Health inspection·April 14, 2025

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 four sampled residents (Resident 1) when Resident 2 punched Resident 1 in the stomach which caused Resident 1 to fall and hit her head. This failure resulted in an injury to Resident 1's head. Findings: Resident 1 was admitted to the facility late 2021 with diagnoses which included memory loss, weight loss, muscle wasting, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/10/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a standardized test that screens for cognitive impairment) score of 9/15 which showed moderate cognitive impairment. During a review of Resident 1's eINTERACT Change in Condition Evaluation [eCOCE], dated 4/7/25 at 5 p.m. the eCOCE indicated, .Resident was punched by other resident in the stomach, fell down, hit back of her head on the metal door frame, bleeding a lot. Send out via 911 . During a review of Resident 1's Order Summary Report [OSR], dated 4/8/25, the OSR indicated, Monitor laceration to head . During an observation on 4/14/25 at 2:52 p.m. of Resident 1's scalp with Licensed Nurse 2 (LN 2), Resident 1 had a small area of dried dark material on the back of her head and yellow discoloration on her left shoulder. Resident 2 was admitted to the facility mid 2023 with diagnoses which included memory impairment caused by impaired blood flow to the brain, behavioral disturbances, progressive degenerative disorder that caused a decline in memory, thinking and behavior, and a language disorder. During a review of Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 0/15, which showed severe cognitive impairment. During a review of Resident 2' s eCOCE dated 4/7/24 at 5:37 p.m. the eCOCE indicated, . resident [Resident 2] was witnessed making contact with other resident [Resident 1] stomach resulting in resident [Resident 1] to lose balance and fall to floor . Page 1 of 2 555083 555083 04/14/2025 Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's Care Plans (CP) dated 12/30/24-4/7/25, the CPs indicated Resident 2 had multiple episodes of physical aggression, increased agitation and aggression. During an interview on 4/14/25 at 12:20 p.m. with the Unit Secretary (US), the US stated she witnessed Resident 2 walked past Resident 1 and punch her in the stomach, which caused Resident 1 to fall to the floor and hit her head on the door frame. The US stated Resident 1 had a history of being aggressive. During an interview on 4/14/25 at 12:37 p.m. with the Social Services Director (SSD), the SSD stated Resident 1 was able to walk around the facility and had hit other residents in the past. During an interview on 4/14/25 at 2:42 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1 had a repeated history of aggression and stated, Safety for the resident's is our top priority, we don't want residents to get hurt. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/17, the P&P indicated, .Resident safety and supervision and assistance to prevent accident are facility-wide priorities .Resident supervision is a core component of the systems approach to safety . 555083 Page 2 of 2