Health inspection·May 28, 2025

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: 42 CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CFR § 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 CFR § 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. 22 CFR § 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. On 4/16/2025, the California Department of Public Health (CDPH) received a facility-reported incident (FRI) alleging a resident (Resident 2) approached Resident 1 in a hallway and hit Resident 1 in the face without provocation. On 4/28/2025, the CDPH conducted an unannounced FRI investigation at the facility. The facility failed to: 1. Monitor Resident 2 for verbal and physical aggression, as ordered by the physician. 2. Ensure Resident 1 was free from abuse when Resident 2 hit her in the face. 3. Implement its policy and procedure (P&P) titled “High Risk Safety Monitoring,” which indicated residents who are at risk for unsafe behavior will be monitored. These failures had the potential to lead to another physical altercation between Resident 2 and other residents, including a repeat physical altercation with Resident 1. Resident 2 was a 27-year-old female, admitted to the facility on 1/13/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 2’s Minimum Data Set (MDS, a resident assessment tool), dated 1/26/2025, indicated Resident 2 occasionally exhibited hallucinations (the apparent perception of something not present) and delusions (a false belief or judgement), and occasionally exhibited disorganized thinking (e.g., unclear or illogical flow of ideas). The MDS indicated Resident 2 had cognitive impairments. The MDS indicated Resident 2 was independent with mobility while both in and out of bed and had no impairments to her upper or lower extremities. A review of Resident 2’s Change of Condition (COC) assessment, dated 4/16/2025, indicated that on 4/16/2025, Resident 2 hit Resident 1 without provocation. The COC further indicated Resident 2 verbalized a desire to hit someone again. A review of Resident 2’s physician order, dated 4/23/2025, indicated staff were to monitor Resident 2 for verbal and physical aggression and document the number of episodes. A review of Resident 2’s care plan titled “[Resident 2] was physically aggressive towards female peer,” dated 4/16/2025, indicated the goals were that Resident 2 would show no further signs of aggression towards her peers. Resident 1 was a 32-year-old female, originally admitted to the facility on 6/11/2020, and readmitted on 5/24/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1’s MDS, dated 3/9/2025, indicated Resident 1 did not have impaired cognition (difficulties with thinking, learning, remembering, and making decisions). The MDS indicated Resident 1 was independent with mobility while in and out of bed. A review of Resident 1’s assessment titled "New Pain/Pain Reassessment,” dated 4/16/2025, indicated Resident 1 complained of 4 out of 10 pain (on a scale of 0 to 10, with 10 being the most severe pain) to her face. The assessment indicated Resident 1 was offered pain medication but declined. During an interview on 4/28/2025 at 9:05 a.m., Resident 1 stated on 4/16/2025, Resident 2 hit her in the face while they were walking in the hallway. Resident 1 stated she did not know why Resident 2 hit her. Resident 1 stated she sustained pain to her face after being hit. During an interview on 4/28/2025 at 9:25 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 2 had a history of aggressive behavior towards others and could become agitated very quickly. CNA 1 stated on 4/16/2025, Residents 1 and 2 were walking in the hallway when Resident 2 hit Resident 1 unprovoked. CNA 1 stated she separated the residents and notified the charge nurse. During an interview on 4/28/2025 at 10:28 a.m., CNA 2 stated Resident 2 was aggressive with both staff and residents. CNA 2 stated Resident 2 was a safety risk to others and stated, “I even get scared of her (Resident 2) sometimes.” During a concurrent interview and record review on 4/28/2025 at 12:01 p.m., with the Director of Nursing (DON), Resident 2’s physician orders dated 4/23/2025 were reviewed. The DON stated Resident 2 had orders to be monitored for verbal and physical aggression, and staff were to document the number of episodes. The DON stated staff were to document on Resident 2’s behavior monitoring flowsheet. During a concurrent interview and record review, on 4/28/2025 at 12:04 p.m., with the DON, Resident 2’s behavior monitoring flowsheet, dated 4/2025, was reviewed. The DON stated the behavior monitoring flowsheet did not indicate staff were monitoring Resident 2 for verbal and/or physical aggression. The DON stated the purpose of the monitoring was to identify escalating behaviors and prevent additional incidents of aggression and abuse towards other residents. The DON stated monitoring was required to ensure the safety of the other facility residents. A review of the facility’s policy and procedure (P&P) titled “Preventing Resident Abuse,” revised 2023, indicated staff were to monitor residents with needs and behaviors that may lead to conflict. A review of the facility’s P&P titled “High Risk Safety Monitoring,” revised 2024, indicated it was the facility’s policy to monitor the status of residents who are at risk for unsafe behavior. The P&P indicated the licensed nurse was to monitor the resident at frequent intervals for safety and document all actions taken in the clinical record. The facility failed to: 1. Monitor Resident 2 for verbal and physical aggression, as ordered by the physician. 2. Ensure Resident 1 was free from abuse when Resident 2 hit her in the face. 3. Implement its P&P titled “High Risk Safety Monitoring,” which indicated residents who are at risk for unsafe behavior will be monitored. These violations had a direct or immediate relationship to the health, safety, or security of patients or residents.