Health inspection·August 22, 2025

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. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. California Code of Regulations, Title 22, Section 72311. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 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. 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, Title 22, 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 7/8/2025 at 11:30 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate a complaint regarding abuse involving Resident 1. The facility failed to: Protect resident’s rights to be free from physical abuse (any intentional act causing injury or trauma to another person) for Resident 1 as indicated in the facility’s Policy and Procedure (P&P) titled, “Abuse Prevention and Prohibition Program,” when: On 4/11/2025, Resident 2 hit Resident 1 in the face during a staff-supervised activity, and staff did not revise Resident 2’s care plan interventions to decrease Resident 2’s physical altercations with peers. On 5/7/2025, Resident 2 went inside Resident 1’s room, and staff did not redirect Resident 2 back to Resident 2’s room, Resident 2 hit Resident 1 in the face after Resident 2 entered Resident 1’s room. On 6/27/2025, Resident 2 went inside Resident 1’s room again and restrained and hit Resident 1 while Resident 1 was lying in bed. As a result, Resident 1 was physically assaulted three times by Resident 2. Resident 1’s rights were violated and Resident 1 experienced emotional distress, feelings of insecurity, and felt unsafe in the facility. a. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, a 33-year-old male, on 12/13/2024 with diagnoses that included schizophrenia. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 3/28/2025, indicated Resident 1’s cognition was intact, and Resident 1 was independent on staff with activities of daily living (ADLs) and with walking. A review of Resident 1’s Interdisciplinary (IDT) note, dated 4/15/2025 and timed at 10:39 am, indicated Resident 2 hit Resident 1 in the face during supervised patio activities on 4/11/2025. A review of Resident 1’s Change in Condition Evaluation (CIC), dated 5/7/2025 and timed at 12:35 pm, indicated Resident 1 came out of Resident 1’s room and stated another resident came into Resident 1’s room and hit Resident 1 once in the face. A review of Resident 1’s IDT note, dated 6/27/2025 and timed at 9 pm, indicated Resident 1 was “struck by a male peer [Resident 2] who was experiencing a psychotic break” and the incident was unprovoked by Resident 1. A review of Resident 1’s untitled Care Plan Report (CP), initiated on 4/14/2025 and revised on 5/7/2025 and on 6/27/2025, indicated Resident 1 had a problem with psychosocial well-being related to emotional distress and feelings of insecurity following an alleged incident of being hit by another resident [Resident 2] on 4/11/2025. The CP indicated, on 5/7/2025, Resident 1 was struck by a peer [Resident 2] inside Resident 1’s room. The CP indicated, on 6/27/2025, Resident 1 was physically assaulted by a male peer [Resident 2] without provocation. The CP further indicated Resident 1 was not moved to a different room and was not removed from Resident 2’s line of sight. A review of Resident 1’s Physician’s Progress Note (PPN), dated 6/27/2025 and timed at 11:57 pm, indicated Nurse Practitioner (NP) 1 received a report from nursing staff that Resident 2 hit Resident 1 while Resident 1 was in bed. A review of Resident 1’s Census List (CL), indicated Resident 1 had been in room 25-C since 3/18/2025. A review of the facility floor plan indicated Resident 1’s room and Resident 2’s room were across the hall from each other, and Resident 1 was in Resident 2’s line of sight. b. A review of Resident 2’s AR, indicated the facility admitted Resident 2, a 29-year-old male, on 11/1/2024 with diagnoses which included schizoaffective. A review of Resident 2’s MDS, dated 5/17/2025, indicated Resident 2’s cognition was intact, and Resident 2 was independent with ADLs and with walking. A review of Resident 2’s untitled CP, initiated on 5/7/2025 and revised on 6/7/2025, indicated Resident 2 hears voices which contributed to Resident 2’s physical aggression. The CP indicated Resident 2 heard voices that peer [Resident 1] had urinated in Resident 2’s food so Resident 2 went to male peer’s room and struck male peer on 5/7/2025. The CP indicated Resident 2 heard voices which led to an unprovoked assault on a male peer on 6/27/25. The CP interventions indicated Resident 2 was placed on one-to-one supervision for only 24 hours on 5/8/2025. A review of Resident 2’s IDT note, dated 5/7/25 and timed at 4 pm, indicated Resident 2 heard voices that peer had urinated in Resident 2’s food so Resident 2 went to male peer’s room and struck male peer. Resident 2 was placed on one-to-one supervision for 24 hours. A review of Resident 2’s IDT note, dated 6/27/25 and timed at 9 pm, indicated Resident 2 had an episode of physical aggression towards a male peer and Resident 2 was placed on one-to-one supervision to ensure the safety of other residents. A review of Resident 2’s CIC Evaluation, dated 6/27/25 and timed at 11:45 pm, indicated Resident 2 was physically aggressive to Resident 1 while inside Resident 1’s room. A review of Resident 2’s Nurses Notes (NN), dated 6/27/25 and timed at 11:57 pm, indicated Resident 2 was witnessed by Licensed Vocational Nurse (LVN) 2 inside Resident 1’s room holding on to Resident 1’s back while Resident 1 was in bed. The NN indicated Resident 2 was “restraining” Resident 1 and was “not allowing (Resident 1) to move or get away.” A review of Resident 2’s Physician’s Progress Note (PPN), dated 6/27/25 and timed at 11:57 pm, indicated NP 1 received a report from the nursing staff that Resident 2 hit Resident 1 while Resident 1 was in bed. The PPN indicated NP 1 ordered an antipsychotic medication to be given to Resident 2 every bedtime and for Resident 2 to be on one-to-one supervision. The PPN also indicated NP 1 ordered an emergency antipsychotic injection to be given to Resident 2 due to Resident 2’s aggression and Resident 2 being a danger to others. A review of Resident 2’s CL indicated Resident 2 had been in Resident 2’s room since 11/1/2024. During an interview on 7/8/2025 at 1:45 pm, Resident 1 stated Resident 2 had hit Resident 1 two times prior to 6/27/25. Resident 1 stated on 6/27/25, Resident 1 was asleep in bed when Resident 2 hit Resident 1 for no reason. Resident 1 stated there was another incident which happened on another day (5/7/2025) when Resident 2 went inside Resident 1’s room and hit Resident 1. Resident 1 stated there was another incident which happened two months ago (4/11/2025) when Resident 1 was watching television in the patio and Resident 2 hit Resident 1 unprovoked. Resident 1 stated he did not feel safe in the facility and did not want to be in the facility. During an interview on 7/8/2025 at 3:15 pm, the Director of Staff Development (DSD) reviewed the CL for Resident 1 and Resident 2 and stated there had been no room changes for Resident 1 and Resident 2 as indicated on the CL. The DSD reviewed Resident 2’s CP’s which addressed Resident 2’s incidents of physical aggression towards Resident 1 on 4/11/2025, on 5/7/2025, and on 6/27/2025. The DSD stated the CP interventions did not include room changes and only placed Resident 2 on one-to-one supervision for 24 hours after each incident. The DSD stated the CP interventions were not revised after Resident 2 punched a male peer in the face on 4/11/25. During an interview on 7/9/2025 at 12:02 pm, LVN 1 stated staff redirected residents and tried to keep Resident 1 and Resident 2 away from each other, but the facility only has one hallway. LVN 1 stated if Resident 1 and or Resident 2 were on one-to-one supervision, it would be easier to keep the residents away from each other. During an interview on 7/9/2025 at 1 pm, the Director of Nursing (DON) stated Resident 2 was not on one-to-one supervision before Resident 2 hit Resident 1 on 6/27/2025. The DON reviewed Resident 2’s care plans which addressed Resident 2’s incidences of physical aggression towards Resident 1 and stated the facility should have implemented other interventions like removing Resident 1 from Resident 2’s line of sight. The DON stated the facility did not keep Resident 2 from hitting Resident 1 and should have placed Resident 2 on one-to-one supervision indefinitely to prevent Resident 2 from hitting others. The DON stated Resident 2 also refused to take Resident 2’s antipsychotic medication and Resident 2’s responsible party (RP) did not give consent for Resident 2 to receive the antipsychotic medication as an injection which made it difficult to manage Resident 2’s behavior. DON stated the facility will now place Resident 2 on one-to-one supervision until the facility finds another solution to Resident 2’s physical aggression towards Resident 1. A review of the facility’s P&P titled, “Abuse Prevention and Prohibition Program,” dated 7/9/2024, indicated each resident has the right to be free from abuse and the facility is committed to protecting the residents from abuse by anyone. The P&P indicated, “The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse… Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict.” The facility failed to: Protect resident’s rights to be free from physical abuse for Resident 1 as indicated in the facility’s P&P titled, “Abuse Prevention and Prohibition Program,” when: On 4/11/2025, Resident 2 hit Resident 1 in the face during a staff-supervised activity, and staff did not revise Resident 2’s care plan interventions to decrease Resident 2’s physical altercations with peers. On 5/7/2025, Resident 2 went inside Resident 1’s room, and staff did not redirect Resident 2 back to Resident 2’s room, Resident 2 hit Resident 1 in the face after Resident 2 entered Resident 1’s room. On 6/27/2025, Resident 2 went inside Resident 1’s room again and restrained and hit Resident 1 while Resident 1 was lying in bed. As a result, Resident 1 was physically assaulted three times by Resident 2. Resident 1’s rights were violated and Resident 1 experienced emotional distress, feelings of insecurity, and felt unsafe in the facility. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.