Health inspection·April 23, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to] Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness Dementia [impairment of at least two brain functions, such as memory loss and judgment] .All staff to be aware of residents location. Res [resident] to be distracted away from exit doors, other resident rooms, and dining room . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . RN 1 stated Resident 1 has dementia and wonders into other resident rooms. During a concurrent interview and record review on 4/23/24 at 1:30 p.m. with RN 1, Resident 2 ' s Progress Notes (PN), dated 4/11/24 was reviewed. The PN indicated, .Resident was verbally and physically abusive to another resident. CNA's were on break and I was in the process of obtaining vitals [measure the basic functions of your body] and doing my med [medication] pass when a resident from [room number] came to the hall saying her neighbor and another resident were about to get into a fight .witnessed her [Resident 1] and another resident [Resident 2] holding each other's wrists being verbally abusive towards each other .gently pulled them apart and [Resident 2] said Get her the F**k [profanity] out of my room .she [Resident 2] was fine just upset and wanted me to keep [Resident 1] away from her and out of her room . RN 1 stated all staff should monitor Resident 1 so she does not go into other resident rooms. During a review of Resident 1's Abuse Investigation Worksheet (AIW) dated 4/12/24 was reviewed. The AIW indicated, .[Resident 1] .entered room of resident [Resident 2] insisting it was her room [Resident 2] asked [Resident 1] to leave and grabbed her to turn her chair away to have [Resident 1] then bit [Resident 2] on her inner hand between thumb and index finger . During a concurrent interview and record review on 4/23/24 at 2:22 p.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled Comprehensive Care Plan dated 03/2001 was reviewed. The policy indicated, . Each resident will have a comprehensive person-centered care plan that includes measurable objectives and time frames to meet his/her, medical, nursing, mental and psychological needs . the comprehensive person centered care plan has been designed to . incorporate identified or potential problem areas . goals and objectives are defined as the desired outcome for a specific problem. They are resident oriented, behaviorally stated . Goals and objectives are entered on the person-centered care plan so that all disciplines have equal access to the information . person centered care plans are initiated and maintained in the resident's electronic record . The DON stated the importance of the care plan was so that all staff was aware of the residents specific care needs. The DON stated that if staff were aware of Resident 1's location, the altercation could have been avoided. During an interview on 4/23/24 at 2:35 p.m. with Resident 3, Resident 3 stated Resident 1 had entered her room before. Resident 3 stated on 4/10/24, Resident 1 entered the room and began to go through her belongings then went over to Resident 2's bed. Resident 3 stated she went to inform the nurse that Resident 1 was in their room. During a review of Resident 3's MDS dated 3/21/24, it indicated Resident 3's BIMS assessment score was 15. The BIMS assessment indicated Resident 3 was cognitively intact. During a telephone interview on 4/23/24 at 5:20 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/10/24 Resident 3 informed her that Resident 1 and Resident 2 were going to get into a fight. LVN 1 stated that she entered Resident 2's room and observed Resident 1 and Resident 2 holding each other wrists. LVN 1 stated the CNA assigned to Resident 1 was on break and that she was preparing to begin medication pass. LVN 1 stated the importance of the care plan was to ensure staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete following safety protocols to avoid altercations. LVN 1 stated she was not aware that Resident 1 wondered into other resident rooms and that is it was her first time caring for Resident 1. LVN 1 stated staff should have monitored Resident 1 to prevent her from going into Resident 2's room. During a telephone interview on 4/25/24 at 9:31 a.m. with CNA 2, CNA 2 stated she was Resident 1's assigned CNA on 4/10/24. CNA 2 stated when Resident 1 was out of her room she needed to be monitored to prevent her from entering other resident rooms. CNA 1 stated she communicated to the LVN on shift that she was going on break. CNA 1 stated the altercation could have been avoided if Resident 1 was monitored. Event ID: Facility ID: 056155 If continuation sheet Page 3 of 3