Health inspection·May 2, 2025

F689 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 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. 22 CCR § 72527 Patient’s 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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 3/18/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident (FRI) regarding a resident causing an injury to another resident using a knife. The facility failed to protect the residents’ right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) and to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of residents) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility's smoking patio (a designated outdoor area, often part of a building or property, where smoking is permitted), had a verbal altercation that led to a physical altercation in which Resident 2 used a knife (which was not found and is possible it is still in the facility) in his (Resident 2) possession to cause an injury to Resident 1. As a result, Resident 1 sustained abrasions (when the surface layers of the skin have been broken) on bilateral (both) knees and left thumb laceration (a deep cut or tear in skin) from Resident 2’s knife on 3/16/2025 at 8:29 a.m. On 3/16/2025, Resident 1 was sent to General Acute Care Hospital (GACH) 1 for further evaluation and wound treatment. Resident 1’s left thumb laceration, measuring three (3) centimeters (cm - unit of measurement) in length, 0.2 cm in width, with unknown depth, required eight stitches (fine, threadlike materials used to hold the edges of a wound together, promoting healing). Resident 2 sustained an abrasion on Resident 2’s left hand and wrist. Registered Nurse (RN) 1 gave first aid to Resident 2 and Resident 2’s primary medical doctor (MD) 1, on 3/16/2025 at approximately 9 a.m., ordered to transfer Resident 2 to GACH 2 for further evaluation. 1. A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1, a 85-year old male, on 9/15/2020 and readmitted on 5/28/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024, indicated Resident 1’s cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 1’s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating. A review of Resident 1’s "Non-Compliance for Smoking Policy" warning, dated 1/11/2024, indicated Resident 1 was given a verbal warning after Resident 1 was found on the smoking patio during a non-smoking time turning an ashtray dispenser upside down to remove any cigarettes that had already been discarded and Resident 1 chewed on the cigarette butts. A review of Resident 1’s care plan on chronic (a condition lasting longer than a few months) disruptive behavior (actions that interfere with the functioning of an individual or a group and cause disturbances to those around them, often involving aggression, defiance, or violation of social norms), revised on 9/28/2024, indicated Resident 1 had a history of physical abuse with another resident (name not indicated). A review of Resident 1’s care plan with the focus on the resident as a smoker and chews tobacco, revised on 10/3/2024, indicated Resident 1 was non-compliant (disobedient) with the smoking policy and was on the patio during non-smoking time, turning the ash tray dispenser upside down to remove cigarette butts to chew. The care plan indicated Resident 1 will not smoke without supervision. A review of Resident 1’s change of condition (COC – when there is a sudden significant change in a resident’s health status), dated 3/16/2025 at 9 a.m., indicated Resident 1 came to the nursing station on 3/16/2025 at around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation. 2. A review of Resident 2’s Admission Record indicated Resident 2, a 58-year old male, was admitted on 7/19/2024 with diagnoses including anxiety disorder (mental health conditions characterized by excessive fear, worry, and other symptoms that interfere with daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side. A review of Resident 2’s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by Certified Nursing Assistant (CNA) 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2. A review of Resident 2’s History and Physical (H&P), dated 7/22/2024, indicated Resident 2 had the mental capacity to understand and make decisions. A review of Resident 2’s care plan on resident as a supervised smoker (refers to an individual who, due to assessed needs or identified risks, requires direct supervision or assistance when smoking to ensure their safety and the safety of those around them), revised on 10/10/2024, indicated Resident 2 was non-compliant with the use of the smoking apron, schedule time, and was at risk for injury from unsafe smoking practices. The care plan indicated Resident 2’s risk to smoke without supervision will be minimized, and Resident 2 will be monitored for any unsafe smoking practices. A review of Resident 2’s MDS, dated 1/24/2025, indicated Resident 2’s cognition was intact. The MDS indicated Resident 2’s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer. A review of Resident 2’s COC, dated 3/16/2025 at 9 a.m. indicated RN 1 did a body check on Resident 2 and noted an abrasion on Resident 2’s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any pain. RN 1 called Resident 2’s MD 1 on 3/16/2025 at approximately 9 a.m. who ordered to transfer Resident 2 to GACH 2 for further evaluation. A review of Resident 2's COC Evaluation, dated 3/17/2025, indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1). A review of the facility’s "Smoking Schedule," (undated) indicated that on Saturdays and Sundays, residents are scheduled to smoke between 9 a.m. to 9:30 a.m., 11 a.m. to 11:30 a.m., 1 p.m. to 1:30 a.m., 3 p.m. to 3:30 p.m., and 7 p.m. to 7:30 p.m. During a concurrent observation and interview on 3/18/2025 at 10:10 a.m. with Resident 1 in Resident 1’s room, Resident 1’s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was disrespectful and used inappropriate words. Resident 1 stated, "He (referring to Resident 2) has no respect for anybody, he (Resident 2) can't talk like that." During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a.m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio with no staff present to supervise the two residents (Resident 1 and Resident 2). RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation. During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1’s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2). During a concurrent observation and interview on 3/18/2025 at 3:18 p.m. with Activity Staff (AS) 1 in the hallway, AS 1 was sitting in the hallway, near the smoking patio with doors closed. Two residents (names not indicated) were observed smoking in the patio through the glass panel on the doors. AS 1 stated the residents smoking in the patio are independent smokers but require supervision since occasionally, they pick up cigarette butts from the floor and try to chew them. AS 1 also stated she should have supervised residents while staying outdoors in the smoking patio. AS 1 stated the entire smoking patio is not visible from behind the hallway doors and she is not able to see all the residents in the patio. AS 1 stated all residents smoking in the patio should be supervised to prevent resident injury. During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio. During a concurrent interview and record review on 3/19/2025 at 11:22 a.m. with the MDS Specialist, Resident 2’s "Smoking Evaluation," dated 10/10/2024, was reviewed. The "Smoking Evaluation" indicated Resident 2 was noted with episode of non-compliance with the use of the smoking apron and required periodic supervision. The MDS Specialist stated Resident 2 was a supervised smoker. The MDS Specialist also stated residents should not be smoking outside of the scheduled smoking times and all residents should be supervised by the facility staff while smoking. During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility’s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs, were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times: a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen. b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance. c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and they were exchanging words. d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1’s hand while Resident 1 was pointing his hand towards Resident 2. e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1’s face. f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2’s hands. g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking