Health inspection·April 8, 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 three sampled residents (Resident 2) the right to be free of physical abuse, when Resident 1 slapped Resident 2's in the face. This failure caused repeated resident to resident altercations, emotional distress and potential to result in injuries. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 1/24/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 1's score was 07 meaning impaired cognition. Resident 1 exhibited physical behavioral symptoms directed toward others e.g., hitting, kicking, pushing that put others at significant risk for physical injury. MDS indicated Resident 1 has a serious mental illness. Resident 1's diagnoses included schizophrenia (a disorder that affect a person's ability to think, feel and behave clearly). During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 1/1/25, the MDS indicated Resident 2's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 2's score was 11 meaning mild cognition. Resident 2 had clear speech, able to make self-understood and able to understand others. Resident 2's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function, or language). During a concurrent observation and interview on 4/8/25 at 11:10 a.m. with Resident 2 and an Interpreter/Maintenance Supervisor (IT), Resident 2 sat up in bed awake alert and verbally responsive. Resident 2 was non-English speaker. Resident 2 stated Resident 1 came into her room and pull open the curtain around her bed. Resident 2 screamed, asked Resident 1 to leave her bed space. Resident 2 stated when Resident 2 got up from her bed and asked Resident 1 to leave her room, Resident 1 slapped Resident 2 on the left side of the face. Resident 2 stated she screamed and nurses care and remove Resident 1 from her room. Resident 2 stated she was upset. During an interview on 4/8/25 at 10:15 a.m. with Resident 1, Resident 1 alert , verbally responsive Page 1 of 2 056103 056103 04/08/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0600 with confusion. Resident 1 stated he did not remember what happened with Resident 2. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/8/25 at 10:52 a.m. with Resident 3, Resident 3 was Resident 2 roommate. Resident 3 stated Resident 1 slapped Resident 2 on the cheek. Resident 3 stated Resident 2 was an elderly woman. Resident 3 stated facility need to relocate Resident 1 for aggressive behavior. Resident 3 stated the incident disturbed their sleep. Residents Affected - Few During a review of Resident 1's impaired behavioral patterns care plan dated 11/12/24, the care plan indicated Resident 1 was unpredictable due to paranoia and schizophrenia. Resident 1 yelled at another resident who got in his face. Resident 1 had resident to resident altercation. During a review of Resident 2's Interdisciplinary notes (IDT), dated 3/25/25, the IDT indicated, Resident 1 slapped Resident 2 on the face with his right hand. IDT indicated it was close to midnight when Resident 1 stopped by Resident 2's room. Resident 2 and roommates yelled for help for Resident 1 to not come into her room. IDT indicated when Resident 2 stood up Resident 1 slapped Resident 2 on left side of face. During an interview on 4/8/25 at 11:32 a.m. with Social Services Director (SSD), SSD stated facility had started to search for facility options that will accomodate Resident 1's need in order to safely discharge Resident 1. During an interview on 4/8/25 at 12:47p.m. with Director of Nursing (DON), DON stated facility plan to transfer resident to a mental health facility. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised 8/2017, the P&P indicated, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 056103 Page 2 of 2