Health inspection·June 18, 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 ensure one of three sampled residents (Resident 1) was free from physical abuse, when Resident 2 punched Resident 1 ' s leg in the activity room. This failure decreased the facility ' s potential to maintain Resident 1 ' s highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record, dated 6/17/25, indicated, Resident 1 was admitted to the facility in 2025 with a diagnosis of anxiety (a feeling of worry, nervousness, or unease). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 5/16/25, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) scored 14 out of 15 with no memory impairment. A Progress Notes, dated 6/11/25 and written by Activities Director (AD), indicated, [Resident 1] was in the activity room when another resident [Resident 2] was wheeling by and rammed his wheelchair into [Resident 1 ' s] wheelchair. [Resident 2] then started punching [Resident 1] in the leg. A Progress Notes, dated 6/11/25 and written by Social Services Director (SSD), indicated, ss [Social Service] interview [Resident 1] he stated he is scared to go back into the activities room when the resident [Resident 2] who attack him is in there. A review of Resident 2 ' s admission Record, dated 6/17/25, indicated, Resident 2 was admitted to the facility in 2021 with diagnoses including dementia (a progressive state of decline in mental abilities) and depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). A review of Resident 2 ' s clinical record included the following documents: An MDS, dated 5/11/25, indicated Resident 2 had a BIMS scored three out of 15 with memory impairment. A Progress Notes, dated 6/11/25 and written by Doctor of Nursing Practice, indicated, [Resident 2] Page 1 of 2 056139 056139 06/18/2025 Roseville Point Health & Wellness Center 600 Sunrise Avenue Roseville, CA 95661

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a physical altercation with another resident [Resident 1] today. He was in the activity room and was found to be punching the other resident . [because] the other resident was on his way. A Progress Notes, dated 6/11/25 and written by AD, indicated, This resident [Resident 2] . rammed his wheelchair into the other resident ' s [Resident 1 ' s] wheelchair then started punching the other resident in the leg. During an interview on 6/17/25 at 10:08 a.m. with Resident 1, Resident 1 stated he remembered the incident when a male resident punched his left leg in the activity room. Resident 1 stated he felt unsafe while being in the facility and scared of someone will hit him again. During an interview on 6/17/25 at 10:26 a.m. with the Activity Assistant (AA), AA stated Resident 2 was wheeling himself toward Resident 1 while Resident 1 was watching television. Then, Resident 2 punched Resident 1 ' s leg four times. Next, Resident 2 tried to hit the AA too. During an interview on 6/17/25 at 2:25 p.m. with the Director of Nursing (DON), DON confirmed Resident 2 punched Resident 1 ' s leg and stated the activities assistant witnessed the altercation. A review of the facility ' s policy titled, Abuse Prevention and Management, revised on 5/30/24, indicated, Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. The policy further indicated, The administrator or designated representative will provide for a safe environment for the resident . 056139 Page 2 of 2