Health inspection·July 17, 2025

F 609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(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. T22 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 6/5/25, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding patient abuse. As a result of the investigation, the CDPH determined the facility failed to report an allegation of verbal abuse on Patient 1 by Patient 2, within two hours to the CDPH and State Ombudsman in accordance with the facility's Policy and Procedure (P&P) titled, “Abuse Reporting and Investigation." This failure violated Patient 1's right and had the potential for delay in abuse investigation and actual physical abuse. A review of Patient 1's Admission Record (AR) indicated Patient 1, a 76-year-old female was admitted to the facility on 3/9/24 and readmitted on 9/16/24, with diagnoses that included major depressive disorder, anxiety disorder and chronic pain syndrome. A review of Patient 1's History and Physical (H&P) dated 11/25/24 indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS) dated 3/27/25 indicated Patient 1 required set up or clean-up assistance for eating, oral and toilet hygiene, shower, upper and lower dressing, and personal hygiene. A review of Patient 1's Care Plan (CP) initiated 5/25/25 indicated Patient 1 was at risk for emotional distress by physical altercation noted on 5/25/25. The CP indicated Patient 1 was hit on the right cheek by another patient while ambulating via wheelchair back to her room. The CP interventions included monitoring Patient 1 for emotional distress and pain assessment. A review of Patient 1's Physician Order (PO) dated 5/25/25 at 2:32 PM indicated transferring Patient 1 to General Acute Care Hospital 1 (GACH1) for redness to the right face and for further evaluation. A review of Patient 1's Emergency Department (ED) notes dated 5/25/25 at 1:10 PM indicated Patient 1 was seen for evaluation of right sided facial pain. The ED notes indicated Patient 1 was in a wheelchair going one way when a patient came towards Patient 1 and punched Patient 1. The ED notes indicated Patient 1 was punched in the face once by a patient at the facility. The ED notes indicated Patient 1 complained of face pain despite taking Percocet prior to arrival at the ED. A review of Patient 1's Psychiatric Follow Up Note (PFUN) dated 5/27/25 indicated the facility requested a follow up. The PFUN indicated per facility, Patient 1 was involved in an incident with another patient. The PFUN indicated Patient 1 was seen virtually with staff assistance. The PFUN indicated Patient 1 stated "fine” when Patient 1 was asked about the incident. The PFUN indicated Patient 1 stated Patient 1 was heading towards the medication cart when Patient 2 punched Patient 1 on the face (on 5/25/25). The note indicated that Patient 1 did not know why Patient 2 hit Patient 1. The PFUN indicated Patient 1 had pain, but the pain improved, and Patient 1 felt safe in the facility. A review of Patient 1's Progress Note (PN) dated 5/28/25 at 12:43 PM indicated Patient 1’s skin was reassessed by licensed staff after altercation with another patient. The PN indicated Patient 1 was noted with slight swelling to the right cheek area but refused to have LVN 1 palpate or touch the affected site. The PN indicated Patient 1 stated" it hurts" (8/10 on pain scale).” The PN indicated there was no open skin noted and possibly will have discoloration on the affected area. A review of Patient 1's Interdisciplinary Team (IDT) meeting notes dated 5/30/25 at 1:17PM indicated Patient 1 had a patient-to-patient altercation on 5/25/25. The IDT notes indicated Patient 1 was hit by another patient on the right face while propelling herself on the wheelchair. The IDT note indicated Patient 1 complained of pain 8/10 on the right cheek and noted with redness and swelling on the cheek. The IDT note indicated first aid, and cold compress was applied on Patient 1 and Patient 1 was sent to GACH 1 for further evaluation on 5/25/25. b. A review of Patient 2's AR indicated Patient 2, a 58-year-old female was admitted to the facility on 12/18/24 and readmitted on 2/25/25, with diagnoses that included anxiety disorder, end stage renal disease, lack of coordination, and hyperkalemia. A review of Patient 2's H&P dated 2/28/25 indicated Patient 2 had the capacity to understand and make decisions. A review of Patient 2's MDS dated 3/18/25 indicated Patient 2 required partial/moderate assistance for toileting hygiene, shower, lower body dressing and putting on or taking off footwear. The MDS indicated Patient 2 required supervision or touching assistance for oral and personal hygiene. A review of Patient 2's CP initiated on 5/22/25 indicated, Patient 2 initiated physical/verbal aggression on 5/22/25 with another patient (Patient 1) A review of Patient 2's PFUN dated 5/22/25 indicated the facility requested a follow-up. The PFUN indicated the facility reported an incident which involved Patient 2 with another patient. Patient 2 was seen virtually with staff assistance. When Patient 2 was asked about the incident, Patient 2 stated "okay." The PFUN indicated Patient 2 states "I do not want to talk about it. It's no one's business." PFUN indicated Patient 2 did not provide further information about the incident. PFUN indicated Patient 2 was agitated and guarded. The PFUN indicated per facility staff, Patient 2 was physically aggressive and threatened the other patient (Patient 1). A review of Patient 2's PN dated 5/22/25 at 10:00 AM indicated License Vocational Nurse 2 (LVN 2) was in the hallway on 5/22/25 completing med pass when LVN 2 heard Patient 2 initiating verbal aggression with Patient 1. The PN indicated Patient 2 started entering Patient 1's room yelling and threatening to "sock" Patient 1. The PN indicated LVN 2 asked Certified Nursing Assistant 1 (CNA 1) to block the doorway and take Patient 2 away from the room. The PN indicated CNA 1 took Patient 2 out of the room and LVN 2 ran to the room to block Patient 1 from Patient 2. The PN indicated Patient 2 charged towards the door with Patient 2’s wheelchair trying to kick the door. The PN indicated LVN 2 closed the door and blocked it, keeping both parties away from each other. The PN indicated LVN 2 notified the Administrator (Admin) of the situation between Patients 1 and 2 and was instructed to call the local Police Department (PD). The PN indicated Patient 2 continued to kick the door and stated, "I want my shirt back and you are going to stay in your room all day until I get it or I'm going to sock you in the face". The PN indicated the local PD arrived on 5/22/25 at 10:15 AM and diffused the situation. The PN indicated Patient 2 verbalized to the police officer that Patient 2 was going to sock Patient 1 in the face whether the police officers were there or not. A review of Patient 2's IDT conference note dated 5/30/25 at 12:27 PM indicated an IDT meeting was conducted on Patient 2 who had a verbal aggression on 5/22/25 to Patient 1 and a patient-to-patient altercation with another female patient (Patient 1) on 5/25/25. The IDT note indicated on 5/22/25, Patient 2 had a verbal aggression on a female patient (Patient 1). The IDT note indicated on 5/25/25 in the hallway while propelling their wheelchair on separate sides, Patient 2 punched the other patient (Patient 1) with a closed fist. During an interview with LVN 1 on 6/5/25 at 9:03 AM, LVN 1 stated any type of patient abuse should be reported within two (2) hours to the Abuse Coordinator who is the Admin, CDPH, PD, Ombudsman, patient’s primary physician and the patient’s responsible party (RP). During an interview with the Social Service Director (SSD) on 6/5/25 at 10:38 AM, SSD stated the Social Service Assistant (SSA) informed SSD on 5/23/25 that Patient 1 told her there was a verbal altercation between Patient 1 and Patient 2 on 5/22/25. Per SSD, the incident had been reported to the Admin on 5/22/25. During an interview with the SSA on 6/5/25 at 10:50 AM, SSA stated on 5/22/25 after 1:30 PM, Patient 1 said to SSA that Patient 1 had a verbal disagreement with Patient 2. SSA stated SSA followed up with LVN 2 who told her she had already started the process for the report. SSA stated, "I am a mandated reporter, if I witness any type of abuse, I need to report it to the Abuse Coordinator who is the Admin and the report needs to be made immediately or at least within 2 hours.” During an interview with the facility’s Director of Nursing (DON) on 6/5/25 at 11:20 AM, the DON stated there was a verbal abuse incident between Patient 1 and Patient 2 on 5/22/25 which was reported to the Admin. The DON stated LVN 2 heard Patient 2 screaming at Patient 1 over a t-shirt. During an interview with LVN 2 on 6/5/25 at 11:31 AM, LVN 2 stated on 5/22/25 while passing medications, LVN 2 heard Patient 1 and Patient 2 arguing over a shirt. LVN 2 stated LVN 2 witnessed CNA1 was by Patient 1's door. LVN 2 stated, LVN 2 witnessed Patient 2 going to enter Patient 1's room. LVN 2 stated LVN 2 told CNA 1 to get Patient 2 from the room and CNA 1 took Patient 2 out of the room, but Patient 2 got in the doorframe of Patient 1's room and Patient 1 was screaming that Patient 2 was trying to come inside Patient 1’s room. LVN 2 stated LVN 2 observed Patient 2 tried to kick CNA 1 and became aggressive. LVN 2 stated Patient 2 was cussing at everyone and told Patient 1 if Patient 1 did not return the shirt Patient 1 stole, Patient 2 was going to hit Patient 1. LVN 2 stated Patient 2 was verbally threatening Patient 1. LVN 2 stated Patient 1 was afraid at the moment and when the PD showed up, LVN 2 stated Patient 1 started sobbing. LVN 2 stated, even when the PD was there, Patient 2 was still yelling and threatening Patient 1. LVN 2 stated Patient 2 said Patient 2 was going to punch Patient 1 in the face whether or not the PD were present. During the same interview with LVN 2 on 6/5/25 at 11:31 AM, LVN 2 stated, the verbal altercation that happened on 5/22/25 between Patients 1 and 2 was considered abuse. LVN 2 stated there was actual physical aggression between Patients 1 and 2 on 5/25/25. LVN 2 stated the physical altercation escalated from the verbal incident on 5/22/25. LVN 2 stated the verbal incident between Patients 1 and 2 on 5/22/25 should have been reported to CDPH. LVN 2 stated LVN 2 called the Admin on 5/22/25 at around 10 AM and asked what LVN 2 needed to do. LVN 2 stated the Admin asked LVN 2 to call the local PD; PD came, assessed the situation and told facility staff PD would not be doing anything because the incident was a civil dispute. LVN 2 stated LVN 2 was a mandated reporter and should have called CDPH to report the incident. LVN 2 stated LVN 2 asked the Admin on 5/22/25 and discussed it with the DON. LVN 2 stated LVN 2 and DON did not know if an SOC341 (abuse report form) needed to be completed, but the Admin said not to fill out. LVN 2 stated, when there was an abuse case, LVN 2 needed to report to the abuse coordinator and report the incident to CDPH, Ombudsman and PD within 2 hours. During an interview with CNA 1 on 6/5/25 at 12:25 PM, CNA1 stated CNA 1 overheard both Patients 1 and 2 yelling at each other on 5/22/25. CNA1 stated Patient 1 wanted Patient 2 to come out of her room because Patient 2 was already in the doorway. CNA1 stated CNA 1 intervened by taking Patient 2 out of Patient 1's room. CNA1 stated Patient 2 grabbed hold of the bed to keep CNA1 from taking Patient 2 out of the room. CNA 1 stated Patient 2 attempted to hit Patient 1. CNA1 stated Patient 2 said Patient 2 wanted to hit Patient 1 and called Patient 1 to come outside the room while Patient 2 was waiting. CNA1 stated, for any type of abuse, a report must be done within 2 hours, and we need to inform the admin, CDPH, the ombudsman and law enforcement and charge nurse. CNA1 stated when PD came to the facility, Patient 2 was still outside Patient 1's room saying Patient 2 was going to punch and hit Patient1. During the same interview with CNA 1 on 6/5/25 at 12:25 PM, CNA 1 stated, the incident on 5/22/25 escalated to physical abuse on 5/25/25 when Patient 2 hit Patient 1 on the face. CNA 1 stated, if the incident was reported to CDPH, it would have been avoided. CNA 1 stated that the facility should have taken action to move one of the patients to the opposite side of the building, because Patients 1 and 2 were next door to each other. During an interview with the facility’s Admin on 6/5/25 at 12:50 PM, the Admin stated the Admin was not in the facility when the incident happened (5/22/25). The Admin stated a nurse (LVN 2) called the Admin on 5/22/25 and informed the Admin that Patients 1 and 2 were arguing over a shirt. The Admin stated the Admin told LVN 2 to call law enforcement if Patient 2 kept on being loud or if Patient 2 continued to go to Patient 1’s room. The admin stated, if the doors were closed and there was a patient in the room and the other patient was screaming and cursing and threatening, then that would be verbal abuse. The Admin stated the abuse was directed at Patient 1 by Patient 2 and it should have been reported to the CDPH. The Admin stated, on 5/22/25 the incident was a verbal abuse and on 5/25/25 when Patient 1 was punched by Patient 2 on the face, it became physical abuse that could have been avoided. A review of the facility’s P&P titled, "Abuse Reporting and Investigation", updated May 25 indicated, "The Facility will report ALL allegations of abuse, unless indicated below, as required by law and regulations to the appropriate agencies within 2 hours. The Facility promptly and thoroughly investigates reports of patient abuse, mistreatment, neglect, exploitation, misappropriation of patient property, or injuries of an unknown source when appropriate." A review of the facility’s P&Ps titled, "Patient to Patient Altercation," revised September 2022 indicated, "All altercations, including those that may represent patient-to-patient abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator." 3. Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation. A review of the facility’s P&Ps titled, "Patient Rights," February 2021 indicated, "Federal and state laws guarantee certain basic rights to all patients of this facility. These rights include the patient's right to: b. be treated with respect, kindness and dignity c. be free from abuse, neglect, misappropriation of property, and exploitation. The facility failed to report an allegation of verbal abuse on Patient 1 by Patient 2, within two hour