Health inspection·April 29, 2025

The following reflects the findings of the California Department of Public Health (CDPH) during an abbreviated standard survey. Facility Reported Incident Numbers: CA00953417 & CA00954893 The inspection was limited to the specific Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility. A Class B Citation was issued for the Facility Reported Incident Numbers: CA00953417 & CA00954893 42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation §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. 42 CFR §483.12(b): Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and 22 CCR §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. On 4/4/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate residents abuse in the facility. The facility failed to protect Resident 4's right to be free from physical abuse by Resident 5. As a result, on 4/2/2025 Resident 5 hit Resident 4 in the nose. Resident 4 suffered pain (pain level not indicated) to the nose and required x-ray of the facial (face) bones to rule out injury. The x-ray report indicated there was no significant soft tissue (damage to body tissue that is not hardened or calcified as a result of blunt force trauma [injury]) swelling. During a record review, Resident 4's Admission Record indicated the facility admitted the resident on 10/8/2024 with diagnoses that included schizoaffective disorder and high blood pressure. During a record review, Resident 4's MDS, dated 1/21/2025, indicated the resident could be understood and could understand others. The MDS also indicated the resident's cognition was intact and the resident was independent with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a record review, Resident 4's potential/risk to exhibit psycho-social distress care plan, initiated 11/28/2024, indicated the resident was at risk for negative psychological impact after reporting an abuse allegation in November 2024. The care plan indicated the resident was at risk for negative psychological impact due to an episode on 4/2/2025 when the resident struck a female peer back. The care plan interventions included to assist the resident in identifying coping skills other than hitting back and to provide the resident one on one with resident to explore feelings and thoughts as needed. During a record review, Resident 4's nose pain care plan, initiated 4/2/2025, indicated the resident exhibited nasal (of the nose) pain related to a physical altercation that day [4/2/2025] with a female peer. The care plan interventions included for staff to monitor for non-verbal signs or symptoms of pain such as increase in agitation, grimace, resistance to care and to medicate for pain as ordered. The interventions also included an x-ray of the Resident 4's facial bones to rule out injury related to a resident-to-resident physical altercation and to report to the physician any significant changes in the resident's condition or significant/abnormal x-ray result. During a record review, Resident 4's Radiology Results Report, dated 4/2/2025, indicated the resident had an x-ray of the facial bones due to physical trauma to the nose. The Radiology Results Report further indicated there was no significant soft tissue swelling and there was no evident of fracture (broken bone). During a record review, Resident 5's admission record indicated the facility admitted the resident on 9/5/2024 with diagnoses of schizoaffective disorder, right eye blindness and insomnia (trouble falling asleep or staying asleep). During a record review, Resident 5's MDS, dated 3/21/2025, indicated the resident's skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. The MDS also indicated the resident's cognition was intact and the resident was independent with all ADLs. During a record review, Resident 5's COC, dated 4/2/2025, indicated Resident 5 had a physical altercation with a female peer. The COC also indicated the resident began yelling and cursing at the female peer while waiting in the medication line. The COC further indicated Resident 5 walked over to female peer's room and started swinging. Resident 5 was hit on both arms and chest with closed fist. During a record review, Resident 5's Individual Psychotherapy Progress Note, dated 4/2/2025, indicated the practitioner met with the resident after the resident's altercation with another resident. The Individual Psychotherapy Progress Note also indicated the resident was observed by staff instigating the altercation. The Individual Psychotherapy Progress Note further indicated the practitioner met with the nursing supervisor and advised a safety plan should include monitoring the resident every 15 minutes and staff supervision to avoid further contact with the other resident [Resident 4]. During a record review, Resident 5's Verbal and Physical Behavior care plan initiated 4/2/2025, the day of the alleged abuse, indicated Resident 5 exhibited verbally aggressive behavior with profanity and physically hit a female peer. The interventions included to assist the resident in identifying coping skills related to anger/agitation towards others, encourage the resident to participate in anger management to assist in management of verbal and physical aggressive behaviors. During an interview on 4/4/2025 at 9:13 AM, Resident 5 stated while walking in the facility hallway, Resident 4 was standing inside the resident's doorway that opened onto the hallway. Resident 5 approached Resident 4 and the two were yelling at each other. Resident 5 stated Resident 5 then hit Resident 4 first and then Resident 4 struck Resident 5 repeatedly and then PC 1 came over and separated Resident 4 and Resident 5. Resident 5 stated previously there was tension between Resident 5 and Resident 4. Resident 5 stated that Resident 4 and Resident 5 had been in verbal altercations previously, but it had never turned physical before. During an interview on 4/4/2025 at 9:30 AM, Resident 4 stated Resident 5 "came up to my door and said why you are always staring at me. I said I wasn't staring at you and then (Resident 5) hit me and then I hit (Resident 5) back to protect myself." Resident 4 stated the fight lasted about for a minute before staff arrived to break it up. Resident 4 stated Resident 4 and Resident 5 had gotten into verbal fights in the past and this was the first time the interaction turned physical. Resident 4 stated both Residents 4 and 5 received an x-rays of their faces after the altercation. During an interview on 4/4/2025 at 12:24 PM, PC 3 stated Resident 4 and Resident 5 were yelling at each other. PC 3 stated then Resident 4 and Resident 5 started hitting each other. PC 3 stated although there were staff members closer to the fighting residents, PC 3 had to run over to Residents 4 and 5 because other staff members were not intervening. PC 3 stated the staff should have intervened when Resident 4 and Resident 5 first started yelling at each other. PC 3 stated the fight between Resident 4 and Resident 5 was inevitable because staff did not approach when Resident 4 and Resident 5 first started yelling. During an interview on 4/4/2025 at 2:04 PM, the Administrator (ADM) stated the facility's investigation between Resident 4 and Resident 5 was ongoing, however, it appeared that the investigation will be substantiated as staff witnessed the altercation. During a phone interview on 4/4/2025 at 2:31 PM Licensed Vocational Nurse (LVN) 1 stated LVN 1 and other staff heard Resident 4 and Resident 5 yelling back and forth at each other. LVN 1 stated Resident 5 then crossed to Resident 4's room and started punching Resident 4. LVN 1 further stated Resident 4 was to get a facial x-ray due to the resident stating they were hit in the nose. During a record review, the facility policy and procedures titled, "Abuse Prohibition," revised 10/25/2024, indicated "physical abuse" includes hitting, slapping, pinching, kicking, etc.com, as well as controlling behavior through corporal punishment ... The facility will protect patients from further harm ..." The facility failed to protect Resident 4's right to be free from physical abuse by Resident 5. As a result, on 4/2/2025 Resident 5 hit Resident 4 in the nose. Resident 4 suffered pain (pain level not indicated) to the nose and required x-ray of the facial bones to rule out injury. The x-ray report indicated there was no significant soft tissue swelling. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 4.