Health inspection·June 10, 2025

F600 Code of Federal Regulations, Title 42, Section 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Code of Federal Regulations, Title 42, Section 483.25(d) Accidents The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents California Code of Regulations, Title 22, Section 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. On 4/28/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a Facility Reported Incident (FRI) regarding an alleged physical abuse of Resident 2 towards Resident 1. During the investigation CDPH determined the facility failed to protect Resident 1's right to be free from physical abuse. The facility failed to: 1. Supervise Resident 1 and Resident 2, who were smoking on the patio and having an argument on 4/12/2025 at 3:45 a.m., as indicated in both residents' Smoking Assessment Form and in accordance with the facility's policy and procedure titled, "Smoking Policy-Residents." 2. Assess and monitor Resident 2 when he was restless and had an escalating behavior manifested by yelling, demanding staff provide a cigarette to smoke, and pacing back and forth at the facility's nursing station and hallways on 4/12/2025, from 12:00 a.m. to 3:30 a.m. 3. Ensure Certified Nursing Assistant (CNA) 1 knew the whereabouts of Resident 1 and Resident 2 while she was assigned to care for them on 4/12/2025. 4. Inform Resident 2's physician when Resident 2 was exhibiting behavior manifested by yelling, demanding staff give him cigarettes, pacing in the hallways, and verbalizing that a "guy was giving [him] methamphetamine (synthetic stimulant that is highly addictive)." As a result, when Resident 1 and Resident 2 were smoking unsupervised on 4/12/2025 at 3:35 a.m., Resident 2 and Resident 1 had an argument which resulted in Resident 2 punching Resident 1 multiple times on the mouth and face. Resident 1 sustained swelling and a cut/tear on the mid left corner of his lower lip. A review of Resident 1's Admission Record indicated Resident 1, a 60-year-old male, was initially admitted to the facility on 5/31/2023 and readmitted on 8/13/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and chronic obstructive pulmonary disease (COPD a chronic lung disease causing difficulty in breathing). A review of Resident 1's History and Physical (H&P) dated 8/16/2024, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, indicated Resident 1 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 1 required set up or clean-up assistance (helper sets up or cleans up) with eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair. A review of Resident 1's Smoking Assessment Form dated 2/7/2025, indicated Resident 1 "utilizes tobacco, must be supervised at all times and had to wear a protective non-flammable apron when smoking." A review of Resident 1's Body Assessment dated 4/12/2025, indicated Resident 1 had a cut on the lower lip. A review of Resident 1's Change in Condition (COC) Evaluation dated 4/12/2025 at 4:21 a.m., indicated Resident 1 was hit in the face by Resident 2 and sustained a cut/tear at the mid left corner of the lower lip. The COC Evaluation indicated Resident 1 was in distress when he reentered the facility from the patio, where he had been smoking. The COC Evaluation indicated Resident 1 stated he was hit by Resident 2 on the mouth and face after an argument with Resident 2. The COC indicated Resident 1 sustained a cut to mid-bottom corner of his lip with a minimal bleeding. The COC indicated Licensed Vocational Nurse (LVN) 1 applied ice pack to Resident 1. A review of the facility's Incident Report dated 4/12/2025 and timed at 3:45 a.m., indicated Resident 1 was smoking on the patio near the lobby at 3:45 a.m. The Incident Report indicated Resident 1 verbalized to LVN 1 that Resident 2 hit him due to an argument over a cigarette. The Incident Report indicated Resident 2 hit Resident 1 multiple times in the face and Resident 1 had lost his balance. A review of Resident 1's Care Plan, titled "Resident 1 has the potential for injury related to smoking," initiated on 4/28/2025, indicated the interventions included maintaining the resident within line of sight of personnel, supervising smoking schedule, strict implementation of smoking schedule (starts at 8 a.m. and ends at 7:30 p.m.), and maintaining safety at all times. A review of Resident 2's Admission Record, indicated Resident 2, a 50-year-old male, was originally admitted on 3/7/2025 and was readmitted on 4/8/2025 to the facility with diagnoses including bipolar disorder, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest causing impairment in daily life) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 2's MDS dated 3/18/2025, indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was independent in walking, rolling left to right on the bed, and transferring to and from bed to a chair. A review of Resident 2's Smoking Assessment Form dated 3/7/2025, indicated Resident 2 utilized tobacco, must be supervised at all times and had to wear a protective non-flammable apron when smoking. A review of Resident 2's COC Evaluation dated 4/12/2025, timed at 4:19 a.m., indicated on 4/11/2025 at 11:00 p.m., Resident 2 asked the licensed nurse at the nursing station to smoke in the patio which was facing the facility's lobby. The COC Evaluation indicated LVN 1 observed Resident 2 pacing the hallways and nursing station on 4/12/2025 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 3:30 a.m. The COC indicated at around 3:45 a.m., Resident 1 entered the facility from the patio and was distressed. The COC indicated Resident 1 stated that Resident 2 punched him in the face multiple times and Resident 1 sustained a cut with a small amount of blood on Resident 1's lip. A review of Resident 2's Care Plan titled, "Resident 2 has a behavior problem (fluctuations of emotions from pleasant to angry) related to diagnosis of bipolar disorder" initiated on 4/8/2025, indicated a goal for Resident 2 was to have fewer episodes of emotional fluctuations by review date on 7/8/2025. The Care Plan indicated the interventions included assisting the resident to develop appropriate methods of coping and interacting with others, monitoring behavior episodes of fluctuations of emotions from pleasant to angry every shift, considering time, location, time of the day, persons involved and situations. During a telephone interview on 4/28/2025, at 8:25 a.m., CNA 1 stated she was assigned to Resident 1 and Resident 2 on 4/12/2025 but did not know that they had a resident-to-resident altercation and did not remember the altercation happened the day of 4/12/2025. CNA 1 stated there were no smoking breaks for residents at night. CNA 1 stated the last daily smoking time for the residents was scheduled at 7:30 p.m. CNA 1 stated Resident 1 and Resident 2 were both ambulatory (able to walk and move around) and independent. During a telephone interview on 4/28/2025, at 9:07 a.m., LVN 1 stated Resident 2 was getting aggressive at the start of the 11 p.m. to 7 a.m. shift on 4/11/2025, at around 11:00 p.m. LVN 1 stated Resident 2 kept coming to the nursing station, demanding a cigarette to smoke, and threatening to leave the facility if he did not get a cigarette. LVN 1 stated Resident 2 was having hallucination (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) when he stated there was a "guy" giving him methamphetamine. LVN 1 stated they were able to redirect his behavior several times during the night. LVN 1 stated Resident 2 was pacing in and out of the patio and around the facility, yelling and demanding to have a cigarette. LVN 1 stated she was in the nursing station and saw Resident 1 went out to the patio to smoke but did not see Resident 2 going out to the patio. LVN 1 stated Resident 1 came inside from the patio and told her Resident 2 was trying to beat him up. LVN 1 stated Resident 1 had a cut on his lip with redness and slight swelling. During a telephone interview on 4/28/2025, at 9:30 a.m. and subsequent telephone interview, at 10:57 a.m., LVN 2 stated the incident between Resident 1 and Resident 2 happened around 3:30 a.m. to 4:00 a.m. on 4/12/2025. LVN 2 stated Resident 1 had been going out to smoke on the patio at random times during the night and carried his own cigarettes. LVN 2 stated Resident 1 was not supervised when he goes out to smoke and smokes by himself because Resident 1 "was independent and could pretty much do it on his own." LVN 2 stated on 4/12/2025 the patio was dim and the only light that could be seen was the light coming from the nursing station and the lobby. LVN 2 stated Resident 2 was agitated and had been yelling, walking around the facility and asking random staff members for a cigarette during that night (4/12/2025). LVN 2 stated LVN 1 instructed him to go back to his room and gave Resident 2 a cigarette on 4/11/2025, at 11:30 p.m. LVN 2 stated on 4/12/2025 at around 3:30 a.m., she heard a sound coming from the patio door when Resident 1 walked in with blood on his mouth while Resident 2 followed him behind. LVN 2 stated Resident 2 was talking loudly and was agitated while Resident 1 was trying to explain what happened to LVN 1. During an interview on 4/28/2025, at 12:40 p.m. the Director of Staff Development (DSD), stated she provided an in-service related to resident-to resident abuse that happened between Resident 1 and Resident 2 on 4/12/2025. The DSD stated if a resident was going to smoke outside on the patio from 3:00 a.m. to 4:00 a.m., the staff must be present to supervise and monitor the residents for safety. The DSD stated the CNAs should be making rounds every two hours to ensure the whereabouts of each resident. The DSD stated the CNAs should be aware where their assigned residents were to prevent falls, any change in condition, injury and/or elopement (the act of leaving the facility unsupervised and without prior authorization). The DSD stated residents smoking unsupervised could lead to injury and physical abuse. The DSD stated the residents (in general) were not allowed to have cigarettes in their possession because the residents could burn, hurt themselves, or hurt other residents. During an interview on 4/28/2025, at 1:10 p.m. the Director of Nursing (DON), stated residents do not smoke at night and if the residents carry a cigarette, the staff should confiscate their lighter and cigarette. The DON stated the licensed nurse should have assigned a CNA to monitor Resident 2's aggressive behavior and notify the physician to manage his behavior on 4/12/2025. The DON stated there should be staff supervising Resident 1 and Resident 2 while smoking to prevent the risk of injury. The DON stated this incident was avoidable and preventable if only the staff supervised Resident 1 when he went out to smoke in the patio, and the licensed nurse identified and managed Resident 2's aggressive behavior. A review of facility's policy and procedure (P&P), titled "Abuse, Neglect and Exploitation" (undated), indicated "Each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation." The P&P indicated the residents must not be subject to abuse from anyone in the facility, and the staff will make efforts to protect the residents. The facility will observe residents' behavior and their reaction to other residents, and train staff about appropriate interventions to deal with aggressive reactions by residents. The P&P indicated the facility will assess, monitor and develop appropriate plans of care with needs and behaviors which might lead to conflict or neglect like residents with history of aggressive behaviors to prevent abuse, neglect and exploitation of residents." A review of facility's P&P titled, "Resident Smoking," (undated), the P&P indicated "Residents who smoke will be further assessed using Resident Safe Smoking Assessment to determine if the resident would need supervision or not or will be allowed to smoke in designated smoking areas, at designated times and in accordance with the resident's care plan. The P&P indicated smoking materials of residents requiring supervision will be maintained by nursing staff. The facility failed to: 1. Supervise Resident 1 and Resident 2, who were smoking on the patio and having an argument on 4/12/2025 at 3:45 a.m., as indicated in both residents' Smoking Assessment Forms. 2. Assess and monitor Resident 2 when he was restless and had an escalating behavior manifested by yelling, demanding staff provide a cigarette to smoke, and pacing back and forth at the facility's nursing station and hallways on 4/12/2025, from 12:00 a.m. to 3:30 a.m. 3. Ensure CNA 1 knew the whereabouts of Resident 1 and Resident 2 while she was assigned to care for them on 4/12/2025. 4. Inform Resident 2's physician when Resident 2 was exhibiting behavior manifested by yelling, demanding staff to give him ciga