Health inspection·December 10, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the light switch and turned on the lights. Resident 2 told Resident 1 to turn off the lights but Resident 1 refused and yelled No . Resident 2 then reached for the light switch, which was close to her bed and turned off the lights, but Resident 1 turned on the lights again. Resident 2 stated she stood up and walked to Resident 1 and patted Resident 1 lightly in her right cheek. Resident 1 in return, scratched Resident 2 in her left arm. Resident 2 stated she did not intend to pat Resident 1 in the cheek but stated she lost her patience. Resident 2 stated she apologized to Resident 1 later that night. Resident 2 stated, nobody saw the altercation between her and Resident 1, but she told the Social Service Director (SSD) about what happened the following day on 11/22/24 afternoon, because she felt bad about what she did. Stated she moved to another room after she talked to the SSD. Review of Resident 2's Minimum Data Set ( MDS, an assessment tool) dated 12/4/24, indicated she had a brief interview for mental status or BIMS of 15 (BIMS score of 13 to 15 indicates cognition is intact). The MDS indicated Resident 2 had no physical and verbal behavior symptoms directed toward others. The MDS also indicated that Resident 2 only needed supervision from the staff when moving from seated to standing position and walking ten feet in a room. Review of Resident 2's Departmental Notes dated 11/22/24 at 5:24 p.m., indicated Resident 2 mentioned to the SSD that she had an altercation with her roommate Resident 1 the previous night (11/21/24) because Resident 1 wanted their room lights on, and Resident 2 wanted the lights off. The residents Page 1 of 5 555016 555016 12/10/2024 St John Kronstadt Convalescent Center 4432 James Avenue Castro Valley, CA 94546

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disagreed verbally and then Resident 2 slapped Resident 1 and Resident 1 scratched Resident 2 which gave Resident 2 two scratches in her left arm. The notes also indicated that Resident 2 was moved to another room and the facility called the police department. During an interview with SSD on 11/10/24 at 1:39 p.m., SSD stated on 11/22/24, at around 4:00 p.m., Resident 2 told her that she had a disagreement with Resident 1 because Resident 1 wanted the lights on but Resident 2 wanted the lights off. Resident 2 stated the situation escalated, and Resident 2 lost her temper and slapped Resident 1 in the face, and Resident 1 scratched Resident 2 in her left arm. SSD stated Resident 2 said she was sorry for what happened because she reacted to what Resident 1 was doing when she kept turning on the lights. SSD stated Resident 2 was moved to another room. SSD stated Resident 2 obtained 2 scratches in her left arm and Resident 1 had no injuries. During an observation on 12/10/24 at 11:53 a.m., Resident 1 was seen wheeling herself around the facility's hallways repeatedly and independently in a wheelchair unaccompanied by staff. Review of Resident 1's indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 1's MDS dated [DATE], indicated BIMS of 4 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS indicated that Resident 1 had physical and verbal behavioral symptoms directed toward others daily. The MDS also indicated that Resident 1 only requires setup or clean-up assistance with her wheelchair, meaning a helper will set up the wheelchair or clean up after use. The MDS further indicated Resident 1 was independent once sitting in the wheelchair and had the ability to wheel herself for at least 150 feet in corridor or similar space. The MDS revealed Resident 1 had wandering (travelling aimlessly from place to place) episodes. During an interview CNA 1 on 12/11/24 at 1:09 p.m., stated Resident 1 wandered around the facility, went to other residents' rooms, and sometimes took things that belonged to other residents. During an interview with the Director of Nursing (DON) on 12/13/24 at 2:16 p.m. and concurrent review of Resident 1's Departmental Notes, the notes indicated that there were three other incidents when Resident 1 had altercations with three other residents (Residents 3, 4 and 5). One incident was on 10/18/24 at 3:17 p.m., when Resident 3 reported that Resident 1 wandered in her room, and when she asked Resident 1 to leave, Resident 1 kicked her. Another incident happened on the same day of 10/18/24 at 10:11 p.m. when Resident 1 attempted to go to Resident 4's room and had a verbal altercation with Resident 4 (both of these incidents happened 35 days before the incident with Resident 2 on 11/21/24). Upon further review, Resident 1 had another verbal altercation with Resident 5 on 12/8/24 at 1:22 p.m.( happened 17 days after incident with resident 2 on 11/21/24), when Resident 1 took Resident 5's snowman decoration from Resident 5's board. The residents were separated right away on all three incidents, and no injuries were observed to the residents on all occasions. Further review with the DON of Resident 1's behavioral care plans, the DON could not find care plans that addressed Resident 1's altercations and behaviors with Residents 3 and 4 on 10/18/24, with Resident 2 on 11/21/24 and with Resident 5 on 12/8/24 . DON acknowledged a plan of care should have been developed and revised on all four altercations to monitor and prevent Resident 1's wandering and aggressive behavior towards other residents. DON also could not find Interdisciplinary Team (IDT-are an approach to healthcare that integrates multiple disciplines through collaboration) meeting notes which addressed or discussed interventions for Resident 1's altercations with Resident 2, 3, 4, and 5. 555016 Page 2 of 5 555016 12/10/2024 St John Kronstadt Convalescent Center 4432 James Avenue Castro Valley, CA 94546

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents, revised September 2016, the P&P indicated, .Identifying Residents at Risk for Accidents: Procedure: 1. The interdisciplinary team will evaluate accident potential during admission, quarterly and annual assessments; and when a resident experiences a significant change of condition .3. Accident hazards identified by the interdisciplinary team will be recorded on the Interdisciplinary Team Notes. 4. the plan of care developed by the interdisciplinary team will be recorded on the resident care plan . Based on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the light switch and turned on the lights. Resident 2 told Resident 1 to turn off the lights but Resident 1 refused and yelled No . Resident 2 then reached for the light switch, which was close to her bed and turned off the lights, but Resident 1 turned on the lights again. Resident 2 stated she stood up and walked to Resident 1 and patted Resident 1 lightly in her right cheek. Resident 1 in return, scratched Resident 2 in her left arm. Resident 2 stated she did not intend to pat Resident 1 in the cheek but stated she lost her patience. Resident 2 stated she apologized to Resident 1 later that night. Resident 2 stated, nobody saw the altercation between her and Resident 1, but she told the Social Service Director (SSD) about what happened the following day on 11/22/24 afternoon, because she felt bad about what she did. Stated she moved to another room after she talked to the SSD. Review of Resident 2's Minimum Data Set ( MDS, an assessment tool) dated 12/4/24, indicated she had a brief interview for mental status or BIMS of 15 (BIMS score of 13 to 15 indicates cognition is intact). The MDS indicated Resident 2 had no physical and verbal behavior symptoms directed toward others. The MDS also indicated that Resident 2 only needed supervision from the staff when moving from seated to standing position and walking ten feet in a room. Review of Resident 2's Departmental Notes dated 11/22/24 at 5:24 p.m., indicated Resident 2 mentioned to the SSD that she had an altercation with her roommate Resident 1 the previous night (11/21/24) because Resident 1 wanted their room lights on, and Resident 2 wanted the lights off. The residents disagreed verbally and then Resident 2 slapped Resident 1 and Resident 1 scratched Resident 2 which gave Resident 2 two scratches in her left arm. The notes also indicated that Resident 2 was moved to another room and the facility called the police department. During an interview with SSD on 11/10/24 at 1:39 p.m., SSD stated on 11/22/24, at around 4:00 p.m., 555016 Page 3 of 5 555016 12/10/2024 St John Kronstadt Convalescent Center 4432 James Avenue Castro Valley, CA 94546

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 told her that she had a disagreement with Resident 1 because Resident 1 wanted the lights on but Resident 2 wanted the lights off. Resident 2 stated the situation escalated, and Resident 2 lost her temper and slapped Resident 1 in the face, and Resident 1 scratched Resident 2 in her left arm. SSD stated Resident 2 said she was sorry for what happened because she reacted to what Resident 1 was doing when she kept turning on the lights. SSD stated Resident 2 was moved to another room. SSD stated Resident 2 obtained 2 scratches in her left arm and Resident 1 had no injuries. During an observation on 12/10/24 at 11:53 a.m., Resident 1 was seen wheeling herself around the facility's hallways repeatedly and independently in a wheelchair unaccompanied by staff. Review of Resident 1's indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 1's MDS dated [DATE], indicated BIMS of 4 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS indicated that Resident 1 had physical and verbal behavioral symptoms directed toward others daily. The MDS also indicated that Resident 1 only requires setup or clean-up assistance with her wheelchair, meaning a helper will set up the wheelchair or clean up after use. The MDS further indicated Resident 1 was independent once sitting in the wheelchair and had the ability to wheel herself for at least 150 feet in corridor or similar space. The MDS revealed Resident 1 had wandering (travelling aimlessly from place to place) episodes. During an interview CNA 1 on 12/11/24 at 1:09 p.m., stated Resident 1 wandered around the facility, went to other residents' rooms, and sometimes took things that belonged to other residents. During an interview with the Director of Nursing (DON) on 12/13/24 at 2:16 p.m. and concurrent review of Resident 1's Departmental Notes, the notes indicated that there were three other incidents when Resident 1 had altercations with three other residents (Residents 3, 4 and 5). One incident was on 10/18/24 at 3:17 p.m., when Resident 3 reported that Resident 1 wandered in her room, and when she asked Resident 1 to leave, Resident 1 kicked her. Another incident happened on the same day of 10/18/24 at 10:11 p.m. when Resident 1 attempted to go to Resident 4's room and had a verbal altercation with Resident 4 (both of these incidents happened 35 days before the incident with Resident 2 on 11/21/24). Upon further review, Resident 1 had another verbal altercation with Resident 5 on 12/8/24 at 1:22 p.m.( happened 17 days after incident with resident 2 on 11/21/24), when Resident 1 took Resident 5's snowman decoration from Resident 5's board. The residents were separated right away on all three incidents, and no injuries were observed to the residents on all occasions. Further review with the DON of Resident 1's behavioral care plans, the DON could not find care plans that addressed Resident 1's altercations and behaviors with Residents 3 and 4 on 10/18/24, with Resident 2 on 11/21/24 and with Resident 5 on 12/8/24 . DON acknowledged a plan of care should have been developed and revised on all four altercations to monitor and prevent Resident 1's wandering and aggressive behavior towards other residents. DON also could not find Interdisciplinary Team (IDT-are an approach to healthcare that integrates multiple disciplines through collaboration) meeting notes which addressed or discussed interventions for Resident 1's altercations with Resident 2, 3, 4, and 5. During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents, revised September 2016, the P&P indicated, .Identifying Residents at Risk for Accidents: Procedure: 1. The interdisciplinary team will evaluate accident potential during admission, quarterly and annual assessments; and when a resident experiences a significant change of condition .3. Accident hazards identified by the interdisciplinary team will be recorded on the Interdisciplinary Team Notes. 4. the 555016 Page 4 of 5 555016 12/10/2024 St John Kronstadt Convalescent Center 4432 James Avenue Castro Valley, CA 94546

F 0689 plan of care developed by the interdisciplinary team will be recorded on the resident care plan . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555016 Page 5 of 5