Health inspection·December 10, 2025

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22CCR §72315. Nursing Service - Patient Care. a) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22CCR §72523 Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR § 72527 Patient's Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 11/3/25, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) was hit by his roommate (Resident 2). On 11/4/2025 at 7:55 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Implement its policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation" which indicated each resident had the right to be free from abuse and neglect when Resident 2 physically assaulted Resident 1. As a result, Resident 1 sustained lacerations (skin tears) to his upper right eye, right ear, and occipital (back of the head) scalp measuring 1-centimeter (cm-unit of measurement) which required hospitalization at a general acute care hospital (GACH) for evaluation and treatment. a. Resident 1 was a 78-year-old male who was originally admitted on 5/14/2025 and readmitted on 6/11/2025. Resident 1's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and encephalopathy (a medical condition that affects the brain, causing a decline in brain function). A review of Resident 1's history and physical (H&P) form, dated 6/11/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's care plan, titled "Risk for Harm: Self Directed or Other- Directed Behavior Potentially Causing Harm, dated 8/12/2025, indicated staff will monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/18/2025, indicated Resident 1's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 required partial/moderate (helper does less than 1/2 the effort) assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's change of condition (COC) form, dated 11/2/2025, indicated on 11/2/2025 at 8:56 a.m., Resident 1 was allegedly attacked by his roommate, and he (Resident 1) sustained a laceration to his head and ear. The COC indicated Resident 1 was assessed and had discolorations, lacerations and bleeding to the top of his head, right ear and right side of the face. The COC indicated Resident 1 was transferred to a GACH for further evaluation. A review of Resident 1's physician orders, dated 11/2/2025, indicated to transfer Resident 1 to a GACH for injuries due to the alleged altercation with Resident 2. A review of Resident 1's GACH Progress Notes dated 11/02/2025 at 10:35a.m., indicated Resident 1 was brought to the GACH for evaluation after being assaulted by his roommate , for evaluation of a lacerations to his scalp and upper right eye. The notes indicated the laceration above Resident 1's right eye measured 1 centimeter. The notes indicated the laceration on Resident 1's occipital (back of the head) scalp was superficial (not deep). A review of Resident 1's GACH Emergency Department (ED) Course notes dated 11/02/2025, ta 12:05p.m., indicated Resident 1 was brought for evaluation following an assault which resulted in Resident 1 sustaining an injury with lacerations above his right eye and occipital scalp. The notes indicated Resident 1 was offered wound care and laceration repair, but the resident refused. The notes indicated Resident 1 was admitted to the GACH for risk of decompensation ( the failure of an organ or system to maintain its normal function, especially during times of stress or illness) and or an adverse event (any unfavorable, unintended medical occurrence such as a symptom, sign, or disease). The notes indicated Resident 1's head and facial computerized tomography (CTs- process of taking pictures of the body to diagnose and treat diseases) indicated Resident 1 had no acute findings. The notes indicated Resident refused treatment and was discharged back to the facility on 11/4/2025. b. Resident 2 was a 51-year-old who was originally admitted on 10/24/2025 with diagnoses which include psychosis disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) and type 2 diabetes. A review of Resident 2's MDS indicated Resident 2's cognitive skill was moderately impaired. The MDS also indicated Resident 2 required partial/moderate assistance with ADLs. A review of Resident 2's care plan, dated 10/28/2025, titled "The resident has potential to be physically aggressive related to history of harm to others", indicated for staff to monitor/document/report any signs and symptoms of resident posing danger to self and others. A review of Resident 2's H&P, dated 11/1/2025, indicated Resident 2 had the capacity to make his needs known and could not make medical decisions. A review of Resident 2's progress notes, dated 11/1/2025, indicated Resident 2 was being monitoring for aggressive behavior towards roommate (yelling) and staff and had aggressively thrown food trays to the floor and yelled at staff. A review of Resident 2's COC form, dated 11/2/2025, at 9:53a.m., indicated Resident 2 hit and injured Resident 1 in their room. The COC indicated Resident 2 stated Resident 1 was talking about his (Resident 2's) father and family after breakfast. The COC indicated Resident 2 stated "I hit him with my right hand." The COC indicated Resident 2 was a danger to self and others, was "hitting and kicking and talking to unseen being." The COC stated the residents were separated and a 1:1 monitoring (one staff monitoring the resident in close proximity) initiated. The COC indicated Resident 2 appeared to be still agitated and the doctor recommended to call the emergency number. A review of the facility's five-day follow-up letter, dated 11/6/2025, indicated Resident 2 admitted to hitting Resident 1 once and there were no major injuries reported from the hospital notes and exams. c. Resident 3 was a 73-year-old admitted to the facility, on 9/3/2025 with diagnoses which include osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), alcohol abuse, obesity and muscle wasting and atrophy (a weakening, shrinking, and loss of muscle caused by disease or lack of use). A review of Resident 3's H&P, dated 9/4/2025, indicated Resident 3 had capacity to understand and make decisions. A review of Resident 3's MDS indicated Resident 3's cognitive skills were moderately impaired. Resident 3 required partial to moderate assistance with ADL's. During an interview, on 11/5/2025 at 8:30 a.m., Resident 3 stated, on 11/2/2025 around 8:30 a.m., he heard Resident 1 and Resident 2 arguing. Resident 1 began screaming, "Don't you hit me. Resident 3 stated he lifted his privacy curtain and observed Resident 2 standing over Resident 1's bed. Resident 2 did not change rooms. During an interview, on 11/5/2025 at 9:15 a.m., CNA 2 stated on 11/2/2025 at approximately around 8:30 a.m., she saw Resident 2 standing over Resident 1 who was in bed. CNA 2 stated as she walked into the room, Resident 2 was mumbling "That's what you get for last night." CNA 2 stated she observed blood on Resident 1's head. CNA 2 stated she called for assistance immediately. During an interview, on 11/5/2025 at 9:45 a.m., Licensed Vocational Nurse 1 (LVN 1), stated she was passing medications when she heard CNA 2 scream for assistance. LVN 1 stated she went into the room and observed Resident 1 covered in blood from his head. Resident 1 was observed with multiple hematomas on his head, a scalp laceration, blood clots pouring from his ears, blood on his pillow, bed sheets, hands and clothing. Resident 1 told her that Resident 2 physically attacked him. LVN 1 stated she instructed a staff member to call 911 and grabbed the crash cart as protocol. The ambulance arrived at the facility at 9:21 a.m. and transferred Resident 1 to the GACH. During an interview, on 11/5/2025 at 10:08 a.m., LVN 2 stated she was working at another nurse's station when CNA 2 called out for assistance with the incident. She (LVN 2) went to Resident 1's room and observed blood on Resident 1's scalp, face, clothing and bedsheets. LVN 2 stated she called 911 immediately while LVN 1 assessed Resident 1's injuries. Resident 1 was transferred to the GACH after she called 911. LVN 2 stated Resident 2 was placed on continuous monitoring immediately after the altercation until he was transferred to a GACH for a psychiatric evaluation. During an interview, on 11/5/2025 at 11:28 a.m., the Director of Nursing (DON) stated staff should have removed Resident 2 from the room when he started displaying aggressive behaviors by throwing food trays and yelling on 11/1/2025. A review of the facility's policy and procedures, titled "Abuse and Neglect Prohibition Policy", dated 6/2022, indicated it was the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents and if the suspected abuse was a resident to resident incident, the resident who threatened or attacked another resident would be removed from the setting or situation. The facility failed to: 1. Implement its policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation" which indicated each resident had the right to be free from abuse and neglect when Resident 2 was not prevented from hitting Resident 1. As a result, Resident 1 sustained lacerations to his upper right eye, and occipital scalp measuring 1-centimeter which required hospitalization for evaluation and treatment. This violation, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1.