Health inspection·April 1, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their policy and procedure to thoroughly investigate an allegation of abuse for one (Resident 1) of three sampled residents. Resident 1 alleged that a Certified Nursing Assistant (CNA1) hit him on the right leg because he refused to wear a sock. Facility designee/Director of Nursing (DON) did not interview alleged CNA, staff member assigned to provide care for Resident 1 and/or implement care plan to suspend alleged abuser while incident was under investigation. Residents Affected - Few This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 3/11/25, 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 9 meaning mild cognition. Resident 1 had clear speech, difficulty communicating some words or finishing thoughts, misses some part or intent of message. Resident 1 was dependent on helper does all task to put on and take off socks. Resident 1 ' s diagnoses included cerebrovascular accident (CVA) or stroke. During a concurrent observation and interview on 4/1/25 at 10:20 a.m. with Resident 1 in his room. Resident 1 stated he did not want to talk about the allegation. During a review of Resident 1 ' s care plan dated 3/16/25, the care plan indicated Resident 1 alleged physical abuse from facility ' s CNA, interventions included to suspend alleged abuser while incident is under investigation. During an interview on 4/1/25 at 11:01 a.m. with Certified Nursing Assistant (CNA1) , CNA1 stated she was not aware that Resident 1 alleged physical abuse by a CNA. CNA1 stated she was not informed of any allegation of abuse and was not suspended. CNA 1 stated she continued to assist Resident 1 with care as needed. During a concurrent interview and record review on 4/1/25 at 1:56 p.m., with Director of Nursing (DON), the investigation summary completed 3/21/25 was reviewed. The investigation summary did not include documentation that alleged CNA 1 and or Resident 1 ' s care givers were interviewed. DON stated facility process was to interview staff when the allegation involved staff member. DON stated alleged CNA1, and Resident 1 assigned care giver were not interviewed or suspended because Resident 1 was Page 1 of 4 056359 056359 04/01/2025 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0610 a poor historian. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Reporting Abuse, revised January 08, 2014, the P&P indicated, Upon an allegation of abuse by facility staff member, the facility staff member will be suspended and removed from the premises during the investigation. Residents Affected - Few 056359 Page 2 of 4 056359 04/01/2025 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure necessary treatment and care services was provided for one (Resident 2) of three sampled residents in accordance with professional standards of practice when, rehabilitation referral for restorative nursing (RNA) for Resident 1 was not followed up. Residents Affected - Few This failure had the potential for Resident 1 to not receive the necessary care and services to ensure mobility and muscle strength. Findings: During a review of Resident 2's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 2/26/25, 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.) score was 15 and indicated intact mental status. The MDS indicated Resident 2 was able to recall the correct year, month, and day of the week. MDS indicated Resident 2 need partial assistance from another person with walking from room to room. The MDS indicated Resident 2 had diagnoses that included morbid obesity. During a concurrent observation and interview on 4/1/25 at 11:15 a.m. Resident 2 sat up in bed in his room, awake and verbally responsive. Resident 2 stated he was not able to walk. Resident 2 stated Restorative Nursing Assistance (RNA) had not provided him treatment to help him to walk. During a concurrent interview and record review on 4/1.25 at 12:32 p.m. with Director of Rehabilitation (DOR1), Resident 1 ' s Occupational Therapy (OT) Discharge summary dated [DATE] was reviewed. OT and (PT) Physical therapy discharge recommendation indicated RNA for bilateral upper extremities (BUE) treatment and standing with front wheel walker (FWW) to facility maintenance of mobility and bilateral upper extremities (BUE) strength. DOR 1 stated Resident 1 was discharge from PT/OT therapy into RNA for functional maintenance of mobility and strength. During an interview on 4/1/25 at 12:30 p.m. with Restorative Nursing Assistant (RNA1), accompanied by RNA2 and RNA3, RNA1 stated Resident 1 was not on RNA services. RNA 1 stated facility process was when resident was discharged from PT/OT, RNA referral is given to nursing department. RNA1 stated she was not aware Resident 1 had an RNA referral. During a concurrent interview and record review on 4/1/25 at 12:48 p.m. with Licensed Vocational Nurse/Director of Staff Development (LVN1), Resident 1 ' s Restorative Program description dated 3/13/25 was reviewed. Resident 1 ' s restorative program description indicated cable exercises as tolerated three times a week, walking in hallway with front wheel walker. LVN1 stated she was responsible to follow up with Resident 1 ' s RNA referral. LVN1 stated she was sick for two weeks and did not follow up on Resident 1 ' s RNA referral. During a concurrent interview and record review on 4/1/25 at 2:10 p.m. with Director of Nursing (DON), Resident 1 ' s Restorative Program description dated 3/13/25 was reviewed. DON stated he will investigate what happened and why Resident 1 ' s referral for RNA was not followed up. 056359 Page 3 of 4 056359 04/01/2025 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0825 Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s policy and procedure (P&P) titled, Restorative Nursing Program Guidelines, revised September 19, 2019, the P&P indicated, The Director of Nursing Services (DON), or their licensed nurse designee, manages and directs the Restorative Nursing Program. Residents Affected - Few 056359 Page 4 of 4