Health inspection·August 29, 2025

F600 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 §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under 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 7/23/2025 California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate Facility Reported Incident regarding resident-to-resident abuse (deliberately aggressive or violent behavior with the intention to cause harm). The facility failed to protect the resident's right to be free from physical abuse for Resident 1 when on 7/7/2025 at 7:50 pm, Resident 2 hit Resident 1 in the face three times without provocation (an action was taken without any apparent reason or cause). On 7/8/2025 both Resident 1 and Resident 2 were in another resident group activity when Resident 2 came over to Resident 1 and began hitting Resident 1 in the face for no reason. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 on two occasions while under the care of the facility. On 7/8/2025 Resident 1 sustained a skin coloration (refers to any change in your natural skin tone) measuring 1.5 centimeter (cm - unit of measurement) by 3 cm under the right eye. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on 2/18/2020 with diagnoses that included essential (primary) hypertension (when a person has abnormally high blood pressure that's not the result of a medical condition), paranoid schizophrenia (Persistent, false beliefs, often centered around persecution, where the individual believes they are being harmed or negatively affected by others). During a review of Resident 1's History and Physical (H&P) dated 10/30/2024, the H&P indicated Resident 1 did not have the capacity to understand and make medical decisions, however, he can make needs known. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2025, the resident's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) was intact. The MDS indicated Resident 1 could communicate needs and wants. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) Summary for providers dated 7/8/2025 at 10:44pm, the SBAR indicated that on 7/7/2025 at approximately 7:50pm, male peer (Resident 2) walked in the television (TV) room and hit resident (Resident 1) with close fist in the face area times three without provocation. The SBAR indicated a medical doctor (MD) and conservator (is a person appointed by a court to manage the financial affairs and/or healthcare decisions of an adult who is deemed unable to do so themselves due to a mental or physical disability) were notified, and the MD ordered X-ray to rule out (R/O) fracture (break in a bone). During a review of Resident 1's Care Plan (CP) titled "Resident with Potential/risk to exhibit Psycho-Social (refers to anything that negatively impacts a person's mental well-being, like their thoughts, feelings, and emotions) distress related to abuse allegation," and initiated on 4/25/2025, indicated that on 7/7/2025 Resident 1 was hit in the face by a male peer (Resident 2). The CP also indicated that on 7/8/2025, Resident 1 was hit in the face with open hands by a male peer (Resident 2). The CP interventions included to investigate thoroughly and integrate all appropriate interventions, to evaluate the nature and circumstances (i.e. triggers) ..., and adjust care delivery appropriately. During a review of Resident 1's Room Transfer/New Roommate Change Form., dated 7/7/2025 at 9 pm indicated Resident 1 was moved to another room after an incident with roommate (Resident 2) on 7/7/2025. During a review of Resident 1's Progress Note dated 7/7/2025, the progress note indicated Resident 1 was placed on Q (every) 15 minutes monitoring (every 15 minutes report on the whereabouts and activity of the resident) checks for 72 hours per Medical Doctor (MD) 1 orders after witnessed incident of resident to resident (one resident abusing another resident within the facility) abuse. During a review of Resident 1's Body Check Assessment Form dated 7/8/2025 indicated "Skin coloration under right eye 1.5 cm X 3 cm, applied ice compress (cold therapy- is the application of cold to a body part to reduce pain, swelling, and inflammation [the body's response to injury or infection]) on affected area," and MD 1 notified. During a review of Resident 1's physician telephone order dated 7/8/2025 at 1:04pm, the physician telephone order indicated to perform stat (now) x-ray of the face to rule out fracture. During a review of Resident 1's Facial Bones Less Than 3 View Radiology (is a branch of medicine that uses imaging technology to diagnose and treat disease) Results Report dated 7/8/2025 at 12:26pm, indicated, "FINDINGS: Evaluation hindered: poor positioning. Bones: No acute fracture or bone lesion. Soft tissues: Unremarkable....no foreign body." During a review of Resident 1's Follow-up Documentation dated 7/10/2025 at 2:17pm, the follow up documentation indicated ... Resident 1 has a purplish discoloration under right eye, swelling noted, and no visual disturbances noted. During a review of Resident 2's Admission Record, the admission record indicated Resident 2 was admitted to the facility on 9/17/2024 with diagnoses that included essential hypertension and paranoid schizophrenia During a review of Resident 2's H&P dated 10/30/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions, however, the resident could make needs known. During a review of Resident 2's MDS dated 7/3/2025, the MDS indicated Resident's cognition was intact. The MDS indicated Resident 2 could communicate needs and wants but did not have the capacity to make decisions concerning care. During a review of Resident 2's CP titled physical altercation related to poor impulse control and resolving interpersonal conflicts initiated on 4/17/2025 and revised on 7/8/2025, the CP indicated to monitor Resident 2 to help prevent potential future physical altercations, related to Resident 2 hit male peer (Resident 1) three times in the head on 7/7/2025. The CP also indicated that on 7/8/2025, Resident 2 hit male peer (Resident 1) in the face with his hands. The CP interventions indicated that Resident 2 was on (Q) (every) 15 minutes (every 15 minutes report on the whereabouts and activity of the resident) checks monitoring. During a review of Resident 2's Nursing Note dated 7/7/2025 at 9:23 pm, the nursing note indicated a change of condition (COC- acute change of condition (ACOC), or significant change of condition) that Resident 2 hit another resident (Resident 1) in the face three times without provocation. The Nursing Note indicated MD 1 was notified and MD 1 gave an order for Resident 2 to be placed on Q15-minute checks for 72 hours. During a review of Resident 2 MD 1 telephone order dated 7/8/2025 at 6:38 pm, the telephone order indicated MD 1 placed Resident 2 on one to one (1:1) (close supervision to prevent aggressive behavior) monitoring precautions after the second incident of resident to resident (Resident 2 on Resident 1) abuse on 7/8/2025. Order stated the following: "ok to place resident on 1:1 close supervision due to (d/t) aggressive behavior" During an interview on 7/22/2025 at 9:07 am Resident 1 stated, on 7/7/2025 in the evening, Resident 1 was sitting in the residents group meeting room when Resident 2 came into the room and started punching him (Resident 1) in the face for no reason. Resident 1 stated facility staff came and stopped Resident 2 from hitting him in the face. Resident 1 stated that the next morning on 7/8/2025 both Resident 1 and Resident 2 were in another resident group activity on 7/8/2025, when Resident 2 came over to him and began hitting Resident 1 in the face for no reason. During an interview on 7/22/2025 at 10:35am, Behavioral Specialist (BS - staff that assist residents and help monitor activity of residents throughout the day) 1 stated, that on 7/8/2025 during the first group meeting called "News of the Day", both Resident 2 and Resident 1 were attending the same group. Once the group was over, Resident 2 walked over to Resident 1 and started hitting Resident 1 for no reason. BS 1 stated he told Resident 2 to stop hitting Resident 1, and Resident 2 complied and stopped hitting Resident 1. Resident 2 was on Q15 minutes monitoring protocol and Q15 means that certified nursing assistant (CNA) checks the residents whereabouts every 15 minutes. During an interview on 7/22/2025 at 11:27am, BS 2 stated that on 7/7/2025 he (BS 2) was downstairs in the dining room assisting with the News of the Day" residents group meeting. BS 2 stated both Resident 1 and Resident 2 were in the same group meeting but seated at a different tables. News of the Day," Resident 2 just got up, and walked over to Resident 1 and started hitting Resident 1 in the face. Resident 2 did not say anything, just got up like he (Resident 2) was going to leave the room but instead turned and went over to Resident 1 and started hitting Resident 1 in the face. During an interview on 7/22/2025 at 12:08 pm, Certified Nurse Assistant (CNA) 1 stated that on 7/8/2025 she was assigned to monitor Resident 2 every 15 minutes. CNA 1 stated that when staff are assigned to monitor a resident every 15 minutes, that means the resident is on Q15 minute monitoring and that staff assigned to the resident must check on the resident every 15 minutes. Q15 minute monitoring does not mean staying with the resident and reporting to staff every 15 minutes but to check on the whereabouts of the resident every 15 minutes. However, while the resident is in group, the resident is left with the staff that run the group. CNA 1 stated, even though she is assigned to perform to monitor the residents Q15 minutes, she still has six to eight other residents to attend to. During an interview on 7/22/2025 at 12:40 pm, Licensed Vocational Nurse (LVN) 1 stated that on 7/8/2025, he (LVN 1) was upstairs at the nursing station when he overheard one of the residents say that there was a fight downstairs. LVN 1 stated he went downstairs to see what was happening. Once he was downstairs, he noticed that staff had already separated the residents (Resident 1 and Resident 2). LVN 1 stated he performed a visual assessment on Resident 1 to determine if he needed medical attention and Resident 1 stated he (Resident 1) was alright. During an interview on 7/22/2025 at 12:52 pm, the Program Counselor (PC -a staff that assists residents with group activities and assists in monitoring resident behavior) stated that on 7/8/2025, Resident 1 was participating in an evening group activity in the TV room. Resident 2 was not participating in this activity. The PC stated that at the end of the evening group activity, Resident 2 walked into the same TV room and starting hitting Resident 1 in the face. The facility's Assistant Program Director (APD- the supervisor of the program counselors and behavioral specialists) was in the TV room and used crisis communication (firm commands to residents that stops negative behavior) to try and stop Resident 2 from continuing to hit Resident 1 in the face. During an interview on 7/22/2025 at 1:05 pm, the APD stated that on 7/8/2025, he was in the television room speaking to one of the counselors when suddenly Resident 2 came into the room and started hitting Resident 1. The APD stated he used verbal crisis communications, and Resident 2 then stopped his aggressive behaviors on Resident 1. During an interview on 7/22/2025 at 1:30pm, the Registered Nursing Supervisor (RNS) stated, after the first incident on 7/7/2025, Resident 2 was placed on Q15 minute monitoring and that after the second incident on 7/8/2025 the resident was placed on 1:1 monitoring by Medical Doctor (MD) 1. RNS stated that next day on 7/8/2025, Resident 2 assaulted Resident 1 again in a group that they were both attending. During an interview on 7/22/2025 at 1:42 pm, MD1 stated, 1:1 order is used to monitor the residents very closely to prevent them from harming themselves or others. During a review of the facility Policy and Procedures (P&P) titled "Resident Rights" dated revised 2/25/2025, indicated: "Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence; b. Be treated with respect, kindness, and dignity; c. Be free from abuse, neglect, misappropriation of property, and exploitation. During a review of the facility P&P titled "Abuse Prohibition Policy and Procedure" dated revised 2/25/2025, indicated: "Policy: HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The Center will implement an abuse prohibition program through the following: * Screening of potential hires; * Training of employees (both new employees and ongoing training for all employees); * Prevention of occurrences; * Identification of possible incidents or allegations which need investigation; * Investigation of incidents and allegations; * Protection of patients during investigations; and * Reporting of incidents, investigations, and Center response to the results of their investigations." The facility failed to protect the resident's right to be free from physical abuse for Resident 1 when on 7/7/2025 at 7:50pm, Resident 2 hit Resident 1 in the face three times without provocation. On 7/8/2025 both Resident 1 and Resident 2 were in another resident group activity when Resident 2 came over to Resident 1 and began hitting Resident 1 in the face for no reason. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 on two occasions while under the care of the facility. On 7/8/2025 Resident 1 sustained a skin coloration measuring 1.5 cm by 3 cm under the right eye. The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result to Resident 1.