Health inspection·August 1, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 four sampled residents (Resident 1) from abuse when Resident 2 spit on Resident 1 in the face during a verbal altercation.This failure had the potential for Resident 1 to experience fear or distress.Findings:During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in July 2025 with diagnoses that included encephalopathy (brain disease that alters brain function or structure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had intact cognition.During a review of Resident 2's admission records, the records indicated Resident 2 was admitted in July 2025 with diagnoses that included sepsis (infection in the blood), depression, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). Resident 2's MDS indicated Resident 2 had intact cognition.During a review of Resident 3's admission records, the records indicated Resident 3 was admitted in July 2025 with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). Resident 3's MDS indicated Resident 3 had intact cognition.During a review of Resident 4's admission records, the records indicated Resident 4 was admitted in July 2025 with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer, and complete traumatic amputation of right midfoot (a severe injury involving the loss of part or all of the foot due to an external force). Resident 4's MDS indicated Resident 4 had intact cognition.During a review of Resident 1's progress notes, dated 7/30/25, the notes indicated, .CNA [Certified Nursing Assistant] notified nursing staff that [Resident 2] tried to hit this resident [Resident 1] with his W/C [wheelchair] aggressively while residents were watching TV in the activity room.During interview [Resident 1] stated, Other resident [Resident 2] spitted on him, he got some droplets on his forehead, didn't get anything on his face (mouth) and in his eyes. I already cleaned my face.During a review of Resident 2's care plan, dated 7/30/25, the care plan indicated, [Resident 2] exhibits, or has the potential to exhibit physical behaviors related to: Ineffective coping skills, i.e., poor anger management, Poor impulse control.During a review of Resident 2's Social Service Progress Notes, dated 7/31/25, the notes indicated, [Resident 2] was noted to have been involved in a verbal altercation with a co-resident [Resident 1].[Resident 2] was noted to have spat on his co-resident [Resident 1] on his forehead.During a concurrent observation and interview on 8/1/25 at 10:02 a.m. with Resident 1 in his room, Resident 1 was observed lying in bed, alert and calm, verbally responsive to questions. Resident 1 stated, .I was watching [television] and the fire alarm went off and he [Resident 2] turn around yelling at me.And then he spit on me.happened a couple days ago.I had to control Page 1 of 2 055402 055402 08/01/2025 River City Post Acute 2540 Carmichael Way Carmichael, CA 95608

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few myself.During an interview on 8/1/25 at 10:30 a.m. with Resident 3, Resident 3 stated, .There was a guy in the wheelchair getting crazy in his mind.We tried to get away from [Resident 2].[Resident 2] felt claustrophobic and spit on him [Resident 1].I saw the whole thing.I was watching boxing that time later in the afternoon about two days ago.It was like [Resident 2] wanted trouble and he saw [Resident 1].Then he spit on his face.[Resident 2] left me alone because he knows me.[Resident 2] was on wheelchair.That's the first time I saw him.[Resident 2] wanted to make trouble to weak ones.During an interview on 8/1/25 at 10:57 a.m. with Resident 4, Resident 4 indicated, .Happened the night before.We were watching tv.[Facility] had the fire alarm, and [Resident 2] said close the door.[Resident 1] held the door.[Resident 2] guy flipped out, he was in his wheelchair.[Resident 2] slammed his wheelchair.I thought they are going to start fist fighting.[Resident 2] had rage.I've seen [Resident 2] before, I've never seen that side of him, he had some rage.During a telephone interview on 8/1/25 at 12:15 p.m. with CNA 1, CNA 1 stated, .My last shift, I had [Resident 2], there was an altercation between two residents [Resident 1 and Resident 2] on 7/30/25 around 7 or 7:30 p.m.I did see the incident. CNA 1 confirmed he saw Resident 2 spit on Resident 1's face, separated the two, and reported it to the nurse after the fire drill.During a telephone interview on 8/1/25 at 12:21 p.m. with Licensed Nurse (LN 1), LN 1 stated, .There was a fire drill going on, when I came back there was an altercation.[Resident 2], he spit on [Resident 1], [staff] separated them.I asked [Resident 1], [Resident 2] tried to hit [Resident 1] aggressively but it was not effective.[Resident 1] said [Resident 2] spit on him.We gave [Resident 1] shower at the same time.[Resident 2] was very aggressive, cursing the staff like a gangster.[Resident 2] was not aggressive before the incident.They [Resident 1, Resident 3, and Resident 4] were watching tv in the dining room.Suddenly [Resident 2] went there.During an interview on 8/1/25 at 12:52 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the expectation is that all residents in the facility are safe. The ADON stated, This is their home, they have to feel safe here.During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 12/2021, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.b. be treated with respect, kindness, and dignity.c. be free from abuse, neglect, misappropriation of property, and exploitation. 055402 Page 2 of 2