Health inspection·September 11, 2025

The following reflects the finding of the California department of Public Health during Investigation of a facility reported incident numbers 2566872, 2567292 & 2569925. A Class B citation was issued. F600 Free from Abuse and Neglect §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. California Code of Regulations, Title 22, Section 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 7/30/2025 California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident regarding resident-on-resident abuse. The facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for Resident 1 by Resident 2. Resident 1 had a behavior of wandering behavior into other residents' rooms. The facility failed to: - Develop a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to address Resident 1's wandering, per the facility policy and procedures (P&P) titled, "Wandering and Elopements." - Accurately assess Resident 1's risk for wandering upon admission - Adequately monitor Resident 1's location to ensure the resident's safety and prevent the resident from wandering into other resident rooms. - Provide a safe environment for Resident 1 As a result, Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 7/6/2025, Resident 1 wandered into Resident 2's room and ate Resident 2's sandwich. On 7/20/2025, Resident 1 again wandered into Resident 2's room and drank Resident 2's sports drink causing Resident 2 to become angry and throw a bottle at Resident 1's head. During a review of Resident 1's Admission Record, the admission record indicated the facility admitted the resident on 6/26/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 1's Wandering Risk Assessment, dated 6/26/2025 [upon admission], the wandering risk assessment form indicated the form consisted of seven sections that addressed the resident's orientation, behavior/mood, recent experiences, mobility, diagnosis, medications and history of wandering. A further review of the wandering risk assessment form indicated the facility did not assess Resident 1's orientation, behavior/mood and recent experiences. The Wandering Risk Assessment form also indicated the Resident 1 scored number four (4 - the resident is a low risk for wandering). During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/3/2025, the MDS indicated Resident 1 had severe cognitive impairment (problems with a person's ability to think, remember, and make decisions). The MDS also indicated the resident had no episodes of wandering in the previous one to three days. The MDS indicated Resident 1 required substantial to maximal assistance from facility staff with eating, oral hygiene and dressing and was dependent upon staff for toileting hygiene, showering and personal hygiene. During a review of Resident 1's Wandering Risk Assessment form, dated 7/9/2025, the wandering risk assessment form indicated Resident 1 risk wandering score was 11 (the resident is at high risk for wandering). During a review of Resident 1's Change of Condition (COC- technique provides a framework for communication between members of the health care team and used as a tool to foster patient safety), dated 7/20/2025, indicated Resident 1 was found in Resident 2's room. The COC indicated that Resident 2 became upset and hit Resident 1 in the back of the head. The COC further indicated Resident 1's physician was notified and then ordered for Resident 1 to be transferred to a general acute care hospital (GACH). During a review of Resident 1's care pan (CP) on resident demonstrated wandering behaviors, initiated 7/21/2025 (the day after the altercation between Resident 1 and Resident 2), the CP indicated the goal was for the resident to remain safe in the environment into other resident's spaces and to prevent recurrence of altercation (a loud argument or disagreement) or conflict with other residents. The CP interventions included to monitor Resident 1's whereabout frequently, assess the resident for underlying causes of wandering, and to educate staff on resident's wandering pattern and preferred redirection techniques. During a review of Resident 1's care plans, it indicated there were no care plans developed that addressed Resident 1's wandering behavior prior to 7/21/2025 (after the altercation involving Resident 1 and Resident 2) and there was no documented evidence regarding monitoring Resident 1's whereabouts prior to 7/21/2025. During a review of Resident 2's admission record, the admission record indicated the facility admitted the resident originally on 3/31/2021 and re-admitted the resident on 12/26/2024 with diagnoses that included right sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) , seizures (a sudden burst of electrical activity in the brain) and a history of falling. During a review of Resident 2's COC form, dated 7/20/2025, the COC indicated Resident 2 became angry that another resident [Resident 1] came into Resident 2's room and drank his (Resident 2's) juice. The COC also indicated Resident 2 hit Resident 1 on the back of the head. During an interview on 7/30/2025 at 11:46 AM, Resident 2 stated that on 7/6/2025, Resident 1 entered Resident 2's room and ate Resident 2's sandwich. Resident 2 stated a facility staff member (unknown to Resident 2 and FM 1) removed Resident 1 from the room. Resident 2 further stated that two weeks later on 7/20/2025, Resident 2 arrived at his room and again found Resident 1 drinking a sports drink from Resident 2's bedside. Resident 2 stated he (Resident 2) "became very upset and "acted out" (to expressing something through actions rather than words, or to behave in a way that is considered inappropriate) because the facility staff were not doing their job properly by not monitoring Resident 1 and because Resident 1 entered his room twice. During a review of the electronic medical charts for both Resident 1 and Resident 2 on 7/30/2025 at 12:17 PM, the electronic medical charts for Resident 1 and Resident 2's indicated there was no documented evidence that Resident 1 entered Resident 2's room and ate Resident 2's sandwich. During an interview on 7/30/2025 at 12:21 PM, Certified Nursing Assistant 1 (CNA) 1 stated Resident 1 wanders inside other residents' rooms since "the first day" of his admission and that some residents have become upset due to Resident 1 wandering into their rooms. During an interview on 7/30/2025 at 1:02 PM, Licensed Vocational Nurse (LVN) 1 stated Resident 1, "is very antsy (impatient and or restless)." LVN 1 stated it was not often possible to keep Resident 1 in one location. LVN 1 further stated that she (LVN 1) would try to utilize the certified nursing assistants (CNAs) to monitor Resident 1's location but they (the CNAs) are busy. LVN 1 further stated that Resident 1 has been wandering in the facility and the residents' rooms since Resident 1 arrived at the facility. During an interview on 7/31/2025 at 10:02 AM, CNA 2 stated that about two weeks ago, CNA 2 heard loud yelling and went to investigate. CNA 2 stated CNA 2, CNA 4, Licensed Vocational Nurse (LVN) 2 and LVN 3 found Resident 1 inside Resident 2's room. CNA 2 stated Resident 2 said that Resident 1 was drinking Resident 1's sports drink. CNA 2 stated CNA 2, CNA 4, LVN 2 and LVN 3 saw Resident 2 throw a bottle at Resident 1. CNA 2 further stated the bottle did not hit Resident 1 but fell on Resident 1's lap. CNA 2 stated and confirmed that other staff members had told CNA 2 that Resident 1 wanders into other residents' rooms. During a concurrent interview and record review with LVN 2 on 7/31/2025 at 10:28 AM, LVN 2 stated that on 7/20/2025, LVN 2 along with CNA 2 heard a loud scream and ran toward the noise. LVN 2 stated they found Resident 1 at Resident 2's bedside table. LVN 2 stated Resident 2 was also inside the room and Resident 2 stated Resident 1 was stealing his food and drank Resident 2's juice. LVN 2 stated then Resident 2 threw a water bottle at the back of Resident 1's head. The water bottle did not hit Resident 1's head but did land in Resident 1's lap. LVN 2 further stated that LVN 2 noticed a cane on the floor and while Resident 1 was being wheeled out of the room, Resident 1 was holding his head and stated Resident 2 "hit me in the head." During a concurrent record review of Resident 1's electronic medical record (EMR), LVN 2 stated upon Resident 1's admission to the facility on 6/26/2025, Resident 1 was deemed as a low risk for wandering. LVN 2 stated that on 7/9/2025, during subsequent wandering risk assessment, Resident 1 scored 11 which indicated the resident was a high risk for wandering. LVN 2 stated at this time (the subsequent wandering risk assessment), a care plan (CP) should have been developed to address Resident 1's wandering behavior. LVN 2 stated a CP, "sets goals so we can provide interventions and improve the resident's condition." LVN 2 stated Resident 1's wandering care plan was not initiated until 7/21/2025, after the altercation between Resident 1 and Resident 2. LVN 2 further stated wandering into other residents' rooms could lead to abuse (willfully infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). LVN 2 also stated, "Patient safety is compromised when there is no care plan in place." LVN 2 further stated there was no COC documentation that Resident 1 wandering into other residents' rooms. During a phone interview on 7/31/2025 at 11:46 AM, Resident 2's Family Member (FM) 1, stated that on 7/6/2025 upon returning to Resident 2 rooms, FM 1 and Resident 2 found Resident 1 inside Resident 2's room eating Resident 2's sandwich. FM 1 stated FM 1 called a CAN (unable to recall the name) to Resident 2's room and that the CNA escorted Resident 1 away from the room. During a concurrent interview and record review on 7/31/2025 at 2 PM with the Assistant Director of Nursing (ADON), Resident 1's EMR was reviewed. During a review of Resident 1's admission wandering risk assessment, dated 6/26/2025, the ADON stated the risk assessment was not complete and if completed may have changed the resident's score indicating. The ADON stated a wandering risk assessment is performed to assess and provide safety for the resident. The ADON stated that not completing the wandering risk assessment could lead to the wandering behavior of Resident 1. During a review of Resident 1's care plans, the ADON stated the facility did not develop a CP to address Resident 1's wandering behavior prior to 7/21/2025 (after the altercation incident occurred with Resident 2). The ADON further stated Resident 1's wandering behavior should have been care planned to provide the best care for the resident. During a review of the facility policy and procedures (P&P) titled, "Wandering and Elopements," dated 11/21/2024, the P&P indicated, "it is the facility policy to identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents." The P&P further indicated, "If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety." During a review of the facility P&P titled, "Care Plans, Comprehensive Person-Centered," dated 11/21/2024, the P&P indicated, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident." The P&P also indicated, "Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change." The facility failed to protect the resident's right to be free from physical abuse for Resident 1 by Resident 2. Resident 1 had a behavior of wandering behavior into other residents' rooms. The facility failed to: - Develop a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to address Resident 1's wandering, per the facility P&P titled, "Wandering and Elopements." - Accurately assess Resident 1's risk for wandering upon admission - Adequately monitor Resident 1's location to ensure the resident's safety and prevent the resident from wandering into other resident rooms. - Provide a safe environment for Resident 1 As a result, Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 7/6/2025, Resident 1 wandered into Resident 2's room and ate Resident 2's sandwich. On 7/20/2025, Resident 1 again wandered into Resident 2's room and drank Resident 2's sports drink causing Resident 2 to become angry and throw a bottle at Resident 1's head. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.