Health inspection·August 28, 2025

§483.12 Freedom from Abuse, Neglect, and Exploitation The residents have 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. §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. § 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. On 6/30/2025, the California Health Department of Public Health (CDPH) received a Facility Reported Incident (FRI) that a resident (Resident 1) hit two residents (Resident 2 and Resident 3) in their faces. On 7/2/2025, CDPH received two complaints alleging Resident 1 hit Resident 2 and Resident 3, both had pain and injury to their faces. On 7/15/2025 CDPH conducted an unannounced visit to the facility to investigate the FRI and complaint allegations. During the investigation CDPH determined Resident 1, who had a history of schizophrenia, anxiety, and a major depressive disorder (MDD), without provocation or reason, struck first Resident 2 and then Resident 3 in the face. The facility failed to: 1. Create a care plan to prevent a physical assault by Resident 1 and ensure Resident 2 and 3 were free from physical abuse when Resident 1, suddenly and without provocation, hit Resident 2 on the left side of his face and then proceeded to hit Resident 3 on the right side of his face, causing Resident 3 to fall to the floor. 2. Ensure the facility followed their Policy and Procedure (P/P), titled, “Abuse, Neglect, and Exploitation” that indicated each resident has the right to be free from abuse. The P/P indicated residents must not be subjected to abuse by anyone, including, but not limited to, abuse from other residents. These deficient practices resulted in Resident 2 being transferred to a General Acute Care Hospital (GACH 1), where he was assessed with multiple facial fractures and Resident 3 being transferred via 911 to GACH 2 where he was treated for facial lacerations that required stitches. Resident 1 was arrested by the local area police. A review of Resident 1’s Admission Record (Face Sheet) indicated Resident 1, a forty-seven-year-old male, was initially admitted to the facility on 4/16/2025 and readmitted on 6/24/2025 with diagnoses of schizoaffective disorder, MDD and an anxiety disorder. A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool) dated 4/23/2025 indicated Resident 1’s cognition was moderately impaired. The MDS indicated Resident 1 required set up or clean up assistance (helper sets up or cleans up; resident completes activity) to complete activities of daily living (ADLs). A review of Resident 1’s Psychiatric Evaluation dated 6/24/2025 indicated Resident 1 presented with heightened psychomotor agitation, marked anxiousness, irritability, uncooperativeness, a guarded demeanor (a manner of behavior that is reserved) and restlessness. A review of Resident 1’s Change in Condition (COC) Evaluation dated 6/29/2025 indicated Resident 1, without any reason, suddenly hit Resident 3 who was walking in the hallway. The COC Evaluation indicated Resident 3 was hit on his face causing bleeding to his mouth. The COC Evaluation indicated Resident 1 was redirected to his room and away from others but continued to be physically violent to others. The COC Evaluation indicated 911 was called and Resident 1 was closely watched/guarded by male staff until the local police department arrived at the facility. A review of Resident 1’s Nursing Note dated 6/29/2025 indicated Resident 1 was taken into custody by a local area police department. A review of Resident 2’s Face Sheet indicated Resident 2, a sixty seven year old male, was admitted to the facility on 7/9/2020 with a diagnosis of paranoid schizophrenia, and hallucinations. A review of Resident 2’s MDS dated 7/5/2025 indicated Resident 2’s cognition was moderately impaired. A review of Resident 2’s COC Evaluation dated 6/29/2025 indicated Resident 2 was walking in the hallway when Resident 1 suddenly hit him on his left cheek without any provocation. The COC Evaluation indicated Resident 2’s skin below his left eye was discolored, an ice pack was applied, neuro checks were initiated, and Resident 2 was closely monitored. A review of Resident 2’s Physician’s Order dated 6/29/2025 indicated to transfer Resident 2 to a GACH for further evaluation. A review of Resident 2’s Face Sheet, from GACH 1 indicated Resident 2 was admitted to GACH 1 on 6/30/2025, after being transferred from GACH 2’s emergency room (ER) where he was initially transported after the assault on 6/29/2025. A review of GACH 1’s Department of Emergency Medicine History of Present Illness, dated 6/30/2025 indicated Resident 2 was transferred from GACH 2 to GACH 1, following an assault. The Department of Emergency Medicine report indicated a Computed Tomography (CT) scan was conducted on Resident 2. A review of Resident 2’s CT scan dated 6/30/2025, indicated the following: 1. A fracture of the left zygomatic arch (the upper jawbone and cheek). 2. A fracture of the left lateral orbital wall (the outer wall of the eye socket, side of the eye), which is slightly angled medially (toward the middle of the body). 3. A fracture of the left malar eminence (cheekbone). 4. A commuted fracture (a type of fracture where the bone breaks into multiple pieces of there or more) of the anterior (nearer the front) and posterior (further back in position) lateral wall of the left maxillary sinus (on the left side of the nose) as well as the left orbital floor (the bottom of the eye socket). 5. A fracture of the posterior left nasal bone as well as the anterior left nasal bone with associated paranasal (near or alongside the nasal cavity) soft tissue swelling. A review of the Department of Emergency Medicine “Medical Decision Making” note indicated for Resident 2 to follow up with Oral Maxillofacial Surgery and to schedule an appointment as soon as possible for a visit in two days. During an interview on 7/15/2025 at 11:27 a.m., Resident 2 stated he was standing in the hallway by the double doors, outside of Resident 1’s room, when Resident 1 hit him on the left side of his face. Resident 2 stated after Resident 1 hit him in his face he (Resident 2) was taken to GACH 2. Resident 2 stated Resident 1 also hit another resident (Resident 3), who was also standing in the hallway immediately after hitting him (Resident 2). A review of Resident 3’s Face Sheet, indicated Resident 3, a sixty-six-year-old male, was admitted to the facility on 6/11/2025 with a diagnosis of MDD and anxiety. A review of Resident 3’s MDS dated 6/18/2025 indicated Resident 3’s cognition was intact. A review of Resident 3’s COC evaluation dated 6/29/2025 indicated Resident 3 was hit by Resident 1 on his face/cheek and had minimal bleeding to his mouth. The COC evaluation indicated Resident 3 was walking in the hallway when Resident 1 suddenly and unprovoked hit Resident 3 on his face, resulting in Resident 3 landing on the floor and bleeding from his mouth. The COC indicated Resident 3’s physician instructed that Resident 3 be transferred to a GACH (GACH 3) via paramedics. A review of GACH 3’s Emergency Department (ED) Provider Note dated 6/29/2025 indicated Resident 3 was admitted to GACH 3 on 6/29/2025. The ED Provider Note indicated Resident 3 presented to the ER for evaluation of facial trauma following an assault. The ED Provider Note indicated Resident 3 fell backwards, striking the back of his head, and lost consciousness for several seconds. The ED Provider Note indicated Resident 3 had a small facial laceration to his left cheek, measuring one centimeter (cm) in length, and a laceration to his left lateral lip (measurement unknown). The ED Provider Note indicated Resident 3’s facial laceration on his left cheek and mucosa (the moist, inner lining of the mouth) of the mouth were repaired with stitches. During an interview on 7/15/2025 at 12:10 p.m., Certified Nursing Assistant (CNA) 3 stated Resident 1 was quite tall, not talkative, and only came to the staff when he needed something. CNA 3 stated on 6/29/2025 around breakfast time (exact time unknow), he (CNA 3) was at the nursing station when he heard a commotion and shouting from the area near Resident 1’s room. CNA 3 stated when he responded to the commotion, he saw Resident 3 on the floor with facility staff assisting him. During an interview on 7/15/2025 at 1:12 p.m., Licensed Vocational Nurse (LVN) 2 stated she was around the corner from Resident 1’s room preparing medications when she heard a commotion and shouting. LVN 2 stated when she responded, she found Resident 2 in the hallway near Resident 1’s room, holding his face. LVN 2 stated when Resident 2 was asked what happened, he only stated Resident 1’s name. LVN 2 stated she saw Resident 1 standing by his room and she yelled Resident 1’s name to get his attention when she saw Resident 3 walk past Resident 1 and Resident 1 hit Resident 3 causing Resident 3 to fall to the floor. LVN 2 stated she screamed for help and other staff came quickly to respond to the commotion. During a telephone interview on 7/15/2025 at 1:31 p.m., CNA 1 stated she was standing in the hallway and saw Resident 2 standing in the hallway next to Resident 1’s room, when suddenly Resident 1 came out of his room and hit Resident 2 in the face. CNA 1 stated she screamed and LVN 2 responded. CNA 1 stated she was helping Resident 2 while LVN 2 was trying to get Resident 1’s attention when suddenly Resident 1 hit Resident 3 causing Resident 3 to fall to the floor. During an interview on 7/15/2025 at 2:37 p.m., the Director of Nursing (DON) stated Resident 1 stepped out of his room and hit Resident 2 and then in a matter of seconds, turned to his left and hit Resident 3. The DON stated Resident 2 and Resident 3 were both transported to separate GACHs following the assault by Resident 1. The DON stated Resident 2 was found to have facial fractures and follow up with an oral surgeon was being done. The DON stated Resident 3 sustained bruises and lacerations to his face and received stitches on the corner of his lip. A review of the facility’s undated P/P titled “Abuse, Neglect, and Exploitation” indicated each resident had the right to be free from abuse. The P/P indicated residents must not be subjected to abuse by anyone, including, but not limited to other residents. The facility failed to: 1. Ensure Resident 2 and 3 were free from physical abuse when Resident 1, suddenly without provocation, hit Resident 2 on the left side of his face and then proceeded to hit Resident 3 on the right side of his face causing Resident 3 to fall to the floor. 2. Ensure the facility followed their P/P, titled, “Abuse, Neglect, and Exploitation” that indicated each resident has the right to be free from abuse. The P/P indicated residents must not be subjected to abuse by anyone, including, but not limited to other residents. These deficient practices resulted in Resident 2 being transferred to GACH 1 where he was assessed with multiple facial fractures and Resident 3 being transferred via 911 to GACH 2 where he was treated for facial lacerations that required stitches. Resident 1 was arrested by the local area police. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probably that death or serious physical harm would result to Resident 1.