Health inspection·July 23, 2025

§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. §483.12(a) The facility must §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 483.21(b) Comprehensive Care Plans 483.21(b)(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 § 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. 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. 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. On 5/30/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 5 punched Resident 4 in the face while asleep in his bed. On 6/5/2025, the CDPH conducted an unannounced visit at the facility to investigate the FRI's allegations. Upon investigation, CDPH determined the facility failed to protect Resident 4's right to be free from physical abuse. The facility failed to: 1. Ensure Resident 5 did not hit Resident 4 on the face while Resident 4 was asleep on 5/29/2025 during the 11 p.m. to 7 a.m. shift (on 5/30/2025 at around 5:30 a.m.). 2. Ensure staff recognized Resident 5's aggressive behavior and labile moods (rapid and unpredictable shifts in a person's emotional state). 3. Ensure staff followed Resident 5's Care Plan titled, "Potential for physically aggressive behavior" dated 5/28/2025, by guiding Resident 5 away from source of distress (Resident 4) when Resident 5 became agitated on 5/29/2025 during the 11 p.m. to 7 a.m. shift. 4. Ensure Resident 4 and Resident 5 were separated immediately after Resident 5 hit Resident 4 on the face on 5/30/2025. 5. Ensure staff followed Resident 5's Care Plan titled, "Resident 5 had a behavior problem of bipolar disorder, manifested by fluctuations of emotions from pleasant to angry mood," initiated on 5/28/2025, protecting Resident 4's safety by removing Resident 5 from the situation and taking Resident 5 to an alternate location. 6. Follow facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation,"(undated) which indicated, "the facility must ensure the residents have the right to be free from abuse by observing resident behavior and their reactions to other residents, assessing, monitoring, and developing appropriate care plans of care for residents with needs and behavior which might lead to conflict or neglect such as residents with a history of aggressive behavior." As a result, on 5/30/2025, Resident 5 punched Resident 4 on the face while Resident 4 was asleep. Resident 4 sustained left orbital floor (floor of the left eye socket) fracture and laceration on the left eyebrow. Resident 4 was transferred to a General Acute Hospital (GACH) on 5/30/2025 and received sutures to Resident 4's laceration on the left eyebrow. A review of Resident 4's Admission Record indicated Resident 4, a 58-year-old male, was initially admitted to the facility on 11/10/2015, and readmitted on 4/17/2025, with diagnoses including hypertensive heart disease, morbid obesity, schizophrenia, and left and right knee contractures. A review of Resident 4's History and Physical (H&P) dated 4/18/2025, indicated Resident 4 had fluctuating capacity to understand and make decisions. A review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 5/8/2025, indicated Resident 4 had moderately impaired cognitive skills for daily decision making and was dependent on staff with bathing, dressing, toileting hygiene, transfer to and from a bed to chair and bed mobility. A review of Resident 4's Change in Condition (COC) Form dated 5/30/2025, and timed at 8:45 a.m., indicated on 5/30/2025, at 5:30 a.m., Resident 4 was found with five centimeters (cm) long laceration above his left eyebrow with minimal bleeding and slight swelling. A review of Resident 4's Skin Only Evaluation dated 5/30/2025, and timed at 5:45 a.m., indicated Resident 4 had a left eyebrow laceration which was measured 5.0 cm in length with 1.0 cm in width and 0.5 cm in depth, with erythema. A review of Resident 4's Care Plan titled, "Resident stated he was punched by his roommate," dated 5/30/2025, indicated the goal for Resident 4 was to be free of fear or anxiety. The Care Plan interventions included evaluating Resident 4's verbal expression of fear and providing reassurance to the resident. A review of Resident 4's Progress Notes dated 5/30/2025, and timed at 8:28 a.m., indicated the resident's physician was notified on 5/30/2025, at 7 a.m., about Resident 4's left eyebrow skin laceration and the physician ordered to transfer Resident 4 to the GACH. A review of Resident 4's GACH's Emergency Department (ED) Physician's Note dated 5/30/2025, and timed at 9:31 a.m., indicated Resident 4 had a large laceration just above the left eyebrow. The ED Physician Notes indicated the laceration on the left eyebrow was sutured and bleeding was easily controlled. The ED Physician's Note indicated an impression (clinical summary of information which is the outcome of the clinical assessment) was that Resident 4 had facial laceration, blunt head trauma (head injury caused by a sudden impact from a blunt object or surface) and fracture of left orbital floor. The ED Physician's Note indicated Resident 4 received intravenous (IV) antibiotics and recommended oral antibiotics with discharge. A review of Resident 4's Computed Tomography (CT) scan of the Orbits report dated 5/30/2025, and timed at 9:12 a.m., indicated Resident 4 had a displaced (shifted out of its normal alignment creating a gap between the broken ends) fracture of the left orbital floor. A review of Resident 5's Admission Record, indicated Resident 5 a 45-year-old male, was initially admitted to the facility on 3/12/2025, and readmitted on 5/28/2025, with diagnoses including anxiety disorder, bipolar disorder, major depressive disorder, and schizoaffective disorder. During a review of the Follow-Up Psychiatric Evaluation dated 4/25/2025, indicated Resident 5 reported hearing voices and presented as easily irritable and agitated. The Follow-Up Psychiatric Evaluation indicated Resident 5 "remained redirectable when engaged by staff." A review of Resident 5's MDS dated 5/6/2025, indicated Resident 5 had intact cognitive function and required supervision or touching assistance with bed mobility transfer from bed, bed to a chair, walking, eating, toileting hygiene, and oral hygiene. A review of Resident 5's H&P dated 5/1/2025, indicated Resident 5 was able to make decisions for activities of daily living (ADL). A review of Resident 5's COC Form dated 5/19/2025, and timed at 5:51 p.m., indicated at around 4:30 p.m., on 5/19/2025, Resident 5 was verbally aggressive with another resident (unknown) and stated, "If you don't stop talking to me, I will do something." The COC Form indicated Resident 5 was easily irritated and agitated. The COC Form indicated Resident 5 was transferred to the hospital for behavioral evaluation on 5/20/2025. A review of Resident 5's GACH's Psychiatric Evaluation Note dated 5/21/2025, at 7:58 a.m., indicated Resident 5 had been having auditory hallucinations ( hearing things that do not exist) and visual hallucinations (seeing things that do not exist and are not there). The Psychiatric Evaluation Note indicated Resident 5 was anxious, irritable and dismissive (indifferent and a little rude). A review of Resident 5's GACH Psychiatric Progress Note dated 5/26/2025, indicated Resident 5 was paranoid (a state of mind characterized by intense suspicion and distrust), delusional, impulsive (actions taken without much consideration of consequences), unpredictable, restless, anxious, and was hearing voices that were saying random words. A review of Resident 5's Care Plan titled. "Resident had a behavior problem related to schizoaffective disorder manifested by visual hallucinations, mumbling to self and talking to unseen people" initiated on 5/28/2025, indicated the interventions included: to intervene as necessary to protect the rights and safety of other residents and staff, speaking in a calm manner and removing resident from a situation or taking him to an alternate location as needed. A review of Resident 5's Care Plan titled, "Resident 5 had a behavior problem of bipolar disorder manifested by fluctuations of emotions from pleasant to angry mood," initiated on 5/28/2025, and revised on 5/29/2025, indicated the goal for Resident 5 was to have fewer episodes of fluctuations of emotions by the review date on 8/28/2025. The Care Plan's interventions included intervening as necessary to protect the rights and safety of others by diverting attention and removing the resident from the situation and taking the Resident 5 to an alternate location as needed. A review of Resident 5's Care Plan titled, "Potential for to be physically aggressive" initiated on 5/28/2025, indicated the goal was for Resident 5 not to harm self or others through the review date of 8/28/2025. The interventions included to monitor Resident 5 every shift for episodes of anxiety manifested by agitation, intervene before the agitation escalates, and guide away from the source of distress. A review of Resident 5's Medication Administration Record (MAR) dated 5/29/2025, indicated during the 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift, Resident 5 was observed mumbling to self and talking to unseen people. A review of Resident 5's COC Form dated 5/30/2025, and timed at 5:45 a.m., indicated Resident 4 had a laceration on his left eyebrow with minimal bleeding and slight swelling. The COC Form indicated Resident 4 pointed at Resident 5 and stated that Resident 5 was the person that punched him. The COC Form indicated Resident 5 denied he punched Resident 4, and "appeared calm but would not make eye contact." A review of Resident 5's Transfer Form dated 5/30/2025, timed at 10:34 a.m., indicated Resident 5 was transferred to the GACH for aggressive behavior. During an observation and interview on 6/5/2025, at 10 a.m., in the activity room, and subsequent interview with Resident 4 on 6/6/2025, at 4:30 p.m., Resident 4 was observed sitting in a recliner chair. Resident 4 was observed with purplish discoloration around his left eye and a dressing above the left eye. Resident 4 stated that on 5/30/2025, he was asleep when he was awakened when Resident 5 hit him in the face. Resident 4 stated Resident 5 punched him in the face once. Resident 4 stated after he was hit, Resident 5 remained in the room looking at him, then walked back to his bed. Resident 4 stated he did not know why he did not ask for help when Resident 5 hit him. During a telephone interview on 6/5/2025, at 2:16 p.m., Certified Nursing Assistant (CNA) 1, stated that on 5/30/2025, at 2:50 a.m., Resident 4 had been asking for water, pain pill and his television remote control. CNA 1 stated the last time she spoke to Resident 4 was at 2:50 a.m. CNA 1 stated Resident 4 had no injury on his face at 2:50 a.m. CNA 1 stated she went to Resident 4's room last on 5/30/2025, at 5:20 a.m. because Resident 4 did not sleep well. CNA 1 stated when she turned on the light in Resident 4's room she saw blood on Resident 4's left eyebrow. CNA 1 stated Resident 4 told her it was Resident 5 who hit him. CNA 1 stated Resident 4 was groggy and was in deep sleep when she woke him up to get his diaper changed. CNA 1 stated Resident 5, who was Resident 4's roommate, was quiet at that time, but was going in and out of his room and was not really sleeping in his bed that night. CNA 1 stated Resident 5 was "big and scary" and had behavioral problems. CNA 1 stated she tried to stay away from Resident 5 and just answer his call lights if the resident needed something. CNA 1 stated Resident 5 did not use his call light, and "just looked up in the ceiling and was quiet." CNA 1 stated if there was an alleged physical abuse residents should be separated right away to prevent more arguments that could lead to injury to both residents involved. During a telephone interview on 6/5/2025, at 9:15 a.m., Licensed Vocational Nurse (LVN) 1, stated the last time she had seen Resident 4 was on 5/30/2025, at 2:30 a.m. and did not observe the injury on his face. LVN 1 stated they do hourly rounds on all residents. LVN 1 stated she did not see Resident 4 at 5 a.m., because she was preparing her medication cart for medication pass. LVN 1 stated Resident 5 could walk and get up on his own and was asleep at 4 a.m. LVN 1 stated she did not see Resident 5 after 4 a.m., as she was preparing for her morning medication pass. LVN 1 stated CNA 1 notified LVN 1 at 5:20 a.m., about the laceration on Resident 4's left eye. LVN 1 stated Resident 4 had a laceration on his left eyebrow measuring 5.0 cm long. During a telephone interview on 6/5/2025, at 2:55 p.m., LVN 2 stated that CNA 1 notified her about Resident 4 's left eye laceration. LVN 2 stated Resident 4's left eye was swollen, with a laceration and blood on the left eyebrow. LVN 2 stated Resident 5 was out of his room and walking on 5/30/2025. L VN 2 stated Resident 5 was asking for his medicines on 5/30/2025, and she told him she was not assigned to him and Resident 5 walked away. During a concurrent interview and record review on 6/5/2025, at 12:28 p.m. with RN Supervisor (RNS) 1, Resident 5's electronic health record (EHR) was reviewed. RNS 1 stated on 5/19/2025, a COC was documented due to Resident 5's behavioral aggression and Resident 5 was transferred to GACH on 5/20/2025. On 5/28/2025, Resident 5 was readmitted back to the facility. RNS 1 stated, on 5/19/2025, Resident 5 was talking to himself saying, "If you don't stop talking to me, I will do something to you," and was making a stance and gestures. RNS 1 stated Resident 5 looked physically aggressive and would get easily agitated, even unprovoked. During a telephone interview on 6/5/2025, at 9:15 a.m., LVN 1, stated Resident 4 and Resident 5 were not separated right away after the alleged physical abuse because there were no male beds available and no other staff available to monitor Resident 5 at that time. LVN 1 stated she was administering medications outside Resident 4 and Resident 5's room and did not go inside the room to check on the involved residents. It was important to separate both residents right away to ensure physical abuse would not reoccur. During an interview on 6/5/2025, at 3:50 p.m., Social Worker (SW) 1, stated Resident 4 and Resident 5 should have been separated immediately to prevent physical altercation recurrence which could have led to a more serious injury. SW 1 stated they should have assigned one staff to "sit with the resident and have eyes on Resident 5 to ensure Resident 4's safety." During an interview on 6/5/2025, at 12:40 p.m. the Director of Nursing (DON), state