Health inspection·June 17, 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 observation, interview, and record review, the facility failed to ensure two out of six residents (Resident 1 and Resident 3) were free from physical abuse when: Residents Affected - Few 1) Resident 1 was hit in the head by Resident 2, 2) Resident 3 had lemonade thrown at her by Resident 4. This failure resulted in Resident 1 and Resident 3 being the recipient of physical abuse which affected their physical and psychosocial well-being. Findings: 1) A review of Resident 1 ' s Face Sheet, printed 3/4/25, indicated Resident 1 ' s diagnoses of heart failure (heart not able to pump enough blood to meet body ' s needs) and generalized weakness. A review of Change in Condition Evaluation, written on 12/8/24 at 9:42 a.m., the Change in Condition Evaluation noted Resident 1 was in the room waiting for Resident 2 to come out of the bathroom. Resident 1 stated when Resident 2 came out of the bathroom, Resident 2 hit her twice in the head. In the Pain Assessment section, Resident 1 reported a pain level of 4 (0 being the lowest pain level and 10 being the highest pain level). During an interview on 3/4/25, at 11:35 a.m., with Licensed Vocational Nurse (LVN), LVN stated Resident 1 was in her wheelchair by her room door, gesturing and pointing to the back of the head along with facial grimacing. Per Change in Condition Evaluation, Resident 2 was transferred to another room with no roommate. During an interview on 3/4/25, at 1:45 p.m., with Registered Nurse (RN), RN stated Resident 2 did not have a sitter (staff assigned to a resident to monitor actions and behaviors) on night shift. During an interview on 3/4/25, at 2:10 p.m., with the Director of Nursing (DON), the DON stated Resident 2 had been on 1:1 (designated staff who monitors a resident) for about six months prior to this incident. Per DON, Resident 2 was weaned off 1:1 observation status. The DON added 1:1 observation is guaranteed on AM (7:00 a.m. – 3:30 p.m.) and PM (3:00 p.m. to 11:30 p.m.) shifts but not guaranteed on night (11:00 p.m. to 7:30 a.m.) shifts. The DON confirmed Resident 2 did not have an assigned sitter on the night shift of the incident. The incident occurred on 12/8/24 between 6:30 a.m. and 7:00 a.m. Page 1 of 2 056359 056359 06/17/2025 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/17/25, at 11:30 a.m., with the DON, the DON stated Resident 2 was on staff supervision on AM and PM shifts due to facility activities and multiple interactions with staff and other residents. Resident 2 was not on staff observation status on night shifts because there were no facility activities. A review of the facility ' s Summary of Investigation, completed on 12/13/24, the Administrator (ADM) concluded the incident as a negative interaction between residents. The investigation summary further noted Resident 1 verbalized she will feel safe and not threatened if Resident 2 will not come back to her room again. 2) A review of Resident 3 ' s Face Sheet, printed 6/17/25, indicated Res 3 ' s diagnoses of respiratory failure (lungs cannot properly exchange gases between oxygen and carbon dioxide) and chronic pain syndrome (persistent pain that lasts weeks to years). A review of Resident 3 ' s SBAR (situation, background, appearance, review) Communication Form, written on 12/9/24, the SBAR Communication Form noted on 12/9/24 at around 2:00 p.m., Resident 4 threw lemonade at roommate Resident 3. A review of Resident 4 ' s SBAR Communication Form, written on 12/9/24, the SBAR Communication Form noted in the Behavioral Evaluation section, Resident 4 displayed verbal and physical aggression. Noted on the form, Resident 4 said she threw lemonade at Resident 3 due to Resident 3 lying about her own medical conditions. Both residents were separated and reassigned to other rooms. A review of Progress Notes, written on 12/9/25 at 11:47 p.m., Resident 4 was noted getting irritated with aggressive behaviors towards sitter and nurse. Progress Notes written on 12/10/24 at 2:13 p.m. noted Resident 4 getting irritated late afternoon, grabbing wheelchair and hitting the wall. Progress Notes written on 12/11/24 at 2:42 p.m. noted Resident 4 continued to have aggressive behavior, noncompliance of smoking schedule breaks and became angry and frustrated. A review of Resident 4 ' s SBAR Communication Form, written on 12/18/24, the SBAR Communication Form noted in the Behavioral Evaluation section, Resident 4 was a danger to self or others, had verbal and physical aggression. Resident 4 was placed on 5150 (involuntary 72-hour hold of an individual for psychiatric evaluation) and was taken to a psychiatric emergency hospital. During an interview on 6/17/25, at 4:22 p.m., with Certified Nursing Assistant (CNA), CNA stated she heard screaming from the room of Resident 3 and Resident 4. Per CNA, when she arrived at the room, she saw both residents screaming at each other. CNA called for staff assistance and residents were separated. A review of the facility ' s Summary of Investigation, completed on 12/14/24, the Administrator (ADM) concluded the incident as a negative interaction between residents. A review of the facility ' s policy and procedure (P&P) titled, Abuse – Prevention, Screening, & Training Program, dated July 2018, the P&P indicated, The Facility establishes a safe environment that reasonably supports resident to the extent possible . The facility identifies, corrects, and intervenes in situations in which abuse . is more likely to occur. 056359 Page 2 of 2