Health inspection·January 16, 2026

Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans   §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each patient, consistent with the patient rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a patient's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following —   (i) The services that are to be furnished to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. California Code of Regulations, Title 22, 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 (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 12/3/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding resident altercation. As a result of the investigation, the CDPH determined the facility failed to provide close monitoring (careful, vigilant, and systematic observation or supervision of someone or something, often to detect issues quickly, ensure safety, and make timely adjustments) for Resident 1 in accordance with Resident 1’s care plan.   This failure resulted in Resident 1 hitting Resident 2 in the face on 11/30/2025 at 3 pm. Resident 2 sustained a laceration under Resident 2’s left eye, a skin tear on the left eyelid, and a displaced fracture of the left nasal bone.   A. A review of Resident 1's Admission Record (AR) indicated Resident 1, a 38-year-old male, was admitted to the facility on 7/15/2025 with diagnoses including schizophrenia and anxiety.   A review of Resident 1’s History & Physical (H&P) dated 11/1/2025 indicated Resident 1 did not have the capacity to make medical decisions.   A review of Resident 1's Minimum Data Set (MDS) dated 10/23/2025 indicated Resident 1 had disorganized thinking.   A review of Resident 1’s untitled Care Plan Report (CPR) initiated on 10/9/2025 indicated Resident 1 had a diagnosis of schizophrenia which placed Resident 1 at risk for aggression, anxiety, and unsafe behaviors. The CPR indicated Resident 1 struck a male peer (Resident 2) without provocation due to paranoid ideation on 10/16/2025. The CPR interventions initiated on 10/16/2025 indicated Resident 1 will have Resident 1’s meals in the dining room with assigned 1:1 supervision while Resident 2 will have meals in the patio area or the TV room. The CPR indicated Resident 1 will be permitted in the patio area when Resident 1 was deemed psychiatrically stable, accompanied by Resident 1’s 1:1 staff and only when the patio is not in use by others. The CPR safety plan interventions were updated five (5) days later, on 10/21/2025, and indicated Resident 1 will be closely monitored while at the patio, by assigned Certified Nursing Assistant (CNA). The CPR indicated on 11/30/2025, while out on the patio, Resident 1 struck another resident (Resident 2) without provocation due to paranoid ideations.   A review of Resident 1’s Change of Condition Evaluation dated 10/16/2025 and timed 4 pm indicated Resident 1 showed verbal and physical aggression towards another male peer (Resident 2).   A review of Resident 1’s medical record did not indicate evidence of a behavioral evaluation or an Interdisciplinary Team (IDT) Note addressing Resident 1’s behavior and discontinuation of 1:1 supervision before 11/30/2025.   b. A review of Resident 2's AR indicated Resident 2, a 48-year-old male was admitted to the facility on 8/25/2025 with diagnoses including schizophrenia and anxiety.   A review of Resident 2’s H&P dated 8/27/2025 indicated Resident 2 had the capacity to make medical decisions.   A review of Resident 2's MDS dated 11/24/2025 indicated Resident 2's cognition was intact and Resident 2 was independent with mobility.   A review of Resident 2’s Change of Condition (COC) form dated 10/16/2025 and timed at 4 pm indicated Resident 2 was the victim involved in a resident-to-resident altercation with Resident 1 and sustained an abrasion to Resident 2’s 4th/5th dorsal right medial phalanx. The COC indicated Resident 2 complained of unspecified 3/10 pain on a pain scale of 0-10 (0 equal no pain, 10 equal the worst pain possible).   A review of Resident 2’s COC dated 11/30/2025 and timed 1:53 pm indicated Resident 2 was the victim involved in a resident-to-resident altercation with Resident 1 and sustained a one-centimeter laceration under Resident 2’s left eye and skin on Resident 2’s eyelid.   A review of Resident 2’s Nurses Notes (NN) dated 11/30/2025 and timed 2:45 pm indicated that at 12 pm on 11/30/2025, Resident 2 walked out of the building and without provocation or warning, Resident 1 struck Resident 2. The NN indicated Residents 1 and 2 were separated, and Resident 2 was transferred out of the facility to General Acute Care Hospital (GACH) 1 for wound treatment. A review of Resident 2’s Computed Tomography (CT) scan results from GACH 1’s Emergency Department (ED) dated 11/30/2025 and timed at 1:07 pm indicated Resident 2 sustained a displaced fracture of the left nasal bone.   A review of Resident 2’s GACH 1 Emergency Department Patient Discharge Instruction (EDPDI) dated 11/30/2025 indicated Resident 2 had a nasal fracture and facial contusion.   A review of Resident 2’s NN dated 11/30/2025 and timed at 8:44 pm indicated Resident 2 returned to the facility from GACH 1 on 11/30/2025 at 4:10 pm. The NN indicated Resident 2 complained of unspecified 3/10 pain on a pain scale of 0-10.    During a concurrent observation and interview on 12/3/2025 at 1:14 p.m. with the Administrator (ADM), the facility surveillance video dated 11/30/2025 was reviewed. The surveillance video indicated Resident 1 was walking towards the entrance door into the building from the outside recreation/patio area and struck Resident 2 in the upper facial area with no provocation by Resident 2. Resident 1 struck Resident 2 when Resident 2 exited the door to go out to the recreation area. There was no evidence that Resident 1 was closely monitored by staff. The ADM stated Resident 1 was no longer on 1:1 supervision and Resident 1’s 1:1 supervision was discontinued based on staff discretion and did not require a Physician’s Order (PO).   During an interview on 12/3/2025 at 3:39 pm with Mental Health Worker 1 (MHW 1), MHW 1 stated the incident between Residents 1 and 2 on 11/30/2025 happened quickly, and when MHW 1 came out of the Activity Room, Resident 2 was already on the ground. MHW 1 stated MHW 1 observed Resident 2’s face was red. MHW 1 stated Resident 1 had very little understanding of Resident 1’s diagnosis and symptoms and Resident 1 was unable to distinguish if the voices Resident 1 heard were real.  MHW 1 stated Resident 1 stated Resident 1 did not know why Resident 1 struck Resident 2.  MHW 1 stated Resident 1 had a history of hearing voices and responding to internal stimuli. MHW 1 stated Resident 1 believed people were saying things to Resident 1.  MHW 1 stated Resident 1 had previously stated to staff “they’re talking s_ _ t, it’s okay but, they’re talking s _ _ t.”   During a concurrent observation and interview on 12/3/2025, at 4:23 pm with Resident 2, Resident 2 was alert. Resident 2 stated Resident 2 was attacked by one of the “inmates” for no reason on 11/30/2025 at 12 pm.  Resident 2 stated Resident 2 kicked Resident 1 off Resident 2 because Resident 1 knocked Resident 2 down when Resident 1 attacked Resident 2 by surprise.  Resident 2 stated Resident 2 just walked past Resident 1.   During an interview on 12/3/2025 at 4:36 pm with CNA 1, CNA 1 stated CNA 1 was currently providing 1:1 supervision to Resident 1. CNA 1 stated Resident 1 was unpredictable and would swear and get angry unprovoked. CNA 1 stated Resident 1 was very paranoid and suspicious of others.     A review of the facility’s Policy and Procedure (P&P) titled, Care Planning,” dated 10/1/2023 indicated a Comprehensive Care Plan will be developed for each resident based on their individual assessed needs. The P&P indicated, “Each resident’s Comprehensive Care Plan will describe…services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.” The P&P indicated the IDT will revise the Comprehensive Care Plan as needed, as dictated by changes in the resident’s condition and to address changes in behavior and care of the resident. The facility failed to provide close monitoring for Resident 1 in accordance with Resident 1’s care plan.   This failure resulted in Resident 1 hitting Resident 2 in the face on 11/30/2025 at 3 pm. Resident 2 sustained a laceration under Resident 2’s left eye, a skin tear on the left eyelid, and a displaced fracture of the left nasal bone. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.