Health inspection·July 22, 2025

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation. The Residents have 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.

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 6/16/2025 at 8:30 AM 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. During the investigation CDPH determined that the facility failed to implement the facility’s "Abuse and Neglect Prohibition Policy" to prevent and immediately report and/or no later than two hours the alleged allegation of abuse (an action that intentionally cause harm to another person) when Resident 2 hit License Vocational Nurse (LVN )1 in the chin on 6/2/2025 prior to medication pass which at this time, the facility failed to address Resident 2’s aggressive behavior and implement interventions to prevent abuse. As a result of this deficient practice Resident 2’s aggressive behavior escalated by kicking Resident 3’s wheelchair during a verbal altercation and ultimately Resident 1 on the cheek on 6/5/2025 around 2:30 PM (four and a half hours after the first alleged abuse incident) during an altercation. A review of Resident 1's Admission Record (AR), indicated the resident was admitted to the facility on 2/14/2024 with diagnoses that included depressive episodes (persistent feeling of sadness and loss of interest), dementia (a decline in mental ability, severe enough to interfere with daily life), mood disturbance (a mental health condition that primarily affects your emotional state), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 1's History and Physical Examination (HPE), dated 2/15/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment screening tool), dated 5/21/2025, indicated Resident 1's cognitive status (ability to think, remember, and reason) is moderately impaired. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance with helper) with eating, toileting, dressing, personal hygiene, and required Setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with bathing. A review of Resident 2’s AR indicated the resident was originally admitted to the facility on 4/23/2020 and readmitted on 3/5/2025 with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations (sensory experiences that appear real but are not, meaning someone might see, hear, feel, smell, or taste something that isn't actually there) and delusions (a false belief or judgment about external reality) and mood disorder symptoms, such as depression, mania), bipolar disorder (a mental health condition that causes extreme mood swings), and anxiety disorder. A review of Resident 2's HPE, dated 3/6/2025, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated 6/6/2025, indicated the Resident 2's cognitive status was moderately impaired. The MDS indicated Resident 2 required Setup and clean-up assistance with eating, personal hygiene, bathing, dressing and required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with toileting. A review of Resident 3's AR indicated the resident was originally admitted to the facility on 11/20/2023 and readmitted on 1/23/2025 with diagnoses that included dementia, psychotic disturbance (a condition where a person experiences a significant loss of contact with reality), and anxiety. A review of Resident 3's HPE, dated 1/23/2025, indicated Resident 3 was cooperative, appropriate affect, and normal judgment. A review of Resident 3's MDS, dated 4/29/2025, indicated the Resident 3's cognitively status was moderately impaired and required supervision or touching assistance with eating, personal hygiene, required partial/moderate assistance (helper does less than half the effort) with toileting and dressing, and substantial/maximal assistance (helper does more than half the effort) with bathing. A review of Resident 2’s "SBAR (Situation, Background, Assessment, and Recommendation, a communication framework used to structure conversations, especially in healthcare, to ensure clear and concise information exchange, particularly in urgent situations) Communication Form and progress note" dated 6/2/2025 timed at 9:25 PM, indicated Resident 2 punched LVN 1 on her right jaw in Resident 2's room prior to medication administration. A review of Resident 2’s SBAR Communication Form and progress note" dated 6/5/2025 timed at 10AM, indicated Resident 2 had a physical and verbal aggressiveness towards a Resident (Resident 3) and was noted to have kicked Resident 3's (while in his wheelchair) wheelchair in the hallway. A review of Resident 2's "SBAR Communication Form and progress note" dated 6/5/2025 timed at 2:50 PM, indicated while playing BINGO in the activity room Resident 2 punched the other Resident (Resident 1) on the right side of the face. A review of Resident 2's care plan (CP) for diagnosis of schizophrenia manifested by outburst of anger, revised on 6/5/2025, indicated Resident 2 had episodes of physical aggression toward staff on 6/2/2025, kicking wheelchair of another resident on 6/5/2025, and hitting another resident unprovoked on 6/5/2025. The CP did not have any intervention for how the resident will be supervised and monitored for aggressive behavior. During an interview on 6/16/2025 at 9:45 AM with Activity Staff (AS) (Witness of Resident-to-Resident abuse between Resident 1 and Resident 2). AS stated, on 6/5/2025 in the afternoon, while in the activity room during a game of "BINGO", Resident 1 was reaching for Resident 2's chips (small disc use as currency), Resident 2 then hit Resident 1 on the chin. During an interview on 6/16/2025 at 9:50 AM with the Activity Director (AD), the AD stated the altercation between Resident 1 and Resident 2 happened on 6/5/2025 around 2 PM. The AD stated, the AS reported to her that Resident 2 hit Resident 1 on the chin during a BINGO game, and she reported it immediately to the Director of Nursing (DON). The AD stated, Resident 2 was not on 1 to 1 monitoring (one staff monitoring one resident) or on frequent monitoring prior to the incident. During an interview on 6/16/2025 at 10:00 AM with the DON, the DON stated the incident between Resident 1 and Resident 2 happened on 6/5/2025 around 2 PM, both residents were separated, and Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for evaluation. The DON stated Resident 2 was not placed on frequent monitoring, or 1 to 1 sitter monitoring prior to the abuse incident with Resident 1. During an interview on 6/16/2025 at 10:50 AM with LVN 1 (LVN whom Resident 2 hit on the chin on 6/2/2025), LVN 1 stated, the incident happened on 6/2/2025 around 9 PM. LVN 1 stated, Resident 2 approached her for his medications while she was passing medications for another resident, she then told Resident 2 she could go to his room to give his medications. LVN 1 stated, when she went to Resident 2's room and about to turn on the overhead light to give him his medications, Resident 2 turned around and punched her on her right jaw. During a concurrent interview and record review on 6/16/2025 at 10:55 AM with the DON, facility document titled "SBAR Communication Form and progress note" (PN), dated 6/5/2025 timed at 10:00 AM was reviewed. The document indicated Resident 2 was noted to have kicked a Residents wheelchair in the hallway. DON stated, the incident happened on 6/5/2025 before 10:00 AM, Resident 2 kicked Resident 3's wheelchair and had a verbal altercation as they passed by each other in the hallway. During an interview on 6/16/2025 at 11 AM with the Director of Rehab (DOR), and the MDS Nurse (MDSN) (Witnesses of alleged physical and verbal altercation between Resident 2 and Resident 3 on 6/5/2025 before 10 AM). The DOR stated, the incident happened on 6/5/2025 before 10 AM. DOR stated, she was taking Resident 2 to the rehab room, Resident 2 was ahead of her in the hallway, when she turned around because the MDSN called her, she heard a loud sound and observed Resident 2 and Resident 3 was having loud verbal altercation. The DOR stated, Resident 2 told her that he kicked Resident 3 's wheelchair. The MDSN stated that he intervened with the DOR to prevent further altercation. The DOR and the MDSN both stated, they both reported the incident to the DON and the Administrator (ADM) right away. The DOR and the MDSN both stated that the policy for alleged abuse was to report the incident immediately within 2 hours to the Ombudsman, Police, and California Department of Public Health (CDPH). The MDSN stated, they should have followed up with the DON and the ADM, if it was reported to the proper agencies because they mandated reporter. During an interview on 6/16/2025 at 11:23 AM with LVN 2, LVN 2 stated she was the primary nurse for Resident 2 on 6/5/2025. LVN 2 stated, she learned about the incident between Resident 2 and Resident 3's physical and verbal altercation from the DON, the DOR and the MDSN in the morning. LVN 2 stated, she was not aware that the incident was not reported timely within 2 hours to the proper agencies. LVN 2 stated, the incident of alleged abuse allegation needs to be reported immediately to have interventions in place and to prevent recurrence of aggression, per policy. During an interview on 6/16/2025 at 12:10 PM with the DON, the DON stated, the physical and verbal altercation between Resident 2 and Resident 3 that happened on 6/5/2025 before 10 AM was reported to him. The DON stated there was no physical injury, that was why he did not report the incident to the appropriate agencies. The DON stated, looking back he should have reported the incident to the proper agencies within two hours, to protect other residents and staff in the facility by more frequent monitoring of Resident 2's behaviors. DON stated that not reporting the physical and verbal altercation between Resident 2 and Resident 3 timely within 2 hours had the potential for reoccurrence of Resident 2’s abusive behaviors that could affect other residents and staff safety and potentially could have prevented the resident-to-resident abuse between Resident 2 and Resident 1. A review of the facility's policy and procedure (P&P) titled, "Abuse and Neglect Prohibition Policy", dated 6/2022, indicated: a)the facility policy prohibit abuse, mistreatment through; prevention of occurrence, identification of possible incidents or allegations, reporting of incidents and protection of residents, b) the facility staff are doing that is within their control to prevent occurrence of abuse and mistreatment, and c) under reporting of incidents; upon receiving information concerning a report of suspected or alleged abuse and mistreatment the administrator or designee will report all alleged violations -immediately but no later than 2 hours if alleged violation involves abuse. During the investigation CDPH determined that the facility failed to implement the facility’s "Abuse and Neglect Prohibition Policy" to prevent and immediately report and/or no later than two hours the alleged allegation of abuse (an action that intentionally cause harm to another person) when Resident 2 hit LVN 1 in the chin on 6/2/2025 prior to medication pass which at this time, the facility failed to address Resident 2’s aggressive behavior and implement interventions to prevent abuse. As a result of this deficient practice Resident 2’s aggressive behavior escalated by kicking Resident 3’s wheelchair during a verbal altercation and ultimately Resident 1 on the cheek on 6/5/2025 around 2:30 PM (four and a half hours after the first alleged abuse incident) during an altercation. 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 and 3.