Health inspection·August 30, 2024

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 observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 with a cane. Residents Affected - Few This failure resulted in Resident 1 sustaining injury and pain to the right lower leg . Findings: A review of Resident 1's admission Record indicated Resident 1 was most recently admitted to the facility in October 2023 with multiple diagnoses including paraplegia (paralysis of the legs), Stage 4 pressure ulcer (full thickness skin loss extending into deep tissues due to prolonged pressure to area) of the sacral region (bottom of the spine), diabetes (too much sugar in the blood), and dementia (loss of memory and thinking abilities). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 5/29/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's Change in Condition Evaluation, dated 8/25/24, indicated .skin discoloration d/t [due to] alleged physical aggression with other resident . A review of Resident 1's Progress Notes, dated 8/25/24 at 5:30 a.m., indicated .Licensed nurse received a report at 5:30am from CNA [Certified Nursing Assistant] that resident [Resident 1] was been hit by resident [Resident 2] with the cane and both resident was separated immediately. Body assessment done and Noted skin discoloration at right lower leg . A review of Resident 1's Progress Notes, dated 8/25/24 at 6:39 p.m., indicated .Resident has bruising and raised bumps to his right leg from a reported altercation from his roommate . A review of Resident 1's Progress Notes, dated 8/26/24 at 10:55 a.m., indicated .IDT [Interdisciplinary Team] met to discussed [sic] regarding incident of altercation with his roommate .[Resident 2] hit resident with his cane .DON [Director of Nursing] asked what happened, and he stated I don't know. He just came to me and started hitting me with his cane. I think he is bored of being here and has some mental issues . A review of Resident 1's Progress Notes, dated 8/26/24 at 5:25 p.m., indicated .when asked about the incident, resident stated his roommate all of a sudden started waving his cane at the ceiling and then came over to him and hit him on the leg with his cane. He stated he hit him one time with his Page 1 of 3 056304 056304 08/30/2024 Mission Carmichael Healthcare Center 3630 Mission Avenue Carmichael, CA 95608

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cane, resident stated he did not say anything to the resident, he stated he thinks his roommate was mad about something else . A review of Resident 1's Progress Notes, dated 8/28/24, indicated . Resident's leg with discoloration on the right shin with the fluid buildup, report 7/10 [severe] pain on the pain scale, PRN [as needed] pain medication administered with effectiveness . A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility in July 2024 with multiple diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain), hypertension (high blood pressure), and dysarthria (difficulty speaking) following cerebral infarction. A review of Resident 2's MDS, Cognitive Patterns, dated 7/18/24, indicated Resident 2 had a BIMS score of 15 out of 15 which indicated Resident 2 was cognitively intact. A review of Resident 2's Change in Condition Evaluation, dated 8/25/24, indicated .Alleged physical aggressor . A review of Resident 2's Progress Notes, dated 8/25/24, indicated .Licensed nurse received report from CNA around 5:30am that resident hit roommate . A review of Resident 2's Progress Notes, dated 8/26/24, indicated .IDT met to discussed [sic] incident of allegation of physical aggression towards roommate .resident hit his roommate with his cane for no apparent reason. When staff tried to intervene, he threatened to hit them as well .Today DON went and talked to resident, resident stated what incident? I don't remember. When asked if he had altercation with his former roommate, resident stated, Oh, I didn't hit him hard. He called me a [racial slur] . A review of the facility's five day follow up report, dated 8/29/24, indicated .[Resident 2] hit his roommate [Resident 1] on his leg with his cane .[Resident 1] stated there was no precipitated event that happened to cause the incident. He sated [sic] his roommate, all of a sudden, started waving his cane around pointing it towards the ceiling and then hit [Resident 1] on his leg .[Resident 1]'s assigned CNA .was interviewed .she was across the hallway .when she heard [Resident 1] saying, you're waking me up, I'm trying to sleep here .she overheard [Resident1] calling [Resident 2] a [racial slur] .saw [Resident 2] swing his cane at [Resident 1] .Intervention .[Resident 1] was noted with a skin discoloration on right lower leg . During an interview on 8/30/2024 at 9:27 a.m. with Resident 2, Resident 2 stated, He [Resident 1] was upsetting me. I remember hitting him with a cane. Resident 2 stated that Resident 1 called him a [racial slur] and it upset him. During an interview on 8/30/24 at 10:12 a.m. with the DON, the DON stated, The nurse called me. She said the CNA reported to her that [Resident 2] hit [Resident 1]. I said go ahead do assessment and reporting. I checked with [Resident 1] on Monday. I asked the nurse to check with NP [Nurse Practitioner] for x-ray order, noted some swelling. During a telephone interview on 8/30/2024 at 11:16 a.m. with CNA 2, CNA 2 stated she heard Resident 1 say You woke me up, trying to sleep. Why do you keep going into the bathroom. CNA 2 stated she 056304 Page 2 of 3 056304 08/30/2024 Mission Carmichael Healthcare Center 3630 Mission Avenue Carmichael, CA 95608

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few heard side table moving in the room and entered the room. CNA 2 stated, I saw [Resident 2] with arm straight in the air with cane in the air coming down and hitting [Resident 1] 's leg. During a telephone interview with Licensed Nurse (LN) 2 at 11:36 a.m. LN 2 stated, on 8/25/24 at approximately 5:30 a.m., the CNA reported to her that Resident 2 hit Resident 1. LN 2 stated, The CNA reported that [Resident 1] called [Resident 2] a [racial slur] because [Resident 2] goes to the bathroom by himself and [Resident] 2 was upset at words used. LN 2 stated she noted skin discoloration to Resident 1's right lower leg. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, dated 9/2/2022, indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents .cause physical harm or mental anguish .It includes . physical abuse .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Possible indicators of abuse include .Physical abuse of a resident observed . 056304 Page 3 of 3