Health inspection·September 17, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. 22CCR §72315. Nursing Service - Patient Care. (b)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 Patients' 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. 22 CCR §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: (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. On 7/28/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating Resident 1 was hit by Resident 2. On 8/6/2025 at 10:00 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. 2. Implement its P&P titled "Behavior Management Plan," which indicated, residents with behavioral concerns will have a behavioral management plan to ensure they received appropriate services and interventions to meet their needs. As a result, Resident 2 punched Resident 1 on the right side of the face causing a hematoma (broken blood vessels) on Resident 1's head and left ear bleeding and sustained a one-centimeter ([cm] - unit of measurement) laceration (a deep cut or tear in the skin) on Resident 1's left ear that required sutures (a basic wound closure technique where individual stitches are placed and tied separately along the length of the wound). Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment and was diagnosed with a left ear laceration and right frontal (to the front and adjacent to the forehead) scalp (the skin covering the head) hematoma. Resident 1 was a 81-year-old male initially admitted to the facility on 9/15/2023 and readmitted on 7/25/2025. Resident 1's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest). A review of Resident 1's History and Physical (H&P), dated 4/22/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 6/26/2025, indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 sometimes had the ability to make self-understood and understood others. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from staff with activities of daily living (ADL's - routine tasks/activities) such as oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 1's Change in Condition Evaluation ([COC] - a communication tool used to communicate a resident's change of condition), dated 7/28/2025, indicated Resident 1 was found on the floor with Resident 2 on top of him. The COC indicated Resident 1 stated Resident 2 hit him and pushed him to the floor. The COC indicated Resident 1 was bleeding from the left ear with hematoma on the right side of his face. The COC indicated Resident 1 was transferred to the GACH for evaluation and treatment. A review of Resident 1's GACH Emergency Report (ER), dated 7/28/2025, indicated Resident 1 presented to the ER with injuries to his head, hand, neck, and a left ear laceration. The ER Report indicated Resident 1's Computed Tomography scan ([CT] process of taking pictures of body parts to diagnose and treat disease and injury) of the head indicated Resident 1 had a right frontal hematoma. The ER Report indicated Resident 1 had a 1-cm laceration to his left ear that required sutures. Resident 2 was a 43-year-old male, admitted to the facility on 6/27/2025. Resident 2's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 2's H&P, dated 6/28/2025, indicated Resident 2 could make needs known but could not make medical decisions. A review of Resident 2's MDS assessment, dated 7/10/2025, indicated Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 was independent (Resident completes the activity by themself with no assistance from a helper) on ADLs such as eating, toileting hygiene, and upper body dressing. A review of Resident 2's GACH Psychiatric Evaluation Notes prior to admission to the facility, dated 6/14/2025, indicated Resident 2 was admitted to the GACH on a 5150 (an involuntary 72-hour psychiatric hold, allowing law enforcement or designated mental health professionals to detain individuals who, due to a mental health disorder, are deemed a danger to themselves or others) for danger to others. The Psychiatric Evaluation Notes indicated, Resident 2 was involved in a physical altercation with another resident and had been increasingly agitated and aggressive toward others without any provocation (an action or statement that is intended to make someone angry). A review of Resident 2's Initial Psychiatric Evaluation in the facility, dated 7/14/2025, indicated Resident 2 was agitated, paranoid (unjustified suspicion and mistrust of other people or their actions) and anxious. The Initial Psychiatric Evaluation indicated a treatment plan to observe Resident 2 for deterioration in function, increase socialization to prevent isolation and compliance of medication. A review of Resident 2's Progress Notes, dated 7/28/2025, indicated Resident 2 had experienced an auditory hallucination (perceptions of sound when no actual sound is present) commanding him to fight. The progress Notes indicated Resident 2 went to Resident 1's room and physically attacked Resident 1 and put Resident 1 on the floor. A review of the facility's Five Day Follow Up Investigative Report dated 8/1/2025, indicated on 7/28/2025 CNA 1 witnessed Resident 2 hitting Resident 1 across the face and both residents lost their balance and fell to the ground. The report indicated Residents 1 and 2 were separated immediately and assessed by staff. The report indicated Resident 1 was transferred to the GACH for further evaluation. During a telephone interview on 8/6/2025 at 12:19 p.m., Licensed Vocational Nurse (LVN 1) stated on 7/28/2025 at approximately 5 a.m., she heard a staff calling for help from Resident 1's room, she ran to the resident's room and observed Resident 2 coming out of Resident 1's room. LVN 1 stated she found Resident 1 lying on his back on the floor with a hematoma on the right side of his forehead. LVN 1 stated she observed a moderate amount of blood coming from Resident 1's left ear. During an interview on 8/6/2025 at 3:02 p.m, CNA 1 stated on 7/28/2025 at around 5:00 a.m., she heard a loud noise coming from Resident 1's room. CNA 1 stated she ran to Resident 1's room, observed Resident 1 on the floor and Resident 2 on top of him. CNA 1 stated she observed Resident 2 punching Resident 1's head and the right side of the resident's face with both fists. CNA 1 stated she observed bruises on Resident 1's face and Resident 1's left ear was bleeding. CNA 1 stated she tried to stop Resident 2 from punching Resident 1, but Resident 2 tried to hit her (CNA 1). CNA 1 stated she left Resident 1 and Resident 2 in the room while Resident 2 continued hitting Resident 1, went outside and screamed for help. CNA 1 stated there was a lot of blood on the floor. During an interview on 8/6/2025 at 3:54 p.m., the Minimum Data Set Nurse (MDSN) stated Resident 2 had a history of aggressive behavior and physical altercation with another resident prior to admission to the facility. The MDSN stated there was no comprehensive care plan developed addressing Resident 2's potential to be physically aggressive to others because Resident 1's aggressive behavior was only a history. The MDSN stated he did not develop a care plan for Resident 2's history of physically aggressive behavior until Resident 2 displayed the actual behavior by attacking Resident 1 on 7/28/2025. During an interview on 8/6/2025 at 4:10 p.m., the Director of Staff Development (DSD) stated residents with a history of physical aggressive behavior should have a comprehensive care plan so staff could identify any triggers and better manage the resident's behaviors, provide supervision, and implement other interventions to ensure the safety and well-being of the residents in the facility. The DSD stated she had no answer why the MDSN did not develop a care plan with measurable interventions related to Resident 2's history of physical altercations prior to admission to the facility. The DSD stated without an accurate care plan there was a chance for Resident 2's aggressive behavior to escalate. During an interview on 8/8/2025 at 2:26 p.m., the Social Service Director (SSD), stated failure to develop a comprehensive care plan for a resident with a known history of physical aggression could lead to a resident-to-resident altercation and physical abuse. The SSD stated the physical abuse Resident 1 suffered from Resident 2 could have been prevented if the facility had provided close monitoring and supervision to Resident 2, given the resident's history of physical altercation with other residents prior to admission to the facility. During an interview on 8/8/2025 at 3:36 p.m., the Administrator (ADM) stated all residents had the right to be free from any forms of abuse. The ADM stated Resident 2 should have been closely monitored given his history of agitation and aggressive behavior. The ADM stated that since Resident 1 sustained an injury, the facility did not prevent Resident 1 from physical abuse by Resident 2. A review of the facility's undated P&P, titled "Abuse, Neglect and Exploitation," the P&P indicated, "Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation". The P&P indicated "Physical abuse includes, but not limited to hitting, slapping, punching and kicking". The P&P indicated, "Prevention of Abuse, Neglect, and Exploitation - the facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of resident: l. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors...". A review of the facility's undated P&P, titled "Behavior Management Plan," the P&P indicated, "Residents who exhibit behavioral concerns may require a behavioral management plan to ensure they are receiving appropriate services and interventions to meet their needs". The facility failed to: 1.Implement its P&P titled, "Abuse, Neglect and Exploitation" which indicated each resident had the right to be free from abuse and neglect. 2. Implement its P&P titled "Behavior Management Plan," which indicated, residents with behavioral concerns will have a behavioral management plan to ensure they received appropriate services and interventions to meet their needs. As a result, Resident 2 punched Resident 1 on the right side of the face causing hematoma on the head and left ear bleeding and sustained a one-centimeter laceration on left ear that required suture (a basic wound closure technique where individual stitches are placed and tied separately along the length of the wound). Resident 1 was transferred to GACH for evaluation and treatment and was diagnosed with a left ear laceration and right frontal scalp hematoma. These violations, 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.