Health inspection·May 9, 2025

F600 Federal Code Regulations §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. California Code of Regulations, 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, 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. California Code of Regulations, Section 72527. Patient 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 3/21/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding resident abuse. The facility failed to: Protect residents’ rights to be free from physical abuse (any intentional act causing injury or trauma to another person) for Resident 4 and Resident 5 when on 3/20/2025: a. Resident 4 grabbed Resident 5’s hair. b. Resident 5 punched Resident 4 on the face and the head. As a result, Resident 4 sustained a closed head injury and mildly comminuted (multiple bone splinters) minimally displaced right nasal bone fracture on 3/20/2025. Resident 4 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation of moderate head pain after a head injury from the physical altercation. . Resident 5 had sustained scratches on the right side of the face. a. A review of Resident 5’s Admission Record (AR) indicated the facility admitted Resident 5, a 57-year-old female on 2/27/2025 with diagnoses that included paranoid schizophrenia and major depressive disorder. A review of Resident 5’s Progress Note (PN) dated 3/20/2025 and timed at 11:54 am indicated Resident 5 sustained scratches on the right side of the face, the forehead and bleeding on top of Resident 5’s nose. The PN indicated Resident 5 continued to scream and yell towards staff. A review of Resident 5’s PN dated 3/21/2025 timed at 5:09 pm indicated Resident 5 was transferred to GACH 2 on 5150 hold (involuntary mental health evaluation and temporary detention) for evaluation. b. A review of Resident 4’s AR indicated the facility admitted Resident 4, a 77-year-old female on 2/19/2025 with diagnoses that included dementia, schizophrenia and major depressive order. A review of Resident 4’s Minimum Data Sheet dated 2/25/2025 indicated Resident 4 had moderately impaired cognition. A review of Resident 4’s Situation, Background, Assessment, Recommendation (SBAR) communication form dated 3/20/2025, completed by Licensed Vocational Nurse 1 (LVN 1) who witnessed the incident indicated Resident 4 went to Resident 5’s bed, stood at the end of the bed and held onto the footboard of Resident 5’s bed. When Resident 5 got up, Resident 4 grabbed Resident 5’s hair. A review of Resident 4’s PN dated 3/20/2025 and timed at 12:55 pm indicated CNA 1, and LVN 1 heard screaming coming from Resident 4 and 5’s room. The PN indicated Resident 4 walked toward Resident 5’s bed and started fixing the bed linens of Resident 5 while Resident 5 was sleeping. The PN indicated Resident 5 got up from bed and walked towards Resident 4. The PN indicated Resident 5 screamed, hit Resident 4 on the head with Resident 5’s fist and scratched Resident 4 on the face with Resident 5’s other hand. The PN indicated Resident 4 grabbed the hair of Resident 5. The PN indicated Resident 4 sustained a bump on the forehead, finger scratch marks on the face and bleeding from the right nostril. The PN indicated Resident 4 complained of 5/10 pain (moderately strong pain) on the face. A review of Resident 4’s Physician’s Order (PO) dated 3/20/2025 and timed at 2:36 pm indicated to transfer Resident 4 to GACH 1 for evaluation. A review of Resident 4’s PN dated 3/20/2025 and timed at 4:04 pm indicated Resident 4 was transferred to GACH 1. A review of Resident 4’s GACH 1’s Emergency Department (ED) records dated 3/20/2025 indicated Resident 4 was brought to the ED for evaluation of head pain after a head injury from an assault. The ED records indicated Resident 5 hit Resident 4 in the facility. The ED records indicated Resident 4 had a Computed Tomography (CT) of facial bones because of acute facial pain after an assault. The ED records indicated the Computed Tomography of Resident 4’s facial bones showed mildly comminuted, minimally displaced right nasal bone fracture. The ED records indicated Resident 4 received Tylenol 650 milligrams by mouth for 6/10 pain (moderately strong pain) on the face while in the ED. The ED records indicated Resident 4 was discharged back to the facility with a clinical impression of closed head injury and nasal fracture. A review of Resident 4’s PN dated 3/20/2025 and timed at 9:17 pm indicated Resident 4 returned to the facility from GACH 1. During a concurrent observation inside Resident 4’s room and interview with Resident 4 on 3/24/2025 at 10:51 am, Resident 4 was lying in bed. Resident 4 had a small brown discoloration on the right forehead. Resident 4 could not recall the altercation between Resident 4 and Resident 5 on 3/20/2025. Resident 4 stated Resident 4 had 4/10 pain (moderate pain) on the nose. During an interview with CNA 1 on 3/24/2025 at 11:20 am, CNA 1 stated CNA 1 was the assigned CNA to care for Resident 4 on 3/20/2025. CNA 1 stated on 3/20/2025 before 11 am, CNA 1 heard yelling coming from Resident 4 and 5’s room. CNA 1 stated CNA 1 ran into Resident 4 and 5’s room and saw Resident 4 grabbing Resident 5’s hair. CNA 1 stated CNA 1 removed and redirected Resident 4 to the dining room. CNA 1 stated CNA 1 saw blood on Resident 4 and 5’s faces. CNA 1 stated “all residents with aggressive behavior should be monitored closely to prevent incidents of physical altercation.” During an interview with LVN 1 on 3/24/2025 at 11:47 am, LVN 1 stated on 3/20/2025 at around 11 am, LVN 1 heard screaming coming from Resident 4 and 5’s room. LVN 1 stated LVN 1 ran into Resident 4 and 5’s room and saw Resident 5 stood at the end of Resident 5’s bed and Resident 4 grabbed Resident 5’s hair. LVN 1 stated LVN 1 separated Residents 4 and 5. LVN 1 stated Resident 4 sustained finger scratch marks on the right side of Resident 4’s face, a small bump on the forehead and bleeding from the right nostril. LVN 1 stated Resident 4 complained of 5/10 pain on the face. LVN 1 stated Resident 5 had bleeding on top of Resident 5’s nose and scratches on the right side of the face and forehead. LVN 1 stated Resident 4 was transferred to GACH 1 for medical evaluation. LVN 1 stated on 3/20/2025 at 9:17 pm, Resident 4 returned to the facility with a CT scan result indicating Resident 4 sustained a minimally displaced mildly comminuted fracture of the right nasal bone. LVN 1 stated Resident 5 was transferred to GACH 2 on 3/21/2025 on a 5150 hold. LVN 1 stated all facility staff need to work as a team to ensure the safety of the residents and to prevent incidents of resident-to-resident altercation or any type of abuse. During an interview with the facility’s Administrator (ADM) on 3/24/2025 at 2:30 pm, the ADM stated, the ADM was the abuse coordinator of the facility. The ADM stated, LVN 1 notified the ADM on 3/20/2025 at 11:30 am of the altercation between Residents 4 and 5 that occurred on 3/20/2025 before 11 am. The ADM stated the result of the facility’s investigation indicated Residents 4 and 5 had a resident-to-resident altercation that became physical and both residents sustained physical injuries. The ADM stated all staff should be educated and trained on abuse prevention and abuse reporting to ensure safe interactions with residents. During a telephone interview with the facility’s Director of Nursing (DON) on 3/26/2025 at 11:42 am, the DON stated all residents had the right to be protected from any kind of physical altercation, assault and abuse while residing in the facility. A review of the facility’s Policy and Procedure (P&P) titled, “ Abuse Prevention Program,” revised 8/2006 indicated, “The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.” As a result of the investigation, the CDPH determined the facility failed to protect Resident 4’s right to be free from physical abuse. As a result of these violations, Resident 4 sustained a closed head injury and mildly comminuted minimally displaced right nasal bone fracture on 3/20/2025. Resident 4 was transferred to GACH 1 for evaluation of moderate head pain after a head injury from an assault. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 4 and 5.