Health inspection·December 19, 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 ensure one of three sampled residents (Resident 1) was free of physical abuse when Resident 1 was struck in the face by Resident 2. Residents Affected - Few This failure resulted in Resident 1 sustaining a swollen bruise to her face and feeling unsafe. Findings: Resident 1 was admitted in the spring of 2024 with an admission diagnosis of irregular heartbeat. Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 which indicated his cognitive function was moderately impaired. Resident 1 was her own responsible party. Resident 2 was admitted in the spring of 2024 with an admission diagnosis of spinal stenosis (a narrowing of the spinal canal that compresses the spinal cord and nerve roots, causing pain, numbness, or weakness in the arms or legs). Resident 2 had a BIMS score of 14 out of 15 which indicated she was cognitively intact and was her own responsible party. During an interview on 12/19/24 at 9:10 a.m. with Resident 1, while sitting in her wheelchair in her room, Resident 1 reported that Resident 2 hit her across her face and she sustained a black eye and swollen face from the hit. Resident 1 stated, I don ' t feel safe .I ' m afraid she ' ll [Resident 2] hit [me] again. I stay away from her. Review of Resident 1 ' s SBAR Summary (Situation, Background, Assessment, and Recommendation, a communication framework to share information among healthcare teams), dated 12/7/24, indicated staff heard noise from Resident 1and Resident 2 ' s shared room on 12/7/24. Resident 1 reported to staff that Resident 2 slapped me on the right side of face. There were no witnesses present. The SBAR Summary indicated Resident 1 was assessed by staff and Resident 1 noted with redness to right cheek 5.08cm [centimeter, a measurement] .[Resident 1] noted with bruising to bony prominence above right eye bruise noted 5 cmx1cm. Review of Resident 2 ' s Change in Condition Evaluation dated 12/07/2024, the evaluation indicated, PT [Resident 2] slapped her roommate [Resident 1], and stated, ' I will do it again ' . Review of Resident 1 ' s Social Services note dated 12/09/24, the social services note indicated Resident 1 acknowledged Resident 2 slapped her on the right side of her face documenting, Resident RT Page 1 of 3 555083 555083 12/19/2024 Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608

F 0600 side of face is swollen and has bruises. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/19/24 at 11:46 a.m. with Assistant Director of Nursing (ADON), the ADON acknowledged Resident 2 admitted that she hit Resident 1 on 12/7/24. Residents Affected - Few During an interview on 12/19/24 at 12:06 p.m. with Social Services Director (SSD), the SSD stated she interviewed Resident 1 and Resident 2 two days after the incident on 12/9/2024. The SSD acknowledged she witnessed Resident 1 ' s cheek was swollen then. The SSD stated, [Resident 2 ' s name] did not deny the fact that she slapped her [Resident 1]. During an interview on 12/19/24 at 12:16 p.m. with Resident 2, Resident 2 stated, I slapped her [Resident 1] .I ' ve never once said I didn ' t do it .I was facing her when I slapped her face. Resident 2 stated she had argued with Resident 1 about a secret hiding place for smoking, which prompted the incident. 555083 Page 2 of 3 555083 12/19/2024 Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 provide a functioning call light system for two of four sampled residents (Resident 3 and Resident 4) when neither the outside light above their room lit nor the alarm sounded when the emergency call light was pushed in the bathroom. Residents Affected - Few This failure had the potential to result in unmet care needs and placed the residents at risk for safety. Findings: Resident 3 was admitted on [DATE] for a fracture of the right femur. Resident 3 has a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated the resident was cognitively intact and was her own responsible party. Resident 4 was admitted on [DATE] with a fracture of one rib. Resident 4 has a BIMS score of 12 out of 15 which indicated the resident was moderately impaired in cognitive function. Resident 4 was responsible party for self. During an interview on 12/19/24 at 10:06 a.m. with Resident 3 in her room, Resident 3 stated, The first night wasn ' t good, our [Resident 3 and Resident 4] call lights weren ' t working. Resident 3 stated staff fixed the call lights on 12/10/24 but told Resident 3, not to hit the emergency call light in the bathroom .because our call lights [in our room] won ' t work anymore. Resident 3 stated, He was stern .scared me to death to push it [emergency call light in bathroom]. During an interview on 12/19/24 at 10:18 a.m. with Resident 4, Resident 4 stated she was also told by staff not to hit the emergency call light in the bathroom, because the call lights in the room will not work. Resident 4 stated she did not remember the staff member ' s name or what he looked like. During a concurrent observation and interview on 12/19/24 at 10:33 a.m. with Maintenance (MAIN) in Resident 3 and Resident 4 ' s shared bathroom, the emergency bathroom call light was tested. It was observed the light above the residents ' room in the hallway did not light up nor did the alarm sound. The MAIN acknowledged the emergency call light in the bathroom was not working and stated, It should be (working properly). The MAIN also acknowledged it was a priority to get the call light working. During a review of the facility ' s policy and procedure titled, Call System, Resident, dated September 2022, indicated, Each resident is provided with a means to call staff directly for assistance .from toileting/bathing facilities .the resident call system remains functional at all times. During a concurrent observation and interview on 12/19/24 at 11:09 a.m. with Director of Nursing (DON) in Resident 3 and Resident 4 ' s shared bathroom, the DON verified the emergency call light in the bathroom was not working. The DON stated the expectation was for the emergency bathroom call light to be working so that staff could attend to residents ' needs when they called. 555083 Page 3 of 3