Health inspection·August 13, 2025

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. Freedom from Abuse, Neglect, and Exploitation 483.12 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. On 7/2/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging a resident (Resident 6) was grabbed on the neck and hit on the back of the head by another resident (Resident 7). On 7/8/2025, the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Protect Resident 6’s right to be free from physical abuse by Resident 7.  This failure resulted in Resident 7 physically abusing Resident 6. a. Resident 6 was a 57-year-old male, initially admitted to the facility on 7/4/2016 and readmitted on 1/3/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 6’s Minimum Data Set (MDS- a mandated resident assessment tool), dated 4/10/2025, indicated Resident 6’s cognition was moderately impaired. The MDS indicated Resident 6 required maximal assistance with toileting, bathing, and dressing.  A review of Resident 6’s History and Physical (H&P), dated 8/28/2024, indicated Resident 6 could make needs known but could not make medical decisions. A review of Resident 6’s Change of Condition (COC), dated 7/2/2025, indicated on 7/2/2025, Resident 6 reported to the activity aide (AA) 1 that Resident 7 grabbed his neck and hit him on the head. During an interview on 7/8/2025 at 11:44 a.m., with Resident 6, Resident 6 stated on 7/2/2025, Resident 7 grabbed him from behind, held onto the front of his neck, and hit the back of his head. b. Resident 7 was a 66-year-old male, initially admitted to the facility on 12/9/2024 and readmitted on 5/2/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder, and encephalopathy (any damage or disease that affects the brain). A review of Resident 7’s MDS, dated 6/13/2025, indicated Resident 7’s cognition was moderately impaired. The MDS indicated Resident 7 had delusions. The MDS indicated Resident 7 required supervision with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 7’s H&P, dated 5/3/2025, indicated Resident 7 did not have the capacity to understand and make decisions. A review of Resident 7’s Care Plan titled, “Behavioral Issues,” revised 5/5/2025, indicated Resident 7 had behavioral issues related to schizophrenia manifested by auditory hallucinations (sounds or voices that are no there) telling him to hurt others, schizophrenia manifested by paranoid delusions that someone will hurt him, and schizoaffective disorder manifested by sudden change in mood from pleasant to extreme anger. The interventions indicated to intervene as necessary to protect the rights and safety of others, divert attention, and remove from the situation and take to an alternate location. uring an interview on 7/8/2025 at 12 p.m., Activities Assistant (AA) 1 stated on 7/2/2025 at approximately 9:30 a.m., Resident 6 informed him Resident 7 tried to choke and hit him on the back of the head. AA 1 stated, “[Resident 7]’s behavior is usually up and down.” During an interview on 7/8/2025 at 12:11 p.m., Certified Nursing Assistant (CNA) 5 stated 7/2/2025 at an unknown time in the morning, he observed Resident 7 place his hand onto the back of Resident 6’s neck. CNA 5 stated after observing the incident, he brought Resident 6 to his room to ensure Resident 6 was okay. During an interview on 7/10/2025 at 2:11 p.m., the Administrator (ADM) stated Resident 7, like many residents in the unit, was impulsive and aggressive depending on his triggers. The ADM stated Resident 6 and Resident 7 had a prior physical altercation in March 2025, when Resident 7 hit Resident 6 in the face. The ADM stated after the first incident, both residents were immediately separated for their safety. The ADM stated Resident 6 and Resident 7 were restricted to their unit, however, there should have been enough distance kept between them to ensure no physical contact occurred. The ADM stated Resident 7 was able to be in proximity with Resident 6 and tapped Resident 6 on the back of his neck.  A review of the facility’s Policy and Procedure (P&P) titled, “Abuse Prevention and Management,” revised 5/30/2024 indicated, “The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.” The facility failed to: 1. Protect Resident 6’s right to be free from physical abuse by Resident 7.  This failure resulted in Resident 6 being physically abused by Resident 7. This violation had a direct or immediate relationship to the health, safety, or security of Resident 6 and other residents in the facility.