Health inspection·May 1, 2025

REGULATGORY VIOLATION(S): Title 42 Code of Federal Regulations §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- (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Title 22 California Code of Regulations §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. Title 22 California Code of Regulations §72527.. Licensee - 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. Title 22 California Code of Regulations § 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. (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. (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. Title 22 California Code of Regulations §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 3/18/2025, 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 protect Resident 2 from being physically abused (deliberate, aggressive, or violent behavior with the intention to cause harm), by Resident 1, who had diagnoses of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). The facility failed to: 1. Implement the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Prog," reviewed 1/31/2024, which indicated the facility shall uphold the resident's right to be free from physical abuse. 2. Revise and update Resident 1's Behavior Problem Care Plan dated 1/16/2025, after a Change in Condition (COC) with three different panic attacks of yelling, hitting himself, and grabbed the nursing staff on 2/4/2025. 3. Ensure an Interdisciplinary Team (IDT, healthcare professionals from various disciplines to collaborate and discuss a patient's case, share information, and develop a coordinated care plan) Meeting was conducted on 2/7/2025 upon Resident 1's re-admission to the facility after being transferred to General Acute Care Hospital (GACH) 1 for being a danger to himself and to others, per the facility's P&P titled, "Behavioral Assessment, Intervention and Monitoring," reviewed 1/31/2024. These deficient practices resulted in Resident 2 being subjected to physical abuse by Resident 1. On 3/5/2025, one month after Resident 1 was transferred to a GACH for a psychiatric evaluation due to being a danger to self and others, Resident 1 punched Resident 2 in the face. Resident 2 complained of pain, had discoloration on the right side of her face and first aid was rendered. Resident 2 was transferred to GACH 2 and was diagnosed with a left orbital fracture (a break in the bony structure that supports the eye). During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was a 31-year-old-male admitted on 10/1/2024 with diagnoses including schizophrenia, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities of living), panic disorder (a mental and behavioral disorder characterized by sudden periods of intense fear, discomfort, or a sense of losing control), and anxiety disorder (a mental health condition characterized by feelings of worry or fear that interferes with daily activities of living). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/13/2024, the MDS indicated Resident 1 was cognitively intact (had the ability to think, understand, and reason) and did not exhibit any physical or verbal behaviors directed towards others. The MDS indicated Resident 1 was taking an antipsychotic (medication used to treat symptoms of schizophrenia) and antidepressant (used to treat depression) medications. During a review of Resident 1's Change of Condition (COC) documentation dated 1/16/2025 at 7:23 PM, the COC indicated Resident 1 was having behavioral symptoms and panic attacks without provocation (an action or statement that is intended to make someone angry). The COC indicated Resident 1 was yelling and striking the wall, door, and medical carts. The COC indicated Resident 1 verbalized having panic attacks, the physician was notified and recommended to monitor the resident for 72 hours. During a review of Resident 1's care plan initiated 1/16/2025, the care plan indicated the resident had behavior problems of slamming doors, walls, and the medical cart related to the resident verbalizing he had a panic attack. The care plan indicated a goal for Resident 1 to have fewer episodes of this type of behavior. The care plan interventions indicated to administer Resident 1's medication as ordered, monitor for side effects and effectiveness, anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, minimizing the potential for the resident's disruptive behaviors by offering tasks which divert attention such as encouraging the resident to come to activities, discussing the resident's behavior if reasonable, explaining and reinforcing why the behavior was inappropriate or unacceptable to the resident, providing the resident opportunities for positive interaction, intervening as necessary to protect the rights and safety of others, approaching and speaking in a calm manner, removing the resident from the situation and taking him to an alternate location as needed, and listening to music with his phone and headset to help calm down During a review of Resident 1's COC documentation dated 2/4/2025 (approximately three weeks later) at 2:31 AM, the COC indicated Resident 1was having behavioral symptoms and grabbed the nursing staff when he was having a panic attack. The COC indicated Resident 1 came out of the room yelling into the hallways. The COC indicated when Resident 1 approached the nursing station, the Charge Nurse (CN) asked Resident 1 what happened. Resident 1 stated he had a panic attack but felt okay and went back into his room. The COC indicated the Certified Nursing Assistant (CNA) informed the CN that as soon as Resident 1 came out of his room, he saw the CNA sitting in the hallway, grabbed the CNA, and then shook the CNA. The COC indicated Resident 1's physician was notified and ordered to inform the resident's psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders). During a review of Resident 1's Nursing Progress Note dated 2/4/2025 at 2:34 PM (12 hours later), the Nursing Progress Note indicated Resident 1 had another panic attack, suddenly started yelling, went to the lobby, started striking the wall, went to the social worker's office, came out, went to his room, and yelled again. The progress note indicated the facility ensured Resident 1's safety by removing objects in the resident's way and by watching the resident closely. The progress note indicated staff attempted to assess the cause of Resident 1's panic attack, but the resident did not want to discuss. The Progress Note indicated Resident 1's psychiatric nurse practitioner was notified. During a review of Resident 1's Behavior Note dated 2/4/2025 at 3:18 PM, the Behavior Note indicated Resident 1 suddenly stormed to his room yelling and screaming, hit himself on the wall with his hands, and attempted to hit the staff. The Behavior Note indicated Resident 1's psychiatric nurse practitioner was called and provided orders to transfer the resident on 5150 (a temporary, involuntary psychiatric hold, also known as a 72-hour hold, initiated by law enforcement or mental health professionals) and administer a one-time dose of Ativan (a medication used to treat anxiety) 1 milligram (mg) intramuscularly (IM, medication is injected directly into a muscle). During a review of Resident 1's Nursing Progress Note dated 2/4/2025, the Nursing Progress Note indicated at 5:30 PM Resident 1 had a third episode of anxiety, screaming, and yelling in the hallways. The progress Note indicated at 7 PM an ambulance arrived to transfer Resident 1 to GACH 1 for a psychiatric evaluation due to being a danger to self and others. During a review of Resident 1's application for up to 72-hour assessment, evaluation, and crisis intervention or placement for evaluation and treatment' form dated 2/4/2025, indicated detainment of Resident 1 began at 6 PM. The form indicated Resident 1 was observed pacing, pulling his hair, that staff and residents were in fear for their safety and that Resident 1 was unpredictable. The form further indicated there was probable cause to believe that Resident 1 was a danger to himself and a danger to others as a result of mental health disorders. According to a review of Resident 1's care plan related to behavior problem of slamming doors, walls, and the medical cart, initiated 1/16/2025, the care plan failed to indicate an update or revision after Resident 1's COC on 2/4/2025. During a review of Resident 1's Nursing Progress Note dated 2/7/2025 at 4:10 PM, the Nursing Progress Note indicated Resident 1was readmitted to the facility with no aggressive behaviors noted. During a review of Resident 1's electronic health record (EHR), the EHR indicated the facility did not conduct an Interdisciplinary Team Meeting to discuss and address Resident 1's behavior from 2/4/2025, after Resident 1 returned to the facility from GACH 1 on 2/7/2025. During a review of Resident 1's COC documentation dated 3/5/2025 at 5:24 PM (one month after being readmitted to the facility), the COC indicated Resident 1 had a physical altercation with another resident (Resident 2). Resident 1's physician was notified and recommended to transfer Resident 1 to GACH 3 for a psychiatric evaluation. During a review of Resident 1's Nursing Progress Note dated 3/5/2025, the Nursing Progress Note indicated that at approximately 5:15 PM, a physical altercation occurred between Resident 2 and Resident 1 in the facility's lobby. The Progress Note indicated Resident 2 and Resident 1 were seated side by side, with Resident 2's wheelchair positioned between both residents. The Progress Note indicated that according to witness reports, Resident 1 moved Resident 2's wheelchair, which upset Resident 2 and lead to a verbal disagreement. The Progress Note indicated both Residents stood up, and Resident 1 suddenly threw a punch at Resident 2 striking the right side of Resident 2's face. The Progress Note indicated Resident 1 had no injuries, Resident 1's physician was notified and gave orders to transfer the resident to the GACH for further evaluation of his behavior. The Progress Note indicated at 5:35 PM the RN supervisor and CN interviewed Resident 1 about the incident and Resident 1 called Resident 2 a derogatory name. During a review of Resident 1's Nursing Progress Note dated 3/11/2025, the Nursing Progress Note indicated that at 2:30 PM, Resident 1 returned to the facility from the GACH. During a review of the IDT Note dated 3/11/2025, the IDT Note indicated Resident 1 wrote a letter indicating that Resident 1 would not bring physical harm to residents or to staff and Resident 1 signed the letter. During a review of Resident 2's Admission Record, the Admission Record indicated the facility admitted a 69-year-old-female resident on 1/7/2025 with diagnoses including schizophrenia, bipolar disorder (a mental disorder that causes dramatic shifts in a person's mood or energy and may affect the person's ability to think clearly), depression, unsteadiness on their feet, muscle weakness, and anxiety disorder. During a review of Resident 2's MDS dated 3/6/2025, the MDS indicated Resident 2 had moderately impaired cognition (problems with the ability to think, understand, and reason), did not exhibit physical or verbal behavioral symptoms towards others, and Resident 2 was taking antipsychotic medication. During a review of Resident 2's COC documentation dated 3/5/2025 at 5:28 PM, the COC indicated the resident had a physical altercation with another resident (Resident 1). Resident 2's physician was notified who then recommended to transfer the resident to the GACH for further evaluation and treatment. During a review of Resident 2's Nursing Progress Note dated 3/5/2025, the Nursing Progress Note indicated at approximately 5:15 PM, Resident 2 was noted to have discoloration on the right side of her face due to the altercation with Resident 1. The progress note indicated first aid was rendered, and a neuro check and vital sign assessment was completed for Resident 2. The Progress Note indicated Resident 2's attending physician was notified who then provided orders to apply an ice pack to the affected area every 15 minutes for three applications and to transfer Resident 2 to the GACH for further evaluation of her injury. The Progress Note indicated at 5:40 PM the CN interviewed Resident 2 regarding the incident, and the resident stated she did not remember exactly what happened, all she could remember was that a big man punched her in the face. During a review of the Physician's Order dated 3/5/2025, the Physician's Order indicated to transfer Resident 2 to GACH 2 for further evaluation of facial trauma. During a review of Resident 2's GACH 2 Patient Information, the Patient Information indicated GACH 2 admitted Resident 2 on 3/6/2025 with a diagnosis of facial trauma. During a review of Resident 2's GACH 2 History of Present Illness dated 3/7/2025 indicated Resident 2's computerized tomography scan (CT scan - is a medical imaging technique used in radiology to obtain detailed internal images of the body for diagnostic purposes) showed left orbital fracture. During a concurrent observation and interview on 3/18/2025 at 9:03 AM, in Resident 1's room, Resident 1 was observed sitting on the side of the bed, calm, and watching television. Resident 1 stated he hit Resident 2 because she (Resident 2) was irritating him. Resident 1 stated Resident 2 tried to throw her wheelchair at him, so he (Resident 1) punched Resident 2 in her f