or unrealistic beliefs of persecution and unwarranted suspicion], and hallucinations [sensory experiences like seeing, hearing, or smelling things that aren't real, yet feel very real]), and a generalized anxiety disorder (mental health condition characterized by pervasive worry and fear). During a review of Resident 1's Minimum Datra Set ([MDS] a resident assessment tool), dated 8/13/2025, the MDS indicated Resident 1 had a moderate cognitive (thought process) impairment. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure (when the heart cannot pump enough blood to the body), COPD, paranoid schizophrenia, bipolar disorder (a disorder that causes mood swings ranging from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. During a review of Resident 2's Change of Condition Evaluation, dated 10/31/2025 and timed at 12:34 a.m., the COC evaluation indicated Certified Nurse Assistant (CNA) 2 heard an altercation while in the hallway of Resident 1 and Resident 2's shared restroom and witnessed Resident 2 lying on his back, on the floor, with Resident 1 standing over Resident 2. Residents 1 and 2 were separated immediately and put on one-to-one monitoring ([1:1] continuous, close supervision of a resident). The COC Evaluation indicated Emergency Medical Services (911) were called. During a review of Resident 2's Nursing Comprehensive Skin Evaluation/Assessment, dated 10/31/2025 and timed at 1:52 a.m., the Nursing Comprehensive Skin Evaluation/Assessment indicated Resident 2 was observed with the following: 1. Left periorbital discoloration, measuring 7.0 centimeters ([cm] a unit of measurement) by 9.0 cm, with mild redness, localized swelling, and Page 1 of 2 555565 555565 11/12/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0600 Level of Harm - Actual harm Residents Affected - Few dark purple in color. 2. Nose bridge discoloration, measuring 2.0 cm by 2.0 cm, dark purple in color. 3. Left eyebrow skin tear measuring 0.5 cm by 1.0 cm, presented as a dry scab (protective crust that forms over a wound) with mild redness. 4. Left dorsal fifth digit skin tear, measuring 0.5 cm by 0.5 cm, presented as dry scab with mild redness. During a review of Resident 2's Nurse's Notes, dated 10/31/2025 and timed at 10:28 a.m., the Nurse's Notes indicated Resident 2's physician ordered Resident 2 to be transferred to a GACH for evaluation and treatment related to a physical altercation. During a review of Resident 2's 72 Hours Charting, dated 10/31/2025 and timed at 12:19 p.m., the 72 Hours Charting indicated Resident 2 was transferred to a GACH at approximately 12:15 p.m., for evaluation and treatment. During a review the of the facility's Five Day Follow Up Report, dated 11/4/2025, the Five Day Follow Up Report indicated on interview with Resident 1, Resident 1 stated he was using the restroom when his roommate (Resident 2) opened the door and walked in. Resident 1 stated, I told him to get out but Resident 2 refused to leave the restroom and came towards him (Resident 1). Resident 1 stated at that point he made contact with Resident 2. During a review of the GACH's ED (Emergency Department) Provider Notes, dated 10/31/2025 and timed at 12:48 p.m., the ED Provider Notes indicated Resident 2 presented with eye trauma after he (Resident 2) walked in on his roommate (Resident 1) in the bathroom and was punched by Resident 1. During a review of the GACH's Computerized Tomography ([CT] a type of imaging that uses X-ray techniques to create detailed images of the body) scan without contrast (scan performed without using a contrast agent [specific dye to highlight specific tissues, organs, or blood vessels]), dated 10/31/2025 and timed at 12:38 p.m., of Resident 2's head, the CT scan indicated the following: 1. A mildly depressed nasal bone fracture. 2. A left periorbital hematoma. During an interview on 11/12/2025 at 6:32 a.m., Resident 2 stated Resident 1 was taking too long to use the toilet (Resident 2 unable to provide details). Resident 2 stated Resident 1 punched him (Resident 2) in the face once and pushed him backwards and he (Resident 2) fell back onto the floor. During an interview on 11/12/2025 at 8:55 a.m., the Assistant Director of Nursing (ADON) stated Resident 1 punched Resident 2 in the face after Resident 2 walked in the bathroom while Resident 1 was still using it. The ADON stated Resident 2 sustained skin tears on his left little finger, his left eyebrow, and had facial discoloration. The ADON stated Resident 2 was transferred to a GACH for evaluation and treatment. The ADON stated the altercation between Residents 1 and 2 was considered physical abuse and residents had the right to be free from abuse. During an interview on 11/12/2025 at 9:40 a.m., the Director of Nursing (DON) stated residents have the right to be free from abuse because it can damage the residents' physical and mental wellbeing. The DON stated Resident 2 sustained injuries from the physical altercation between him and Resident 1. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised 1/2025, the P&P indicated residents have the right to be free from abuse and this includes physical abuse. The P&P indicated there was a facility wide commitment to protect residents from abuse from other residents. 555565 Page 2 of 2