Health inspection·June 6, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. 42 C.F.R. § 483.40 Behavioral Health Services Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 22CCR §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. 22CCR §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. 22 CCR § 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. 22 CCR §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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. On 4/21/25, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (resident 1) was found on the floor with Resident 2 in a standing position, resting his foot on Resident 1’s head. On 4/25/2025 at 8:00 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Implement its policy and procedure (P&P) titled, “Identifying Abuse” which indicated the facility did not condone any form of resident abuse or neglect. 2. Ensure that Resident 1 remained free from abuse. 3. Develop an individual, written patient care plan for Resident 2 which specified a time-limited, objective-based approach to his care and safety in the setting of medication noncompliance, such as increasing supervision and developing interventions for staff to follow when behaviors are exhibited due to the resident refusing psychotropic medication. As a result, Resident 2 physically assaulted Resident 1, causing a zygomatic arch fracture (a break in the cheekbone). Resident 1 was a 64-year-old male initially admitted to the facility on 12/19/2024, and readmitted on 4/24/2025 with diagnoses including hypertension (high blood pressure), bilateral hearing loss (hearing loss in both ears), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypercalcemia (a condition in which the calcium level in the blood becomes too high). A review of Resident 1’s Minimum Date Set (MDS- a resident assessment tool) indicated Resident 1’s cognitive (thinking) skills for daily decision making were intact. The MDS indicated Resident 1 required setup and clean up assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1’s Change of Condition (COC- a communication tool used to communicate a resident’s change of condition), dated 4/19/2025, indicated a staff member reported hearing a loud noise coming from the hallway. The COC indicated the staff member went to investigate the noise and saw Resident 1 lying on the floor. The COC indicated the staff member saw Resident 2 physically assaulting Resident 1 with his hands and feet. A review of Resident 1’s General Acute Care Hospital (GACH) physician notes, dated 4/19/2025, indicated Resident 1 was diagnosed with a traumatic injury to the right ear and temple area (side of the head behind the eyes, located between the forehead and ear), temporary unconsciousness (the state of not being awake) possibly due to head trauma, a suspected zygomatic arch fracture (break in the cheekbone), and hearing loss in the right ear. The GACH records indicated Resident 1 was ordered Hydrocodone-Acetaminophen (Norco, used to treat moderate to severe pain) 5/325 milligrams (mg, unit of measurement) 1 tablet by mouth every 4 hours for pain. The GACH physician notes indicated Resident 1 was admitted to the GACH on 4/19/2025 and discharged on 4/24/2025. A review of Resident 1’s readmission Progress Note, dated 4/24/2025 at 4:40 p.m., indicated Resident 1 was readmitted to the facility from the GACH where he was treated for status post (s/p) right temple and ear subarachnoid (the space between the brain and the thin tissues covering it) and subdural (collection of blood in the brain) hemorrhages (bleeding from a broken vessel either inside or outside of the body). Resident 2 was a 71-year-old male, initially admitted to the facility on 3/21/2025 and readmitted on 4/2/2025 with diagnoses including paranoid schizophrenia (a mental health condition characterized by delusions), and mood affective disorder (a mental health condition that affects your emotional state). A review of Resident 2’s MDS indicated Resident 2’s cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 was independent with ADLs. A review of Resident 2’s care plan titled, “Resident non-compliance manifested by: Resident at risk for not being treated related to refusing medication,” dated 3/23/2025, indicated Resident 2 will comply with the facility’s policy/protocols, physician orders daily. The interventions indicated an interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) meeting to be held as needed to address non-compliant behavior. The care plan did not indicate any safety measurements for staff to follow regarding Resident 2’s behaviors. A review of Resident 2’s physician’s order, dated 4/3/2025, indicated Haldol (a typical antipsychotic medication used to treat certain types of mental disorders) 10 mg intramuscularly (an injection administered into a muscle) twice a day starting 4/3/2025. A review of Resident 2’s Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of April 2025, indicated Resident 2 refused Haldol daily from 4/3/2025 to 4/19/2025. A review of Resident 2’s Psychiatric Initial Evaluation dated 4/5/2025, the evaluation indicated Resident 2 appeared visibly anxious, suspicious, and mildly disoriented. The evaluation indicated over the past month the resident had exhibited increasing paranoia (unjustified suspicion and mistrust of other people or their actions) and was now expressing fixed delusions (having false or unrealistic beliefs) that others were attempting to harm him. During an interview on 4/25/2025 at 10:01 a.m., Certified Nurse Assistant (CNA) 1 stated, on 4/19/2025, around 8:30 a.m., she heard loud noises coming from the patio hallway. CNA 1 stated she ran over and saw Resident 2 standing over Resident 1, kicking and stomping (to put a foot down on the ground hard and quickly, making a loud noise, often to show anger) on Resident 1’s head. CNA 1 stated Resident 1 was on the floor and appeared unconscious. CNA 1 stated staff immediately separated the residents. During an interview, on 4/25/2025 at 10:58 a.m., Licensed Vocational Nurse (LVN) 1 stated he heard a bunch of commotion at the patio hallway. LVN 1 stated he saw CNA 1 run to the patio hallway and began screaming. LVN 1 stated he ran over and saw Resident 1 on the floor. LVN 2 stated Resident 2 was kicking and stomping on Resident 1’s head. LVN 1 stated Resident 1 was unconscious for 2 minutes. LVN 1 stated Resident 2 began walking towards him stating, “I’m waiting to get you next.” LVN 1 stated once Resident 1 regained consciousness, Resident 1 was observed with swelling to the forehead, and stumbled upon standing. LVN 1 stated Resident 1 was transferred to the GACH immediately, while Resident 2 was taken into police custody. LVN 1 stated Resident 2 had been refusing Haldol. During an interview, on 4/25/2025 at 11:58 a.m., LVN 2 stated, on 4/19/2025 around 8:34 a.m., she observed a staff member rushing a crash cart over to Resident 1. LVN 2 stated, as she ran to the patio hallway, she observed Resident 1 on the floor, unconscious. LVN 2 stated when Resident 1 regained consciousness, he began bleeding from his nose. LVN 2 stated the ambulance arrived at the facility within 2 minutes after 911 was called and Resident 1 was transferred to the GACH due to the injuries he sustained from Resident 2. During an interview on 4/25/2025 at 12:58 p.m., the Registered Nurse Supervisor (RNS) stated Resident 2’s refusal of Haldol resulted in sudden aggression and a physical altercation towards Resident 1. The RNS stated he contacted Resident 2’s physician for the refusal of Haldol. The RNS stated Resident 2’s physician stated to continue to monitor for any escalating behaviors, however there was no interventions in place for monitoring Resident 2’s behavior. A review of the facility’s policy and procedures (P&P), titled “Identifying Abuse,” revised 9/2022, the P&P indicated, “Abuse of any kind against residents is strictly prohibited.” The P&P indicated “Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking.” The facility failed to: 1. Implement its policy and procedure (P&P) titled, “Identifying Abuse” which indicated the facility did not condone any form of resident abuse or neglect. 2. Ensure that Resident 1 remained free from abuse. 3. Develop an individual, written patient care plan for Resident 2 which specified a time-limited, objective-based approach to his care and safety in the setting of medication noncompliance, such as increasing supervision and developing interventions for staff to follow when behaviors are exhibited due to the resident refusing psychotropic medication. As a result, Resident 2 physically assaulted Resident 1, causing serious injuries such as a swelling to the right side of Resident 1’s forehead, and a zygomatic arch fracture (a break in the cheekbone). These violations, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1.