F0600

D

Failure to Maintain Separation Between Residents With Known History of Altercations Resulting in Injury

Stockton, California Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and follow effective interventions to keep two residents with a known history of altercations apart, resulting in a second physical altercation and injuries to one of the residents. Resident 1 was admitted in 2025 with diagnoses including traumatic subarachnoid hemorrhage and unspecified intracranial injury and was listed as his own responsible party, with a representative payee only for financial matters. Resident 2 was admitted in 2025 with diagnoses including unspecified intracranial injury and generalized anxiety disorder and had a documented history of aggressive behavior toward staff, including laying hands on a CNA during redirection. Staff interviews described Resident 2 as sometimes nice and sometimes not nice, with episodes of yelling at staff when he did not get his way, and being aggressive, including grabbing a CNA by the shirt.

On 1/1/26, Resident 1 and Resident 2 were involved in a physical altercation in the dining room. The Director of Rehab (DOR) reported witnessing Resident 2 stand up from his wheelchair, push Resident 1, and then hit Resident 1, after Resident 1 allegedly tried to grab food from Resident 2’s mother’s plate. Documentation for both residents on 1/1/26 described a physical altercation and indicated that both residents were “physically abused.” Interdisciplinary notes for both residents stated that they would be separated by station and monitored for delayed mental and physical injuries. Resident 1’s care plan, initiated on 1/2/26 and revised on 1/7/26, identified a focus of an alleged resident-to-resident altercation with a goal of no altercation and included interventions such as monitoring for pain and separating the residents. Resident 2’s care plan, initiated on 1/2/26, also focused on an alleged resident-to-resident altercation with a goal of no altercation and an intervention to separate the residents.

Despite these documented interventions, the residents were again together in the dining room on 1/5/26, when a second altercation occurred. Multiple staff, including the Social Services Director, DOR, DON, LNs, and CNAs, reported that Resident 2 approached Resident 1 in his wheelchair and struck Resident 1 multiple times in the head and face, while Resident 1 tried to shield himself with his left arm. The DON, SSD, LNs, and CNAs stated that Resident 2 had been aggressive in the past and that Resident 2 should have been monitored more closely and kept away from Resident 1 after the first incident. The DON and other staff acknowledged that the intervention to keep the residents separate was not followed and that the second altercation could have been avoided if Resident 2 had been monitored for aggressive behavior and the residents had been kept apart.

As a result of the second altercation, Resident 1 sustained injuries including swelling of the left wrist and swelling under the left lower eye, a hematoma of the left zygoma, and an abrasion to the forehead. Progress notes and hospital emergency records documented that Resident 1 complained of pain, rated at 6 out of 10, and was nauseated and vomited. A splint was applied to Resident 1’s left wrist, and he was transferred to the hospital for further evaluation and treatment of his injuries. Resident 1, who had a traumatic brain injury and was described as unable to verbalize coherent thoughts and repetitive in his statements, was later transferred from the hospital to a sister facility. The Administrator stated that she did not discuss the transfer with Resident 1, and the Representative Payee stated she was not notified of the transfer and that she was only responsible for Resident 1’s financial matters. The facility’s abuse policy stated that it would identify, assess, care plan, and monitor residents with behaviors that might lead to conflict and ensure residents are protected from physical and psychosocial harm and additional abuse during and after investigations, but the documented separation interventions for these two residents were not implemented at the time of the second incident.