Health inspection·July 16, 2025

REGULATORY VIOLATIONS  §72315. Nursing Service - Residents Care.  (b) Each resident shall be treated as an individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind.  § 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.    §72523. Residents Care Policies and Procedures.  (a) Written residents care policies and procedures shall be established and implemented to ensure that residents related goals and facility objectives are achieved.  (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, residents or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the resident's care policy committee.  F600   §483.12 Freedom from Abuse, Neglect, and Exploitation   The Residents has the right to be free from abuse, neglect, misappropriation of Residents 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 Residents’ 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.    On 6/6/25 at 12:05 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported incident regarding resident-to-resident abuse.? As a result of the investigation, CDPH determined that the facility failed to protect the resident’s rights to be free from physical and verbal abuse for Resident 2 by failing to protect Resident 2 from Resident 1, after Residents 1 and 2 had a physical altercation on 5/29/2025 around 8 AM and 10 AM.  This deficient practice resulted in Resident 2 experiencing physical and verbal abuse from Resident 1 on 5/29/2025 and had the potential to result in physical injury and/or affect Resident 2 psychosocially.  A review of Resident 1’s Admission Record (AR), indicated Resident 1 was a 64 year old male resident readmitted to the facility on 4/9/2025 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia [a serious mental health condition that affects how people think, feel and behave] and mood disorder symptoms), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting right dominant side, and dysphagia (difficulty swallowing).  A review of Resident 1’s History and Physical Assessment (H&P), dated 11/16/2024, indicated Resident 1 did not have the capacity to understand and make decisions.  A review of Resident 1’s Minimum Data Set (MDS, an assessment and screen tool) dated 4/9/2025, indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience and senses).  A review of Resident 1’s Progress Notes, dated 5/29/2025, timed at 8:03 AM, indicated Resident 1 was moved to another room.  A review of Resident 1’s Progress Notes, dated 5/29/2025 timed at 10:33 AM, indicated Resident 1’s attending physician was notified of Resident 1’s physical altercation with another resident and ordered Resident 1 to transfer to the acute hospital for medical and psychiatric evaluation.  A review of Resident 1’s Progress Notes, dated 5/29/2025. The notes indicated Resident 1 was picked up by ambulance due to elevated blood pressure (the measurement of the pressure or force of blood inside the blood vessels).  A review of Resident 2’s AR indicated Resident 2 was a 65 year old male admitted to the facility on 5/8/2025 with diagnoses including radiculopathy lumbar region (disorder that causes pain in the lower back and hip), polyneuropathies (condition in which a person’s peripheral nerves are damaged), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break down overtime).  A review of Resident 2’s H&P, dated 5/9/2025, indicated Resident 2 had the capacity to understand and make decisions.  A review of Resident 2’s MDS, dated 5/14/2025, indicated Resident 2’s cognition was intact.  A review of Resident 2’s SBAR Communication Form, dated 5/29/2025 timed at 8 AM, indicated “At approximately 7:40 AM, Resident 2 was having a verbal disagreement about his curtain and whether it should be closed. Victim (Resident 2) requested for it to be closed, which led to Aggressor (Resident 1) to get agitated and strike at Victim (Resident 2). Staff immediately responded and separated both residents. Took aggressor (Resident 1) to a different room and a head-to-toe assessment was done on Victim (Resident 2). Police and physician notified. Resident continuing to be monitored.”  During an interview on 6/6/2025 at 12:18 PM, the Social Services Director (SSD) stated on 5/29/2025 before 8 AM (around breakfast time), Resident 1 hit Resident 2. The SSD stated, Resident 2 asked Certified Nursing Assistant (CNA) 1 to close the curtain between Resident 1 and Resident 2’s beds. The SSD stated Resident 1 opened the curtains and hit Resident 2. The SSD stated, both residents were separated, and the police came to the facility. The SSD stated after the first incident, Resident 1 went back to his room to use the bathroom and turned on the TV, then told Resident 2 “I’m going get you.” The SSD stated, Resident 2 told Resident 1 “I’m ready for you to come at me.” SSD staff were able to get Resident 1 out of the room. The SSD stated Resident 2 told her to call the police again and wanted Resident 1 to be arrested (around 10 AM). The police came back around 10 AM.  During an interview on 6/6/2025 at 1:05 PM, Registered Nurse Supervisor (RNS) 1 stated after Resident 1 hit Resident 2 on 5/29/2025 (before 8 AM), Resident 1 was moved to another room. RNS 1 stated, CNA 2 saw Resident 1 return to his original room with Resident 2. RNS 1 stated, she did not know how Resident 1 was able to go back to his original room after being moved to another room, and stated, Resident 1 should have been supervised by facility staff to prevent the resident (Resident 1) from walking back to the room. RNS 1 stated, “I don’t know what happened, maybe lack of communication.”  During an interview on 6/6/2025 at 1:29 PM with CNA 2, CNA 2 stated, on 5/29/2025, she saw Resident 1 go back to his original room and saw him turn on/off the TV. CNA 2 stated, she did not go and follow Resident 1 to the original room to stop Resident 1 from going back.  During an interview on 6/6/2025 at 1:52 PM, Resident 2 stated, on 5/29/2025, he did not want to eat his breakfast and wanted CNA 1 to close the curtain to sleep. Resident 2 stated, Resident 1 did not want the curtain closed and “started hitting me.” Resident 2 stated he had his pillow as defense and the staff came to separate the two residents. Resident 2 stated he had no problems with Resident 1 before; and they never spoke to each other. Resident 2 stated, Resident 1 was not a pleasant person, so he never spoke to Resident 1. Resident 2 stated, after Resident 1 hit him, the staff moved Resident 1 to another room. Resident 2 could not recall the time and heard someone in the bathroom and then turned the TV on. Resident 2 stated, Resident 1 said to him “I’m gonna get you.” Resident 2 stated, he told Resident 1 “come at me then.” Resident 2 stated, the staff took Resident 1 out of the room. Resident 2 stated, he told the SSD to call the police again, because Resident 2 wanted to file charges against Resident 1. Resident 2 stated he did not feel safe while at the facility that time when Resident 1 kept coming back and threatening him.  During a telephone interview on 6/6/2025 at 2:10 PM with Activities Aide (AA) 1, AA 1 stated he was watching Resident 1 and brought Resident 1 to the Dining/Activity Room on 5/29/2025 after the altercation. AA 1 stated AA 2 covered for him when he went to lunch.  During an interview on 6/6/2025 at 2:15 PM with AA 2, AA 2 stated on 5/29/2025 in the morning, AA 1 brought Resident 1 to the activity room after the altercation with Resident 2 and another resident asked for coffee. AA 2 stated, AA 1 left the room to get coffee for the other resident. AA 2 stated, she did not notice Resident 1 leave the activity room. AA 2 stated, she noticed Resident 1 was gone when AA 1 returned from getting the other resident’s coffee.  During a concurrent interview and record review on 6/6/25 at 2:39 PM with RNS 1 of Resident 1’s progress notes, RNS 1 stated, “we didn’t do another progress note because we thought it was the same, no one thought after the second incident happened, that they had to do another one.” RNS 1 stated, the second incident should have been included and should be in the progress notes. RNS 1 stated, it was missed because they were so focused on working on Resident 1’s transfer. RNS 1 stated, Resident 1 should have been supervised the whole time, because he was the aggressor and went back to the room. RNS 1 stated, it was important for the two residents to be separated for resident safety.  During an interview on 6/6/2025 at 3:02 PM with the Director of Nursing (DON), the DON stated, she expected staff to document and notify the physician. The DON stated it was important to include documentation of the second incident to make sure it was included in the resident’s record. The DON stated that the physician would be notified, and interventions would be in place in the care plan for the residents. The DON stated, the residents should have been completely separated to ensure the safety of residents. The DON stated, if there was proper supervision, the second incident between Resident 1 and 2 would not have happened.  A review of the facility’s undated policy and procedure (P&P), titled “Abuse Prevention/Prohibition,” indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops policies, procedures, training programs and systems in order to promote an environment free from abuse and mistreatment.  As a result of the investigation, CDPH determined that the facility failed to protect the resident’s rights to be free from physical and verbal abuse for Resident 2 by failing to protect Resident 2 from Resident 1, after Residents 1 and 2 had a physical altercation on 5/29/2025 at around 8 AM and 10 AM.  This deficient practice resulted in Resident 2 experiencing physical and verbal abuse from Resident 1 on 5/29/2025 and had the potential to result in physical injury and/or affect Resident 2 psychosocially.  These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents of the facility, including Residents 1 and 2.