Health inspection·May 2, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect one resident (Resident 1) of three sampled residents from physical abuse by Resident 2, when Resident 2 deliberately placed his hands on Resident 1 ' s chest and pushed him which caused Resident 1 to fall during an argument over a television (TV) channel inside their room. This failure resulted in a skin tear (a wound caused by direct force which separates the skin ' s layers) and an abrasion (a scrape) on Resident 1 ' s left forearm. Findings: A review of Resident 3 ' s Minimum Data Set (MDS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 3/1/25, indicated a Brief Interview for Mental Status (BIMS- a screening tool used to assess a person ' s memory and cognition (ability to think, understand, remember, and problem-solve)) score of 15, which meant his cognition was intact. A review of Resident 2 ' s MDS dated [DATE], indicated his BIMS score was 13, meaning his cognition was moderately (an observable delay) intact. A review of Resident 1 ' s MDS dated [DATE] indicated Resident 1 ' s BIMS score was 10, meaning his cognition was moderately impaired (diminished). During a concurrent observation and interview on 5/2/25 at 10 a.m. Resident 2 was sitting in his room watching TV. Resident 2 stated Resident 1 changed the channel of Resident 2 ' s television using Resident 1 ' s TV remote control. Resident 2 stated he pushed Resident 1 by placing both his hands on Resident 1 ' s chest to push him. Resident 2 stated Resident 1 fell on the floor. Resident 2 stated there were no staff in the room during that time, but Resident 3 was also in the room. During a concurrent observation and interview on 5/2/25 at 11 a.m., with Resident 1 and Resident 3, Resident 1 showed the Surveyor the island dressing (a highly absorbent layer with an adhesive border) located on his left forearm which measured 2 centimeters (cm- a unit of measure) by 2 cm. Resident 1 stated Resident 2 placed both his hands on his chest and pushed him, causing him to fall. Resident 1 pointed to the part of his bed where he hit his left forearm. Resident 3 stated each resident ' s TV remote controlled all three TV sets in the room. The Surveyor observed Resident 3 use his remote to change the channel of his TV which also changed the channel of Resident 2 ' s television. A review of Resident 1 ' s facility document titled Situation Background, Assessment, Recommendation [SBAR] dated 4/28/25 at 3:15 p.m. indicated, Incident started on 4/28/25, at 3:15 p.m.[Resident 2] Page 1 of 2 055499 055499 05/02/2025 Rocky Point Care Center 625 16th Street Lakeport, CA 95453

F 0600 Level of Harm - Actual harm Residents Affected - Few pushed [Resident 1] resulting in a fall with injury .Things that make the condition or symptom worse are .TV control for [Resident 1] controls both his and [Resident 2 ' s] TV .Other relevant information .2 cm X [by] 2 cm S/T [Skin Tear] with 5 cm X 1 cm abrasion to LFA [left forearm]. A review of Resident 1 ' s progress note dated 4/28/25 at 3:15 p.m., indicated, [Certified Nursing Assistant B (CNA B)] alert [LN A] to [Resident 1] sitting on floor . [Resident 1] states resident [Resident 2] pushed him causing him to fall to floor onto buttocks . A review of Resident 2 ' s progress note dated 4/28/25 at 3:54 p.m., indicated, [Social Service Director] followed up this res [Resident 2] in regards to res-res [resident to resident] altercation this res [Resident 2] being the aggressor when I asked him why he pushed his roommate he stated ' because he changed the tv station he is fine he is not hurt. ' I explained to him [Resident 2] that we due [sic] put our hands at anyone . During a concurrent observation and interview on 5/2/25 at 11:40 a.m., the Maintenance Supervisor (MS) stated each TV in Resident 1 and Resident 2 ' s room had its own remote control and a control box. The MS acknowledged if a resident pointed their remote control toward his roommate ' s TV control box, it could change the channel. The MS stated he had received previous complaints from other residents about this, but this TV system had been in place for a while now. During an interview on 5/5/25 at 1:25 p.m., LN A stated on 4/28/25 at about 2:55 p.m., CNA B alerted him about a fall. LN A stated he saw Resident 1 sitting on the floor with his feet up on the foot of his bed facing the door. LN A stated Resident 2 admitted he had pushed Resident 1 to LN A, the Director of Nursing (DON), and CNA B. Resident 2 stated he had pushed Resident 1 because Resident 1 had changed the channel on Resident 2 ' s TV. LN A stated there was no doubt the push was deliberate, and Resident 2 had admitted it. LN A also stated Resident 1 reported he was pushed by Resident 2. During an interview on 5/5/25 at 2:08 p.m., the DON stated LN A informed her Resident 2 admitted to pushing Resident 1. The DON stated it was determined during the investigation that Resident 2 ' s action was deliberate and intentional. The DON stated she determined the reason for the altercation was there was no individuality to the TVs. The DON stated she informed the MS and the Administrator of the cause of the incident and was told by both staff that they would work on it. A review of the facility ' s policy and procedure (P&P) titled, Elder/Dependent Adult Abuse, undated, indicated, .The facility will protect the rights, safety, and well-being of each resident regardless of physical or mental condition, against any and all forms of abuse including freedom from neglect and exploitation .Abuse is .defined .as: ' The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . ' 055499 Page 2 of 2