Health inspection·June 13, 2025

42 CFR § 483.12 Freedom from Abuse, Neglect, and Exploitation 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. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 42 CFR § 483.21 – Comprehensive person-centered care planning (b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: 22 CCR § 72311 Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 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 § 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 CCR § 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 4/21/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging resident to resident abuse. On 5/2/2025, CDPH conducted an unannounced visit at the facility to investigate the FRI’s allegation of abuse. Based upon observation, record review, and interviews, CDPH determined that the facility failed to: 1. Ensure Resident 1 was free from physical abuse by Resident 2. 2. Implement the facility's Procedure and Policy (P&P) titled, "Individual (care) Plan", dated 3/22/2024 that indicated “an individual plan will be developed when the individual served has co-occurring disorders ……. the Individual Plan specifically addresses those issues in an integrated manner with the active participation of the individual served and the program staff.” by developing and implementing a care plan for each element of care to address Resident 2’s resistance to being redirected, episodes of agitation, poor impulse control, yelling and screaming when his needs were not met immediately, and interventions to address Resident 2’s history of wandering into other resident’s rooms. 3. Implement the facility’s P&P titled, “Abuse Prevention and Reporting” dated 11/15/2024, which indicated “resident to resident abuse was aggressive or inappropriate behavior…the facility is committed to protect the physical and emotional well-being of every resident and any form of mistreatment of residents including but not limited to abuse and neglect.” As a result, Resident 2 (male) entered Resident 1’s (female) bathroom while Resident 1 was sitting on the toilet with her pants down, and punched Resident 1 on the right cheek, leaving a red mark on Resident 1’s right cheek. Resident 1 felt mad, nasty, and embarrassed that a man (Resident 2) was in her (Resident 1’s) female bathroom while her pants were down during the physical altercation. A review of Resident 2’s Admission Record, indicated Resident 2, a 68-year-old male, was admitted to the facility on 5/28/2022 with diagnoses of schizoaffective disorder, benign prostatic hyperplasia (BPH), and overactive bladder. During a review of Resident 2’s Psychiatric Progress Notes dated 3/5/2025, the Progress Notes indicated Resident 2 was resistant to being redirected, had episodes of agitation, poor impulse control, yelling and screaming when his needs were not met immediately. The Progress Note indicated Resident 2’s mood was irritable with angry outbursts. A review of Resident 2’s Minimum Data Set (MDS) dated 3/7/2025, indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 experienced hallucinations and delusions. The MDS indicated Resident 2 had verbal behavioral symptoms directed towards others including threatening, screaming and cursing. A review of Resident 2’s undated care plan titled “Mental Health Recovery: Resident 2 presented with a history of multiple psychiatric hospitalizations with a diagnosis of schizoaffective disorder, and paranoid delusions”, indicated the care plan goal was Resident 2 would demonstrate a reduction in aggressive behavior by utilization of appropriately engaged behavior (AEB- observable actions or participation in activities that are considered suitable or fitting for a specific context or situation) adaptive coping strategies. The care plan interventions included implementing a safety plan (unspecified plan) to closely monitor Resident 2 and minimize any triggers for aggression. A review of Resident 1’s Admission Record, indicated Resident 1, a 65-year-old female, was admitted to the facility on 6/18/2024 with diagnoses of schizophrenia and major depressive disorder. A review of Resident 1’s MDS dated 3/28/2025, indicated Resident 1 was cognitively intact and had no behavioral symptoms. A review of Resident 1’s Post Event Assessment Form dated 4/19/2025, indicated Resident 1 went to the nurses’ station on 4/19/2025 at 2 p.m., and reported she had been hit by a male resident (Resident 2). Resident 1 was assessed and was noted to have slight redness on her right cheek. The Post Event Assessment Form indicated Resident 2 reported he had not realized he was in the wrong room and when he realized the restroom was occupied, he tried to use the trash can in the restroom to urinate, but Resident 1 did not allow him to take the trash can. The Post Event Assessment Form indicated Resident 2 expressed remorse for the incident with Resident 1 (although Resident 2 did not admit to hitting Resident 1). The assessment indicated Resident 1 had pain in her left cheek. A review of Resident 1’s Interdisciplinary (IDT) Team Note dated 4/21/2025, indicated on 4/19/2025, Resident 1 was struck in the face by a male peer (Resident 2) while Resident 1 was using the restroom. Resident 1 reported the male (Resident 2) entered the restroom, attempted to remove a trash can, and upon Resident 1 intervening to stop Resident 2 from removing the trash can, Resident 2 hit Resident 1 in the face, with his hand. The IDT Note indicated Resident 1 had complained of pain to the left cheek and an ice pack was provided. During an interview on 5/2/2025 at 11:36 a.m., certified nursing assistant (CNA) 2 stated Resident 2 had a history of getting very upset if things did not go his way. CNA 2 stated Resident 2 became “explosive” at times. CNA 2 stated Resident 2 frequently threatened facility staff with physical violence. CNA 2 stated Resident 2 was ambulatory and walked around freely in the facility. CNA 2 stated Resident 2 used to go into other patient’s rooms (both male and female) in the past and take their clothes. During an interview on 5/2/2025 at 12:25 p.m., housekeeper (HK) 1 stated Resident 2 did not stay in his room much. HK 1 stated Resident 2 liked to walk around a lot, Resident 2 screamed a lot and threatened to hit staff. During an interview on 5/2/2025 at 12:33 p.m., Resident 2 stated he did not remember an incident occurring with Resident 1. During an interview on 5/2/2025 at 12:45 p.m., licensed vocational nurse (LVN) 1 stated Resident 2 became agitated easily. During an interview on 5/2/2025 at 12:58 p.m., social worker (SW) 1 stated Resident 2 was one of the lower functioning (having difficulties in areas like communication, social interaction, and self-care, which can impact his ability to participate fully in society) residents on her case load and Resident 2 was forgetful and needed frequent redirection. SW 1 stated Resident 2 had a history of aggression and altercations with other residents in the past (unknown date or situation), but nothing recently until the altercation with Resident 1 (4/19/2025). During an interview on 5/2/2025 at 1:20 p.m., SW 2 stated Resident 1 was fixated on and upset that a male (Resident 2) went into her restroom. SW 2 stated Resident 2 informed her (SW 2) that Resident 2 entered the restroom and tried to take Resident 1’s trash can from the restroom but when Resident 1 grabbed the trash can from Resident 2, he struck Resident 1 in the face. During an interview on 5/2/2025 at 1:33 p.m., Resident 1 stated that on 4/19/2025 she was in the restroom with the door closed sitting on the toilet with her pants down when Resident 2 opened the door of the restroom while she was “peeing”. Resident 1 stated they (Resident 1 and Resident 2) got into a struggle over the trash can in the bathroom, when Resident 2 tried to remove it, and Resident 2 punched her in the face causing her glasses to fall off her face and then he (Resident 2) ran away. Resident 1 stated the punch in the face was painful and after she was finished using the restroom she went to the nurse’s station and told registered nurse (RN) 1what had occurred. Resident 1 stated RN 1 took a picture of her right cheek and then gave her an ice pack for the pain. Resident 1 stated she felt, “bad, nasty and embarrassed “that a man (Resident 2) was in her restroom. During a concurrent interview and record review on 5/2/2025 at 2:38 p.m., with the Director of Nursing (DON), Resident 2’s medical record was reviewed. The DON stated Resident 2 acted on impulse and became agitated easily. The DON stated in March of 2024 there was another unprovoked incident where Resident 2 hit another resident (unknown) in the cheek when the resident would not move out of Resident 2’s doorway. The DON stated there was no care plan in place anymore for Resident 2 wandering because the IDT felt as though the care plan had been resolved. The DON stated if a resident has a behavior, there should always be a care plan in place for that behavior because Resident 2 might go a while with no behavior and suddenly exhibit the behavior. The DON stated during this incident on 4/19/2025, Resident 2 punched Resident 1 after he entered Resident 1’s restroom and tried taking her trash can. The DON stated the potential outcome of residents entering other residents’ rooms (uninvited) was altercations occurring such as the one on 4/19/2025 between Resident 1 and Resident 2. The DON stated the potential outcome of a male entering a female restroom was that the female resident could feel unsafe, victimized and that her dignity was compromised. The DON stated staff had to make frequent rounds (every hour during the day and every 30 minutes between midnight and 6:30 a.m.) to ensure resident safety. During an interview on 5/2/2025 at 3:31 p.m., RN 1 stated on 4/19/2025, Resident 1 came to the nurse’s station reporting a male came into her restroom and hit her. Resident 1 pointed out Resident 2 in the hallway. RN 1 stated Resident 1’s right cheek was slightly red when she assessed her following the incident. RN 1 stated Resident 1 reported pain on her right cheek so an ice pack was given and Resident 1 was mostly “upset” that a male was in her restroom. During an interview on 5/2/2025 at 3:40 p.m., the Administrator (ADM) stated the residents, including Resident 2, are monitored by the behavioral team which works on the residents’ goals and medications. The ADM Stated that Resident 2 no longer exhibited the wandering behavior, so the resident’s goals were met, and the care plan was resolved. During a review of the facility’s policy and procedure (P/P) titled “Abuse Prevention and Reporting” dated 11/15/2024, the P/P indicated “resident to resident abuse was aggressive or inappropriate behavior by one resident towards another comprised resident-to-resident abuse.” The P/P indicated physical abuse included hitting, grabbing, and threatening gestures. During a review of the facility's P/P, titled, "Individual (care) Plan", dated 3/22/2024, the P&P indicated, "An Individual Plan will be developed with the active participation of the individual served and the program staff after the enrollment and initial assessment is completed, or as outlined by regulatory/contractual guidelines ... When the individual served has co-occurring disorders and/or significant risk factors, the Individual Plan specifically addresses those issues in an integrated manner." Based upon observation, record review, and interviews, CDPH determined that the facility failed to: 1. Ensure Resident 1 was free from physical abuse by Resident 2. 2. Implement the facility's P&P titled, "Individual (care) Plan", dated 3/22/2024 that indicated “an individual plan will be developed when the individual served has co-occurring disorders ……. the Individual Plan specifically addresses those issues in an integrated manner with the active participation of the individual served and the program staff.” by developing and implementing a care plan for each element of care to address Resident 2’s resistance to being redirected, episodes of agitation, poor impulse control, yelling and screaming when his needs were not met immediately, and interventions to address Resident 2’s history of wandering into other resident’s rooms. 3. Implement the facility’s P&P titled, “Abuse Prevention and Reporting” dated 11/15/2024, which indicated “resident to resident abuse was aggressive or inappropriate behavior…the facility is committed to protect the physical and emotional well-being of every resident and any form of mistreatment of residents including but not limited to abuse and neglect.” As a result, Resident 2 (male) entered Resident 1’s (female) bathroom while Resident 1 was sitting on the toi