Health inspection·March 6, 2025

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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant 1 (CNA 1) hit Resident 1 on the back. Residents Affected - Few This failure had the potential for Resident 1 to obtain physical injuries and have a negative impact on his psychosocial well-being. Findings: A review of Resident 1's admission record indicated he was originally admitted in September 2019 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 11/26/24, indicated Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 0 out of 15 with an inability to express ideas and wants, and behaviors which included wandering. A review of Resident 1's care plan, dated 3/27/23 and revised on 5/21/24, indicated impaired cognitive function/dementia or impaired thought processes. A review of Resident 1's progress note, dated 2/19/25 at 9:20 p.m., written by Licensed Nurse 1 (LN 1), indicated CNA 2 reported he saw CNA 1 hit Resident 1 on his back after Resident 1 knocked over and spilled a food tray. During telephone interview on 3/6/25 at 10:45 a.m. with CNA 2, CNA 2 stated on 2/19/25, during dinner time, that section of the hallway had no feeder help, and went to that hallway to assist with feeding residents. CNA 2 stated I went into the [residents' room] to help Bed B .Bed A [Resident 1] has dementia. He rolled over [in a wheelchair] to B's bed and turned over his dinner tray .he [CNA 1] got upset, I saw him slap Bed A fast on the back, like 1,2,3. During a telephone interview on 3/6/25 at 11:15 a.m. with CNA 1, CNA 1 stated he had a similar incident with two other residents back in January. CNA 1 stated on 2/19/25, I was standing in hallway near [resident room], passing out dinner trays, [CNA 2] went over to Bed B to help feed him. Bed A [Resident 1] has dementia. Bed A pushed Bed B's tray, heard [CNA 2] in room talking about the pushed over tray and I went in. I stood behind him [Resident 1] and locked his wheelchair, tapped him on the shoulder and told him that he couldn't do that. Next thing I knew I was told to come to office . suspended me for 3 days. Page 1 of 3 056139 056139 03/06/2025 Roseville Point Health & Wellness Center 600 Sunrise Avenue Roseville, CA 95661

F 0600 Level of Harm - Minimal harm or potential for actual harm During telephone interview on 3/6/25 at 3 p.m. with CNA 2, CNA 2 stated I was the only witness. I know the difference between tapping and slapping, tapping is up and down and slapping is a side-to-side motion. A review of Resident 1's interdisciplinary team (IDT) note, dated 2/20/25 at 10:37 a.m., indicated that Resident 1 was assessed after the incident, and there was no redness, no bruising, and no apparent injury. Residents Affected - Few During an interview on 3/6/25 at 4:50 p.m. with Administrator (ADM) and Director of Nursing (DON), they stated they unsubstantiated the allegation of abuse because there were no witnesses. They stated the incident was he said he said, which brought about their decision to unsubstantiate the incident. ADM stated expectations are to make sure that resident is safe, free from harm, expect staff to know what to do, separate staff from resident .follow the abuse policy. During a review of the facility's policy titled, Abuse Prevention and Management, revision date 5/30/24, the policy stipulated, The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The Facility develops policies, procedures, training programs, and screening and prevention systems. 056139 Page 2 of 3 056139 03/06/2025 Roseville Point Health & Wellness Center 600 Sunrise Avenue Roseville, CA 95661

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure that allegations of abuse were reported within the required timeframe for one of four sampled residents (Resident 2) when the allegations of abuse were not reported within two hours to the Department. This failure had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of Resident 2's admission record indicated she was admitted in December 2024, with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool), dated 12/23/24, indicated Resident 2's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15 with good memory. A review of a facility document presented from the Administrator (ADM) on 3/6/25 at 4:50 p.m., for Resident 2, indicated on 2/20/25 at 4:28 p.m., the SOC 341 was faxed to the Department. The one-page document presented did not have Resident 2's name, nor any other identifier associated with Resident 2 listed on it. The Department received 11 pages of the SOC 341, related to Resident 2, from the Social Services Director (SSD) on 2/20/25 at 4:28 p.m. The SSD documented time of notification from Resident 2 on 2/19/25 at 6 p.m., indicating allegation of suspected staff to resident abuse. During a concurrent interview and policy review on 3/6/25 at 5:30 p.m. with the Administrator (ADM), regarding abuse reporting to the Department, the ADM stated, By regulation, I go by the book .Within 2 hours if serious bodily injury and 24 hours if no injury .from the state operations manual. The facility Abuse Prevention and Management policy was reviewed with ADM, and she stated, we will need to have that changed to the state operations manual. A review of the facility's policy titled, Abuse Prevention and Management, revision date 5/30/24, stipulated, .7. Notification of Outside Agencies for All Allegations of Abuse. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours. 056139 Page 3 of 3