Health inspection·July 30, 2025

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. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion CCR §72523(a) 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 6/9/2025, during an annual recertification survey, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Resident 23 assaulted Resident 233 unprovoked. During an investigation of the abuse allegation the CDPH identified the facility failed to: 1. Provide Resident 233 with 1:1 (staff members provide dedicated, individualized attention to a single resident) monitoring to prevent Resident 233 from wandering into Resident 23's room. 2. Implement its policy and procedure (P&P), titled, "Resident Rights," which indicated the facility will protect a resident's right to be free from abuse. As a result on 5/31/2025 at 6:35 p.m., Resident 233 unsupervised, wandered into Resident 23’s room and Resident 23 struck Resident 233 on the face. Resident 233 sustained a right cheek abrasion (injury to the skin's surface resulting from friction or impact), right orbital (socket of eye that protects the eyeball) discoloration, and a nosebleed. Resident 23 a-56-year-old male was initially admitted to the facility on 10/27/2015 and readmitted on 5/20/2025. Resident 23’s diagnoses included schizoaffective disorder (a mental illness that can negatively affect thoughts, mood, and behavior), antisocial personality (mental health condition characterized by a persistent pattern of disregard for the rights of others often leading to reckless or criminal behavior), and amnestic disorder (significant memory loss affecting the ability to recall past events and form new memories that result from substance abuse and brain injury) due to known alcohol dependence and traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). A review of Resident 23's Social Service Discharge Summary and Recommendations for Aftercare notes from a general acute care hospital (GACH 1), dated 5/20/2025, indicated Resident 23 had a history of severely, physically assaulting a peer because the peer refused to share a lighter (facility unspecified). The notes indicated Resident 23 stated he suffered from memory loss, remained isolated and guarded (cautious, reserved and untrusting), and exhibited limited ability to tolerate conflict as seen by him striking a peer for "bumping" into him (facility unspecified). The notes indicated Resident 23 continued to exhibit poor impulse control and minimal responses to provided interventions. The Social Service Discharge Summary and Recommendations for Aftercare notes indicated Resident 23 took advantage of his lower functioning peers. A review of Resident 23's History and Physical (H&P), dated 5/21/2025, indicated Resident 23 was unable to make medical decisions. A review Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025 indicated Resident 23's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were moderately impaired. The MDS indicated Resident 23 did not have any impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. The MDS indicated Resident 23 was independent with eating, needed set up assistance for oral hygiene, Needed supervision or touching assistance for toileting hygiene, upper body dressing, and moderate assistance for bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 23 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). A review of Resident 23's Physician's Order Summary Report dated 5/20/2025 - 5/31/2025, indicated the following: 1. Hydroxyzine Pamoate (medication used to treat anxiety) capsule 50 milligram (mg- unit of mass) one tablet by mouth every 12 hours as needed for anxiety disorder for 14 days manifested by (m/b) inability to relax as evidenced by restlessness, dated 5/20/2025 to 6/3/2025. 2. Monitor behavior episodes of anxiety disorder m/b inability to relax as evidenced by restlessness dated 5/20/2025. 3. Olanzapine (medication used to treat mental health condition characterized by severe and persistent disruptions in thought, perception, emotion, and behavior) dated 5/20/2025 indicated give 30 mg by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food. The order was discontinued on 5/28/2025. 4. Olanzapine 15 mg tablet to give two tablets by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food. 5. Monitor behavior of schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025. A review of Resident 23's Medication Administration Record (MAR- record of medications administered to the residents) from 5/1/2025 to 5/31/2025, indicated the following: 1. Resident 23 had an episode of mood swing on 5/30/2025 and another episode on 5/31/2025 during the day shift (7:00 a.m. to 3:00 p.m.). 2. Resident 23 had two episodes of anxiety disorder m/b inability to relax as evidenced by restlessness on 5/31/2025 during the day shift. 3. Resident 23 had two episodes of depression m/b inability to sleep during the evening shift (3:00 p.m. to 11:00 p.m.). A review of Resident 23's Change of Condition (COC) dated 5/31/2025 at 7:46 p.m., indicated Resident 23 had behavioral symptoms (e.g. agitation, psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) and was physically aggressive towards a peer (Resident 233), in Resident 23's room. The COC indicated Resident 23 stated he was attacked by another resident (Resident 233), and he retaliated by hitting Resident 233. The COC indicated Resident 23's left palm and right hand were noted with redness. The COC indicated Resident 23 was sent out to the GACH for further evaluation and treatment. A review of Resident 23's Physician's Order Summary Report dated 5/31/2025 indicated for Resident 23 to have a 1:1 observation until transferred to the GACH A review of Resident 23's Progress Note dated 5/31/2025 at 10:14 p.m., indicated Resident 23 was transferred to GACH 3 at approximately 9:00 p.m., for a psychological (related to mental or emotional) evaluation as a perpetrator of physical aggression towards a peer (Resident 233). A review of a follow up Progress Note dated 6/3/2025 at 9 p.m., indicated Resident 23 was admitted to a behavioral unit at GACH 3 for psychosis and aggressive behavior. A review of Resident 23's Interdisciplinary Team (IDT- resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) note, dated 6/2/2025 at 10:34 a.m. indicated on 6/2/2025 (date of incident indicated was an error, incident occurred on 5/31/2025) at 6:35p.m., Resident 23 had an unwitnessed resident-to-resident altercation with Resident 233. The IDT note indicated Licensed Vocational Nurse (LVN) 7 heard arguing in Resident 23's room, and upon entering the room, LVN 7 observed Resident 23 standing by the footboard of his bed, and Resident 233 was on the floor, leaning against Resident 233’s roommate’s nightstand. The IDT note indicated Resident 23 stated Resident 233 went through his door and punched him, so he (Resident 23) punched him (Resident 233) back with a closed fist. Resident 233 a 54-year-old male was admitted to the facility on 5/9/2025 with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought involving a break with reality, feelings of suspicion and distrust towards others), unspecified dementia (a progressive state of decline in mental abilities) with other behavioral disturbances (pattern of actions that disrupt a person's ability to function), and cognitive communication deficit (trouble participating in conversations). A review of Resident 233's Physician's Order Summary Report dated 5/9/2025, indicated Risperidone (medication used to treat schizophrenia) 3 mg tablet by mouth two times a day for paranoid schizophrenia m/b irritability. A review of Resident 233's MAR from 5/1/2025 to 5/31/2025, indicated to monitor Resident 233's episodes of wandering and document the resident's location every two hours starting 5/12/2025 with a discontinued date of 5/21/2025. A review of Resident 233's H&P, dated 5/12/2025 indicated Resident 233 was not capable of making medical decisions. A review of Resident 233’s Care Plan (CP) titled, “Elopement: Resident is at risk for elopement/exit seeking/wandering related to communication deficits, dementia or other cognitive behavior, psychotropic/mood altering medications, wanders aimlessly dated 5/12/2025. The CP interventions included providing 1:1 supervision, encouraging social interactions, and redirecting resident as needed. A review of Resident 233's MDS, dated 5/16/2025 Resident 233's cognitive skills were moderately impaired. The MDS indicated Resident 233 required moderate assistance with activities of daily living (ADLs- toilet transfer, bathing, toileting hygiene, personal hygiene, chair/bed-to-chair transfer) and required supervision for eating and oral hygiene. The MDS indicated Resident 233 was feeling down, depressed, or hopeless and had little interest or pleasure in doing things for several days. A review of Resident 233's Elopement and Wandering Risk Observation/Assessment dated 5/19/2025 at 10:50 p.m., indicated Resident 233 was disoriented or had periods of confusion and/or an impaired attention span. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited unsafe wandering or elopement attempts but was easily redirected. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited behaviors of agitation leading to noncompliance to care and mood swings. A review of Resident 233's COC dated 5/31/2025 at 10:01p.m., indicated Resident 233 stated he was attacked by another resident in his (Resident 23's) room. The COC indicated the nursing staff arrived and immediately separated the residents and both residents were assessed for injuries. The COC indicated Resident 233 was noted with edema (swelling) on the lip, nose and right cheek and a contusion (discolored skin due to burst blood vessels as a result of a direct blow or impact) to the right cheek. The COC indicated Resident 233 was offered Tylenol and cold compress to the affected sites for pain. The COC indicated Resident 233 occasionally moaned or groaned, had facial grimaces, was tensed, distressed, pacing, fidgeting, and had a headache. The COC indicated Resident 233 complained of pain on the top of the scalp (skin covering the head), on the side of the head, rated at 6 out of 10, on a pain rating scale (0- no pain, 3-4 -moderate pain, 5-7 severe pain and 8-10-excruciating pain). The COC indicated Resident 233 was sent to the GACH for further evaluation and treatment. A review of a late entry Progress Note dated 5/31/2025 at 6:35 p.m., indicated Resident 233 had an unwitnessed Resident-to-Resident altercation. The Progress Note indicated Resident 233 had swelling to the face including the lips, forehead and check) and bleeding from the nose. The Progress Note indicated Resident 233 was transferred to a GACH 3 via 911 at 6:45 p.m., per physician's order. A review of Resident 233's IDT note dated 6/2/2025 at 8:31a.m., indicated on 5/31/2025 at 6:35 p.m., there was an unwitnessed resident-to-resident altercation in Resident 23's room. The IDT note indicated LVN 7 observed Resident 233 lying on the floor, against a nightside in Resident 23’s room and Resident 23 standing by the foot of the bed. The IDT note indicated Resident 233 was observed with swelling to the face including the lips, forehead, and cheek, with scant (minimal) bleeding noted. The IDT note indicated LVN 7 applied a cold compress to Resident 233 and Resident 233 was placed on 1:1 for monitoring and safety precautions. The COC indicated Resident 233 had a right cheek abrasion measuring 5.0 centimeter (cm- unit of length) in length by 3.0 cm in width and a right orbital discoloration. A review of Resident 233's GACH 3 record dated 6/4/2025, indicated Resident 233’s Computed tomography (CT- medical imagining technique to obtain internal images of the body) of the head without contrast (substance taken by mouth or injection into the vein to help visualize the brain and surrounding area) indicated Resident 233 had a left frontal scalp hematoma (a solid swelling of clotted blood within the tissues). During an interview on 6/11/2025 at 5:14 p.m., with LVN 7, LVN 7 stated he was in the Nursing Station (West side) when he suddenly heard Resident 23 yelling and the door to Resident 23's room was closed. LVN 7 stated when he entered the room, he heard Resident 23 telling Resident 233 to get out of his room. LVN 7 stated Resident 23 was standing at the foot of the bed and Resident 233 was sitting on the floor close to a bedside table. LVN 7 stated Resident 233 had blood dripping from his nose. LVN 7 stated he called for assistance, and CNA 4 and CNA 9 arrived to assist, separated the residents, and tended to Resident 233 to stop the bleeding. LVN 7 stated CNA 7 arrived to assist, and indicated he called Registered Nurse Supervisor (RNS 3) LVN 7 stated he asked Resident 23 why he punched Resident 233 and Resident 23 replied Resident 233 was in his home, and he punched him. LVN 7 stated he brought the crash cart (a medical cart equipped with medical equipment and supplies used during emergencies) and grabbed a stack of gauze to stop Resident 233's bleeding from Resident 233’s nose. LVN 7 stated Resident 233 continued to bleed until the paramedics arrived. LVN 7 stated on 5/31/2025, the day of the incident, Resident 23 did not have 1:1 supervision. LVN 7 stated staff needed to walk around to check on the residents as "anything can happen anytime, so staff have to monitor the residents." During an interview on 6/12/2025 at 12:19 p.m., with CNA 9, CNA 9 stated Resident 233 was confused, wandered, in and out of residents’ rooms. CNA 9 stated Resident 233 had 1:1 supervision in the past, because he went into another resident’s room. CNA 9 stated Resident 23 was mostly to himself, would wave, but could not communicate with staff due to a language barrier. CNA 9 stated Resident 23 came from GACH 1 and had a history of being in jail for violence. CNA 9 stated when Resident 23 did not get his way such as wanting multiple packs of sugar but not giving him so much), he (Resident 23) would get aggressive. During an interview on 6/12/2025 at 4:42 p.m., with the Regional Administrator (RADM), the RADM stated once Resident 233 returned to the facility from GACH 1 (Resident 233 was placed on 1:1 for precaution because he wandered into residents' rooms. The RADM stated staff reported R