Health inspection·October 16, 2025

Regulatory Violations:   § 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. § 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 § 72301. Required Services. (d)Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. § 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.  H&S code section 1418.91.    (a)  A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b)  A failure to comply with the requirements of this section shall be a class “B” violation. (c)  For purposes of this section, “abuse” shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. (d)  This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code. § 72543. Patients' Health Records. (a) Records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all patients admitted or accepted for care. All health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18 years, but in no case less than 7 years. All exposed X-ray film shall be retained for seven years. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure, the facility staff or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request. On 9/18/2025 at 1:14 PM, California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding reporting an allegation of resident abuse.  The facility failed to provide appropriate treatment and services to support the mental and psychosocial well-being of Resident 1, who had a diagnosis of Schizoaffective Disorder, Bipolar Type, and exhibited escalating behavioral symptoms beginning on 9/13/2025. Specifically, the facility failed to: 1. Monitor and document Resident 1’s increased verbal aggression from 9/13/2025 to 9/15/2025. 2. Develop and implement additional interventions to ensure Resident 1’s safety and prevent harm to self or others after signs of increased agitation. 3. Conduct an Interdisciplinary Team (IDT) meeting following the behavioral incident on 9/13/2025, despite a documented change in condition, as required by the facility’s behavioral policy. 4. Ensure the safety and security of Resident 2 and other residents present during Resident 1 and 2’s altercation on 9/15/2025 by not implementing timely interventions or protective measures. 5. Report Resident 1 and 2’s altercation on 9/15/2025 as an allegation of abuse, immediately or as soon as practicable but not longer than two hours, to law enforcement and CDPH, in accordance with the facility’s Abuse Reporting and Investigation Policy. 6. Adhere to the following policies and procedures titled Behavioral Assessment, Intervention and Monitoring and Abuse Reporting and investigation. The deficient practices resulted in Resident 1 engaging in a physical altercation with Resident 2 on 9/15/2025. During the incident, Resident 1 pushed Resident 2 twice into her wheelchair as she attempted to stand and bit Resident 2’s left pinky finger. Resident 1 was transferred via ambulance to General Acute Care Hospital (GACH) 1 on the same day for behavioral symptoms, including agitation and psychosis (loss of contact with reality). Additionally, the facility failed to report the incident of alleged abuse involving Resident 1 and 2 to CDPH and law enforcement within the required timeframes, in violation of its policies and procedures and state law. Finding: A review of Resident 1 ' s Admission Records (AR) indicated Resident 1 was admitted to the facility on 6/26/2025 and readmitted to the facility on 6/26/2025 with diagnoses that included Schizoaffective Disorder Bipolar Type  (a mental health condition that combines symptoms of schizophrenia( a mental illness that affect how person think, feel, behave, mixed symptoms such as hallucination, delusion, disorganized thinking) and bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania (highs) and depression (lows),  epilepsy (a chronic neurological condition characterized by recurrent seizures, which are brief episodes of abnormal brain activity), and Anemia (low red blood cell count).  A review of Resident 1 ' s Minimum Data Set (MDS resident assessment tool), dated 8/29/2025, indicated the Resident 1’s cognition (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) is intact.    A review of Resident 1’s History and Physical (H&P), dated 8/31/2025 indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 2 ' s AR, the AR indicated Resident 2 was admitted to the facility on 1/25/2022 and readmitted to the facility on 12/22/2025 with diagnoses that included hypertension (high blood pressure), Parkinson's disease (progressive neurological disorder that affects movement), and anxiety.    A review of Resident 2’s H&P dated 12/24/2024, indicated Resident 2 has the capacity to understand and make decisions. A review of Resident 2's MDS dated 7/3/2025, indicated Resident 2’s cognition was moderately impaired.   A review of Resident 1’s Order Summary Report as of 9/1/2025, indicated an order for Divalproex Sodium extended-release oral tablet 24 hours 500 milligrams (mg- a unit of measurement), give one tablet by mouth (PO) at bedtime for mood stabilizer related to schizoaffective disorder, started on 6/26/2025. A review of Resident 1’s Order Summary Report as of 9/1/2025, indicated an order for clozapine oral tablet 50 mg; Give one tablet by mouth (PO) one time a day for schizophrenia, started on 6/26/2025. A review of Resident 1’s Order Summary Report as of 9/1/2025, indicated an order for Non-Pharmacological Intervention- Behavior: document every shift while on psychotropics, started on 7/18/2025. A review of Resident 1’s Order Summary Report as of 9/1/2025, indicated an order to transfer Resident 1 to the General Acute Care Hospital (GACH) for behavioral management on 9/15/25.   A review of Resident 1 ' s Change of Condition (COC), dated 9/13/2025 at 10:45 PM, by licensed vocational nurse (LVN) 1 indicated Resident 1 was pacing in the hallway by the nursing station and cursed and yelled at staff most of morning. The COC indicated Resident 1 was irritable and argumentative when approached by staff. The COC indicated at noon Resident 1 was quiet with some irritability still present. A review of Resident 1' s Nurse’s Note, dated 9/13/2025 at 11:44 PM, indicated Resident 1 was observed being irritable and cursed at staff during the start of the shift (11:30 PM to 7 AM). A review of Resident 1’s Nurse’s Note, dated 9/14/2025 at 6:42 AM indicated Resident experienced multiple episodes throughout the night of repeatedly walking back and forth to the nursing station. A review of Resident 1's Nurse’s Note, dated 9/14/2025 at 11:04 PM, indicated Resident 1 had episodes of being argumentative when talking and jumping from one subject to another. A review of Resident 1’s Nurse’s Note dated 9/15/2025 at 7:13 AM indicated Resident 1 had multiple episodes throughout the night of repeatedly walking back and forth to the nursing station.   A review of Resident 1 's Nurse’s Note, dated 9/15/2025 at 2:56 PM indicated Resident 1 had episodes of talking nonstop in a low voice.    A review of Resident 1’s Nurse’s Note dated 9/15/2025 at 10 PM indicated Resident 1 was being monitored for irritability, argumentativeness, verbal aggression, cursing and yelling at others, and skipping meals. The Note indicated Resident 1 had a previous incident on the same day at 7:35 PM on 9/15/25, involving Resident 2, in which Resident 1 was verbally aggressive towards Resident 2 on the facility’s patio while Resident 2 was watching television in her wheelchair, as reported by Registered nurse (RN) 1. The Note indicated Resident 1 was placed on hourly behavioral monitoring.  A review of Resident 1's “Transfer Form” dated 9/15/2025 at 10:43 PM, documented by RN 1, indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) for behavioral symptoms of agitation, psychosis, verbal aggression, and yelling at staff and other Residents.   A review of Resident 1's "Hospital Progress Note" provided by the facility from GACH 1, dated 9/16/2025, indicated Resident 1 was admitted with the chief complaint of agitation. The Note indicated Resident 1’s diagnosis was acute exacerbation of schizoaffective schizophrenia. The Note indicated Resident 1 was agitated and yelling. A review of Resident 1’s "Hospital Progress Note" provided by the facility from GACH 1, dated 9/16/2025 at 7 PM and documented by Psychiatrist indicated Resident 1 stated facility staff were making fun of Resident 1 “and painted my nails, calling me “faggot.” The note indicated Psychiatrist was told by the facility that Resident 1 suddenly punched a staff member and kicked a peer. The Note indicated Resident 1 was “very irritable and labile and relatively aggressive verbally.” The Note indicated Resident 1 verbalized hearing both male and female voices and reported that they were conspiring against Resident 1. The Note indicated Resident 1 was paranoid, suspicious, irritable labile, and had major mood swings.   During an interview on 9/18/2025 at 1:30 PM with Resident 2, Resident 2 stated on 9/15/2025 at around 7:30 PM, she was in her wheelchair in the patio with Resident 3 and Resident 4 when Resident 1 walked into the patio. Resident 2 stated Resident 1 started yelling and shouting at her. Resident 2 stated she tried to stand up from her wheelchair, but Resident 1 pushed her back down to her wheelchair two times, then Resident 2 bit her left pinky finger. Resident 2 stated Resident 3 intervened and then Staff 2 came and escorted Resident 1 out of the patio. Resident 2 stated she was familiar with Resident 1 and noticed his behavior had changed within the last 2 to 3 days, such that Resident 1 became more aggressive and yelled at staff and other residents. Resident 2 stated she reported the incident to RN 1, LVN 1, Staff 1, and Staff 2. Resident 2 stated the social worker, DON, and the Administrator (ADM) did not visit her after the incident on 9/15/25 and did not acknowledge the incident. Resident 1 stated being yelled at and bitten by Resident 1 made her upset.    During an interview on 9/18/2025 at 1:50 PM with Resident 3, Resident 3 stated that on 9/15/2025 at around 7:30 PM, he was on the facility patio with Resident 2 and Resident 4 when Resident 1 walked onto the patio. Resident 3 stated Resident 1 started yelling and shouting at Resident 2 and pushed her down into Resident 2’s wheelchair, and then Resident 1 bit Resident 2’s finger. Resident 3 stated the social worker, the DON, and the ADM did not visit him after the incident to find out what happened.  During an interview on 9/18/2025 at 1:55 PM with Resident 4, Resident 4 stated on 9/15/2025 at around 7:30 PM, while on the facility patio with Resident 2 and Resident 3, Resident 1 walked onto the patio and shouted at them. Resident 2 asked Resident 1 to be quiet but Resident 1 grabbed Resident 2 and pushed Resident 2 down into Resident 2’s wheelchair. Resident 4 stated Resident 3 intervened and that’s when the staff came. Resident 2 stated the social worker, the DON, and ADM did not visit her after the incident to find out what happened.   During an interview on 9/18/2025 at 2:56 PM with Staff 1, Staff 1 stated on 9/15/2025 at around 7:30 PM, Resident 1 was yelling and screaming in the patio, so Staff 1 went outside the patio and observed Resident 1 yelling at Resident 2. Staff 1 stated Resident 3 was present between Resident 2 and Resident 1. Staff 1 stated Resident 2 reported to her that Resident 1 hit her. Staff 1 stated RN 1 was there. Staff 1 stated that since RN 1 was there during the incident, Staff 1 assumed RN 1 would report the incident to CDPH and a law enforcement agency.    During an interview on 9/18/2025 at 3:15 PM with RN 1, RN 1 stated on 9/15/2025 at around 7:30 PM she heard Resident 1 yelling and screaming at the patio, so RN 1 went outside the patio and  observed Resident 1 yelling at other residents including Residents 2 and 3. RN 1 stated Resident 2 reported to her that she was upset because Resident 1 disrupted their TV time. RN 1 stated she informed the DON and did not report the incident to CDPH since the incident was a verbal altercation, and she did not see any physical altercation. RN 1 stated she did not create a change in condition since Resident 1 had the same behaviors (yelling and being aggressive) on 9/13/2025 and it was consistent with Resident 1’s ongoing behavior. RN 1 stated she did not initiate a care plan regarding the incident between Resident 1 and Resident 2.    During an interview on 9/18/2025 at 3:15 PM with Staff 2, Staff 2 stated that on 9/15/2025 at around 7:30 PM, Staff 2 heard Resident 1 yelling and screaming in the patio and when Staff 2 arrived, Staff 2 observed Resident 1 yelling at Resident 2 and that they were having a verbal altercation. Resident 3 was there standing between Resident 2 and 1. Staff 2 stated he escorted Resident 1 to his room. Staff 2 stated any resident altercation should be reported to CDPH.  A review of Resident 2’s active care plans indicated no documented evidence regarding the alleged abuse between Resident 1 and Resident 2 on 9/15/2025. A review of Resident 2’s Progress notes from 9/1/2025 to 9/17/25 indicated no documented evidence of the alleged abuse between Resident 1 and Resident 2 on 9/15/25. During a concurrent interview and review on 9/19/2025 at 11:42 AM with the DON, Resident 1’s medical records from 9/13/2025 to 9/15/2025 were reviewed. The DON stated there were no Interdisciplinary Team (IDT) meetings conducted after Resident 1’sincreased aggressive behaviors that started on 9/13/2025. The DON stated an IDT should have been conducted after Resident 1’s COC in accordance to the facility’s P&P for abuse. During a concurrent interview and record review on 9/19/2025 at 11:51 AM with the DON, Resident 1’s COC and care plans were reviewed. The DON stated no COC or care plan was initiated for the 9/15/2025 incident between Resident 1 and Resident 2. The DON stated that based on the facility’s P&P for abuse, RN 1 should have created a COC and initiated a care plan. The DON stated