Health inspection·September 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to protect one of 6 sampled residents (Resident 1) from physical abuse when Resident 1's arm was grabbed by Resident 2. Residents Affected - Few This failure resulted in Resident 1 sustaining a scratch to her arm and felt unsafe in her room. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in August 2024 with multiple diagnoses including anoxic brain injury (damage to the brain caused by lack of oxygen to the brain) and bipolar disorder (a mental health disorder that causes mood swings). A review of Resident 1's Minimum Data Set (MDS-a Federally mandated assessment tool), Cognitive Patterns, dated 9/5/24, indicated Resident 1 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation] & Initial COC [Change of Condition]/Alert Charting & Skilled Documentation, dated 9/18/24, indicated .Unwitnessed resident to resident altercation occurred today at 1010 [10:10 a.m.]. Residents were separated immediately. [Resident 1] noted with skin tear to left upper arm .Per [Resident 1], [Resident 2] entered bathroom and grabbed arm . A review of Resident 1's Care Plan, initiated 9/18/24, indicated .Focus .Altercation .Interventions .Monitor for any psychological effect from the altercation i.e. expression of fear, self isolation, sleep disturbance . A review of Resident 1's Care Plan, initiated 9/18/24, indicated .Focus .Scratches Location: left upper arm .Interventions .Keep site clean and dry . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in October 2021 with multiple diagnoses including Alzheimers disease (a progressive disease that destroys memory and mental functioning), mood disturbance (mental health condition that causes changes in a person's emotional state) and anxiety (mental disorder causing worry and fear). A review of Resident 2's MDS, Cognitive Patterns, dated 7/18/24, indicated Resident 1 had a BIMS score of 11 out of 15 that indicated Resident 2 had moderate cognitive impairment. A review of Resident 2's SBAR & Initial COC/Alert Charting & Skilled Documentation dated 9/18/24, Page 1 of 3 055289 055289 09/20/2024 Lodi Creek Post Acute 321 West Turner Road Lodi, CA 95240

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated .Resident noted with aggressive behavior towards another resident. Event was unwitnessed by staff. Residents were immediately separated. [Resident 2] was noted as the aggressor and sustained no injury .Per [Resident 1], [Resident 2] entered bathroom and grabbed arm . A review of Resident 2's Care Plan, initiated 2/28/24, indicated .Focus . Resident is making statements that this is her house .Interventions . Approach in a calm manner .Do not force resident to comply against his/her wishes . A review of Resident 2's Care Plan, initiated 9/18/24, indicated .Focus .Altercation .Interventions .Will redirect and remind resident that this facility is a home for all residents . During an interview on 9/20/24 at 11:27 a.m. with the Administrator (ADM) and the Infection Preventionist (IP), the ADM stated an unwitnessed incident occurred between Resident 1 and Resident 2 on 9/18/24. The ADM stated Resident 1 and Resident 2 were not in the same room but did share an adjoining bathroom. The ADM stated Resident 1 was in the bathroom and was scratched by Resident 2. The ADM stated Resident 2 thinks people are in her space and house and did not like that Resident 1 was in her space. Resident 1 had a scratch on left upper arm. During a concurrent observation and interview on 9/20/24 at 11:48 a.m. with Resident 1, observed an approximately one-inch red scratch on Resident 1's left upper arm. Resident 1 stated yesterday or the day before a man came into the bathroom when she was washing her hands or on the way out. Resident 1 stated, He grabbed my arm, said I couldn't use the bathroom, that it was his bathroom only. Resident 1 stated, Told them to let go. Resident 1 stated her arm bled at the time. Resident 1 stated, Felt violated in my own space. During an interview on 9/20/24 at 11:58 a.m. with Resident 2, Resident 2 stated, Know I own the place. Resident 2 stated she was in the bathroom; someone came in and wanted to kill her. Resident 2 stated, Don't like people doing things to harm me. I bought this home. No one else is supposed to use the bathroom. Don't remember grabbing anyone's arm. During an interview on 9/20/24 at 12:04 p.m. with Certified Nursing Assistant (CNA)1, CNA 1 stated Resident 2 thinks she owns the whole place and doesn't like anyone in her room. CNA 1 stated that they have to get Resident 2's permission to have someone else in her room. During an interview on 9/20/24 at 12:11 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 2 scratched Resident 1's left arm on 9/18/24. LN 1 stated Resident 2 does not like anyone in her room and Resident 1 in the bathroom may have set her off. During a telephone interview on 9/20/24 at 12:30 p.m. with LN 2, LN 2 stated she was notified of the incident between Resident 1 and Resident 2 on 9/18/24. LN 2 stated Resident 1 had a scratch on left upper arm. LN 2 stated Resident 2 has dementia and believed she was in her own house and believed that Resident 1 was in her house unannounced. During a telephone interview on 9/20/24 at 12:42 p.m. with CNA 2, CNA 2 stated she heard commotion in Resident 1's room on 9/18/24. CNA 2 entered the adjoining bathroom, Resident 1 and Resident 2 were slapping at each others arms. CNA 2 stated Resident 2 was telling Resident 1, Get out of my house. CNA 2 stated Resident 2 does not want to share a bathroom. CNA 2 stated Resident 1 had a bleeding scratch on her arm. 055289 Page 2 of 3 055289 09/20/2024 Lodi Creek Post Acute 321 West Turner Road Lodi, CA 95240

F 0600 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, indicated .Residents have the right to be free from abuse .This includes but is not limited to freedom from physical abuse .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objective .Protect residents from abuse .by anyone including .other residents . Residents Affected - Few A review of the facility's P&P titled Resident-to-Resident Altercations, revised 9/22, indicated .All altercation, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .Behaviors that may provoke a reaction by residents or others include .wandering into others rooms/space . A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 4/21, .All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies .and thoroughly investigated by facility management . 055289 Page 3 of 3