Health inspection·November 20, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (intentional act of causing injury or trauma to another person through bodily contact) for one of four sampled residents (Resident 1) when on 9/8/25, Resident 2 who was known by the facility staff to have abusive behavior, approached Resident 1 and hit her on the hand and attempted to kick Resident 1.This failure resulted in a bruised right hand on Resident 1. In addition, this failure left Resident 1 feeling upset, uncomfortable, and unsafe.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included: need for assistance with personal care, other abnormalities of gait (walking) and mobility (ability to move around freely), and depression (a common mental health condition with continuous feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable).A review of Resident 1's minimum data set (MDS - a resident assessment and screening tool which identifies care needs) dated 8/18/25, under the section titled, .Section C: Cognitive Patterns, - (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) indicated Resident 1's Brief Interview for Mental Status (BIMS - a screening tool used in long-term care to assess a resident's cognitive function [the mental processes like thinking, memory, and perception, that a person uses to understand and respond to their environment] Scoring = 13-15 indicates normal intact cognitive function, 8-12 moderate cognitive impairment, 0-7 signifies severe cognitive impairment) was 14 out of 15 which indicated Resident 1 had normal intact cognitive function.A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included: dementia (a decline in cognitive functions such as memory, language, attention and problem-solving abilities that interfere with daily life) with agitation (a behavioral syndrome [a group of symptoms which consistently occur together] characterized by excessive restlessness, verbal outbursts, and/or physical aggression) and dementia with behavioral disturbance (the presence of a range of behavioral symptoms in a person with dementia such as aggression and agitation which interfere with daily life).A review of Resident 2's MDS dated [DATE], under the section titled, .Section C: Cognitive Patterns, indicated Resident 2's BIMS was 99 which indicated Resident 2 was unable to complete the interview.A review of Resident 2's MDS dated [DATE], under the section titled, .Section E: Behavior, indicated that during the review period Resident 2 had, .A. Physical behavioral symptoms directed towards others (e.g. [for example], hitting, kicking, pushing, scratching, grabbing, abusing others sexually).Behavior of this type occurred 1 to 3 days.Impact on others.A. Put others at significant risk for physical injury?.1. Yes.B. Significantly intrude on the privacy or activity of others?.1. Yes.During a concurrent interview and observation on 9/23/25, at 3:39 PM, in Resident 1's room, Resident 1 stated on 9/8/25 she was attacked by Resident 2, while sitting in a wheelchair in front of her room. Resident 1 explained her room Page 1 of 4 555190 555190 11/20/2025 English Oaks Convalescent & Rehabilitation Hospita 2633 West Rumble Rd Modesto, CA 95350

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was at the end of a long hallway and there was glass door where she could see outside. Resident 1 further explained, when she saw Resident 2 coming toward the end of the hallway, she tried to move out of the way since there was not a lot of room in the hallway. Resident 1 stated as Resident 2 approached her she said hello and then Resident 2 reached out and struck her on her hand with his hand. Resident 1 stated Resident 2 also attempted to kick her, but Resident 1 was able to use her legs to back her wheelchair into her room to avoid being kicked. Resident 1 stated no one was in the hallway when he hit and attempted to kick her, so she yelled out. Resident 1 further stated she felt upset because she was not expecting to get hit by Resident 2. Resident 1 explained she felt uncomfortable and unsafe to get into her wheelchair and roam the facility because Resident 2 frequented the hallways near her path. The end of the hallway was observed where Resident 1's room and the physical abuse incident occurred and was noted to not be visible from the nurses station.During an interview on 9/23/25, at 3:15 PM, Licensed Nurse (LN) 1 confirmed while working on 9/8/25 she was alerted by Certified Nursing Assistant (CNA) 3 of the physical abuse that occurred between Resident 1 and Resident 2. LN 1 stated CNA 3 reported to her that she heard yelling while CNA 3 was in a room and went to check on it. LN 1 further stated when Resident 1 explained what happened, LN 1 checked Resident 1 for injuries and observed Resident 1 had redness on her right hand. LN 1 explained Resident 1 was upset and told LN 1 that she did not want to see Resident 2 again. LN 1 further explained Resident 2 was known to become easily agitated, angry, moody and sometimes not approachable. LN 1 stated that Resident 2 had a history of hitting staff during care. LN 1 further stated because Resident 2 was known to have these behaviors the staff kept a close eye on Resident 2 when he was out of his room.During an interview on 9/24/25, at 11:36 AM, CNA 3 stated while she was working on 9/8/25 she was about 4 rooms down the hall in another residents room when she heard a resident start yelling, stop it. CNA 3 further stated she came out of the room toward the yelling and saw that Resident 2 had wheeled himself in his wheelchair to the end of the hallway and was in front of Resident 1's room. CNA 3 explained she went to check on Resident 1 and was told by Resident 1 that Resident 2 had hit her and attempted to kick her. CNA 3 stated that Resident 1 pointed to her hand where she was hit by Resident 2. CNA 3 further stated she separated the residents and alerted LN 1. CNA 3 stated no other staff was in the hallway when she responded to Resident 1 yelling out. CNA 3 further stated she was not assigned to Resident 1 that day but was covering for her assigned CNA while she was at lunch. CNA 3 explained the abuse occurred during lunchtime and less staff were available to monitor Resident 2.During an interview on 9/24/25, at 11:26 AM, with LN 2, LN 2 stated she was the nurse for Resident 1 on 9/8/25, but was on lunch when the abuse occurred. LN 2 explained she was informed of the incident by LN 1. LN 2 stated she asked the Treatment Nurse (TN 1- provides direct patient care for wounds) to inspect Resident 1's hand for injury. LN 2 further stated Resident 1 told her she just wanted to stay in her room after the abuse. LN 2 stated Resident 2's room was in front of the nurses station so they could keep a closer watch on him. LN 2 explained the facility staff were on alert when Resident 2 was up and out of his room so they could keep him out of reach of other residents. LN 2 added because Resident 2 got easily agitated, for the safety of the other residents, the staff monitor him closely when he was out of his room. LN 2 further explained the abuse could have been prevented if the staff had kept a closer eye on Resident 2 when he went down the far hallway.During a concurrent interview and record review on 9/24/25, at 11:04 AM, with TN 1, Resident 1's electronic health record (EHR -a digital version of a patient's medical history, containing a collection of their health information), Progress Note, (a document in a residents EHR that records their medical treatment by healthcare professionals) dated 9/8/25, was reviewed. The document indicated TN 1 was asked by LN 2 to evaluate 555190 Page 2 of 4 555190 11/20/2025 English Oaks Convalescent & Rehabilitation Hospita 2633 West Rumble Rd Modesto, CA 95350

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's injury to her hand after the abuse by Resident 2. TN 1 stated her note indicated, .scattered discoloration to the back of the patients right hand. TN 1 recalled when she evaluated Resident 1's right hand it had new blue and reddish bruising to the top of her right hand.During an interview on 9/24/25, at 11:53 AM, with the Social Services Director (SSD), the SSD stated she checked on both Resident 1 and Resident 2 for three days after the abuse was reported. The SSD explained Resident 1 did not complain of fear but added Resident 1 told her, she felt uncomfortable from time to time when Resident 1 saw Resident 2. The SSD further explained she checked on Resident 2 after the incident and Resident 2 had no recollection of the abuse. The SSD explained Resident 2 possibly had a room down the hallway near Resident 1 at some point but added that Resident 2 should have been monitored more closely. The SSD further explained Resident 2 was free to roam around but with staff supervision.During a concurrent interview and record review on 9/24/25, at 4:04 PM, with the Administrator (ADM), Resident 2's EHR was reviewed. The ADM reviewed Resident 2's, .MONITORS - Hourly Safety Check.Location of Resident While., document dated 9/8/25, indicating that the facility staff document Resident 2's hourly monitoring for day shift on 9/8/25, as follows:9/8/25 5:50 AM -Box checked that hourly monitoring was completed, Resident 2's location was documented in his room.9/8/25 11:03 AM -Box checked that hourly monitoring was completed. Resident 2's location was documented in his room, and in the hallway.12:37 PM -Box checked that hourly monitoring was completed. Resident 2's location was documented in the hallway.13:25 [1:25 PM] -Box checked that hourly monitoring was completed. Resident 2's location was documented in his room.17:21 [5:21 PM] -Box checked that hourly monitoring was completed. Resident 2's location was documented in his room.The ADM confirmed Resident 2 was on hourly monitoring and the hourly monitoring was initiated because Resident 2 was wandering through the facility and in the hallways. The ADM stated her expectation was that staff were aware of Resident 2's location when he was out of his room, and what he was doing. The ADM acknowledged the hourly safety check was not documented hourly per her expectation on 9/8/25. The ADM confirmed Resident 2 had known behaviors of physically striking out towards staff. The ADM stated it was important for staff to closely monitor Resident 2 so that he did not hurt anyone. The ADM stated the risk when a known physically aggressive resident was not closely monitored was that anything could happen, at any time, and to anyone.A review of Resident 1's EHR document titled, SBAR [Situation Background, Appearance, Review and Notify] Communication Form and Progress Note., dated 9/8/25, completed by LN 2, indicated, .8. Skin Evaluation .Discoloration.9. Pain Evaluation.New.Description/location of pain: pain 5/10 [on a scale of 0-10, 0-meaning no pain, 10-meaning unbearable pain], writer offered pain medication.Summarize your observations and evaluation: Writer [LN 2] notified by another LN that [Resident 1] was hit on the back of right hand by [Resident 2]. Both residents were in wheelchair at the end of hallway when [Resident 1] moved out of the way and other [Resident 2] hit pt [patient].Tx [Treatment] nurse assessed pt [patient], noted with discoloration on back of right hand.A review of Resident 2's EHR document titled, SBAR, dated 9/8/25, completed by LN 1, indicated, .[Resident 2] wheel himself down the hallway and approach [Resident 1] who is sitting outside of her room. [Resident 1] talked to [Resident 2] and he did not respond [sic] her. [Resident 2] hit [Resident 1] on her right hand with [Resident 1] hand. He attempts to kick [Resident 1] but she moved.A review of Resident 2's Care Plan Report (a personalized plan of care document that outlines a person's health conditions, needs, goals, and actions needed to [NAME] them) revised 4/10/24, indicated, .[Resident 2] Receiving [type of medication] r/t [related to].dementia w/[with] behavioral disturbance.AEB [as evidenced by] combative/threatening behaviors towards staff.A review of Resident 2's Care Plan Report, revised 5/30/24, indicated, [Resident 2] admitted with [type of medication] r/t Anxiety (feeling of fear, unease) 555190 Page 3 of 4 555190 11/20/2025 English Oaks Convalescent & Rehabilitation Hospita 2633 West Rumble Rd Modesto, CA 95350

F 0600 Level of Harm - Minimal harm or potential for actual harm AEB yelling at staff, striking out.A review of the facility policy and procedure (P&P) titled, Abuse Prevention Program, revised December 2026, indicated, .Our residents have the right to be free from abuse.This includes but is not limited to.verbal, mental, sexual or physical abuse.As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including.other residents. Residents Affected - Few 555190 Page 4 of 4