Health inspection·May 30, 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. §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, 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. § 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 4/15/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident abuse. The facility failed to ensure Resident 9 did not physically assault (occurs when a person uses physical violence and causes injury to another person's body) Residents 7 and 8. On 3/31/2025, Resident 9 hit Resident 7 multiple times on Resident 7's face with a closed fist and pulled Resident 8's necklace and held Resident 8's neck. As a result, on 3/31/2025 Resident 7 sustained a facial (face) contusion (bruising or skin discoloration), a closed head injury (head injury that does not break through the skull and occurs when the head gets hit hard), swelling and discoloration to Resident 7's left cheek, discoloration to the left and right eyelids, and bleeding from inside Resident 7's mouth. Resident 7 experienced sudden facial pain rated six out of 10 pain (0 means no pain, and 10 means the worst possible pain felt). The facility transferred Resident 7 to General Acute Care Hospital (GACH) 1 for further evaluation due to facial and a head injury. Additionally, Resident 8 sustained redness on the left side of the Resident 8's neck. a. A review of Resident 7’s Admission Record (AR) indicated Resident 7 was a 71-year-old female who was admitted to the facility on 3/15/2022 with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities), Schizophrenia (a serious mental health condition that affects how people think, feel, and behave) and psychosis (abnormal condition of the mind that involves a loss of contact with reality). A review of Resident 7’s Minimum Data Set (MDS, a resident assessment tool), dated 3/11/2025, indicated Resident 7’s cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 7 used a wheelchair for mobility. A review of Resident 7’s Change in Condition Evaluation (COC, a sudden clinically important deviation from a resident’s baseline in physical, cognitive, behavioral, or functional domains), dated 3/31/2025, timed at 8:40 AM, indicated (on 3/31/2025) at 6:30 AM, Resident 7 was sitting in the hallway on Resident 7’s wheelchair saying, “P--a” (offensive language in Spanish) repeatedly and was swinging Resident 7’s doll. The COC indicated the doll touched Resident 9. The COC indicated Resident 9 reacted and made physical contact with Resident 7’s face by using a closed fist. The COC indicated Resident 7 had swelling and discoloration on Resident 7’s left cheek, left and right eyelids, and Resident 7 was bleeding inside Resident 7’s mouth. The COC indicated Resident 7 complained of sudden pain rated six out of 10. A review of Resident 7’s Physician’s Order (PO), dated 3/31/2025 indicated to apply an ice pack to Resident 7’s face PRN (as needed). A review of Resident 7’s Transfer Form (TF) dated 3/31/2025, timed at 1:34 PM, indicated the facility transferred Resident 7 to GACH 1 for further evaluation for facial injury and a CT (computed tomography scan, a medical imaging technique used to obtain detailed internal images of the body) scan of Resident 7’s face. The TF indicated Resident 7 was administered Acetaminophen (pain medication) 325 milligrams (mg, unit of measurement) for facial pain on 3/31/2025 at 10:30 AM. A review of Resident 7’s GACH 1 record, titled, “Emergency Department Note Physician (ENP),” dated 3/31/2025 indicated Resident 7’s chief complaint was bruising and mouth pain (unrated) to Resident 7’s face and head after being physically assaulted by another resident (Resident 9) in the facility. The ENP indicated Resident 7 reported mouth pain (unrated) due to Resident 7 being punched in the face several times (by Resident 9). The ENP indicated Resident 7 had bilateral (left and right side) facial contusions, and a closed head injury. During an observation of Resident 7’s face and concurrent interview with Resident 7, on 4/16/2025 at 8:15 AM, Resident 7 had light gray discoloration around both eyes. Resident 7 stated a guy (Resident 9) “with two hands, hit me on the face, Boom, Boom, in my eyes.” Resident 7 raised Resident 7’s left and right fists and punched the air. Resident 7 stated, “I was bleeding in the mouth.” Resident 7 stated, “It hurt.” b. A review of Resident 8’s AR indicated Resident 8 was a 69-year-old female who was admitted to the facility on 11/5/2021, with diagnoses that included dementia and bipolar disorder (a mental disorder with periods of depression [serious illness that negatively affects how one feels, thinks and acts] and periods of elevated mood). A review of Resident 8’s MDS, dated 1/28/2025, indicated Resident 8’s cognition was severely impaired. A review of Resident 8’s COC, dated 3/31/2025, timed at 7:37 AM, indicated (on 3/31/2025) at 6:33 AM, Resident 8 was standing in the hallway close to the nurse’s station. The COC indicated another resident [Resident 9] came from behind and pulled Resident 8’s shirt and necklace, causing Resident 8’s necklace to break, and held Resident 8 around Resident 8’s neck. The COC indicated Resident 8 had redness on Resident 8’s left side of the neck and first aid was applied (no specific treatment indicated). c. A review of Resident 9’s AR indicated Resident 9 was a 74-year-old male who was admitted to the facility on 2/4/2025, with diagnoses that included dementia and bipolar disorder. A review of Resident 9’s MDS dated 2/8/2025 indicated Resident 9’s cognition was severely impaired. The MDS indicated Resident 9 used a walker and had no impairment to both lower and upper extremities. A review of Resident 9’s COC, dated 3/31/2025, timed at 6:30 AM indicated Resident 9 had a resident-to-resident altercation (fight between two residents) and Resident 9 made physical contact, using closed fists, with another resident’s [Resident 7] face. A review of Resident 9’s Progress Notes (PN), dated 4/1/2025, timed at 9:57 AM, indicated on 3/31/2025 at 6:30 AM, Resident 9 had an altercation with two residents (Resident 7 and Resident 8). A review of Resident 9’s PO, dated 3/31/2025 indicated to transfer Resident 9 to GACH 1 for evaluation of aggressive behavior (act aimed at harming a person or animal or damaging physical property) manifested by hitting other residents. A review of Resident 9’s TF dated 3/31/2025, timed at 7:58 AM indicated Resident 9 was transferred to GACH 1 for behavioral symptoms that included agitation (unpleasant state of extreme arousal) and psychosis. A review of Resident 9’s GACH 1’s ENP, dated 3/31/2025 indicated Resident 9 was at risk for danger to others. The ENP indicated Resident 9 reported, “she [Resident 7] was asking for it” and I [Resident 9] was trying to “kill her [Resident 7].” During an interview on 4/15/2025 at 5:17 PM, the Director of Nursing (DON) stated abuse was defined as intentional harm to another person (physically, verbally, or mentally). The DON stated, “It was not ok” for Resident 9 to pull Resident 8’s necklace or hold Resident 8 around the neck. The DON stated, Resident 9 used a closed fist and harmed Resident 7 more than once. The DON stated Resident 9’s actions were willful, and “This was abuse.” During an interview on 4/16/2025 at 9:20 AM, Licensed Vocational Nurse (LVN) 6 stated on 3/31/2025, Resident 9 was walking by Resident 7 when Resident 7 was swinging Resident 7’s doll. LVN 6 stated, Resident 7’s doll hit Resident 9 and Resident 9 reacted by hitting Resident 7 with a closed fist three to four times on Resident 7’s face. LVN 6 stated Resident 7’s mouth was bleeding, and Resident 7 had swelling around the eyebrows, cheeks, and lips. LVN 6 stated within a minute after Resident 9 hit Resident 7, Resident 9 wheeled himself close to Resident 8, pulled Resident 8’s shirt from behind and held Resident 8’s neck. A review of the facility’s Policy and Procedure (P&P) titled, “Safety of Residents,” dated 1/1/2012 indicated the purpose of the policy was to provide a safe environment for residents and facility staff. A review of the facility’s P&P titled “Abuse – Prevention, Screening & Training Program,” July 2018, indicated, “Abuse was defined as willful, deliberate infliction of injury…with resulting physical harm, pain or mental anguish.” The facility failed to ensure Resident 9 did not physically assault Resident 7 and Resident 8. On 3/31/2025, Resident 9 hit Resident 7 multiple times on Resident 7's face with Resident 9's closed fist and pulled Resident 8's necklace and held Resident 8's neck. As a result, on 3/31/2025 Resident 7 sustained a facial contusion, a closed head injury, swelling and discoloration to Resident 7's left cheek, discoloration to the left and right eyelids, and bleeding from inside Resident 7's mouth. Resident 7 experienced sudden facial pain rated six out of 10 pain on a pain scale from 0 to 10. The facility transferred Resident 7 to GACH 1 for further evaluation due to facial and a head injury. Additionally, Resident 8 sustained redness on the left side of Resident 8's neck. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 7 and Resident 8.