Health inspection·November 15, 2024

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 one of 5 sampled residents (Resident 2) from physical abuse when Resident 2 ' s hands were grabbed by Resident 1. This resulted in Resident 2 sustaining a scratch to her face and felt unsafe in the room. Findings: A review of Resident 1 ' s admission Record indicated she was admitted with diagnoses including cerebral infarction due to occlusion or stenosis of small artery (a type of stroke caused by blockage of blood flow to the brain) and schizophrenia (mental illness that can affect thoughts, mood, and behavior). A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/3/24 indicated Resident 1 had moderate cognitive impairment. A review of Resident 1 ' s undated care plan indicated, [Resident 1] has impaired cognitive function or impaired thought processes r/t [related to] BIMS [Brief Interview of Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident] @ 9. A review of Resident 1 ' s Social Service Note dated 11/1/24 indicated, Reported by nursing [Resident 1] was sitting in her w/c[wheelchair] in her room near the foot of the A bed when her room mate [Resident 2] wheeled into the room. [Resident 2] was wheeling past [Resident 1] and touched her foot which irritated her and she grabbed [Resident 2 ' s] wrists inan [sic] upward motion and shook them and swiped [Resident 2 ' s] right side of her face with her hands . A review of Resident 2 ' s admission Record indicated she was admitted with diagnoses including postconcussional syndrome (symptoms may persist after a concussion or mild traumatic brain injury that affects brain function) and mild cognitive impairment. A review of Resident 2 ' s MDS dated [DATE] indicated she had short term and long-term memory problems. A review of Resident 2 ' s SBAR (Situation, Background, Assessment, Recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/1/24 at 15:31 [3:31 p.m.] indicated, .Altercation between room-mates in which roommate [Resident 1] Page 1 of 3 555219 555219 11/15/2024 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0600 Level of Harm - Minimal harm or potential for actual harm was witnessed holding on to [Resident 2 ' s] arms, residents assessed and scratch was noted on right side of face. A review of Resident 2 ' s Social Service Note dated 11/1/24, indicated, .[Resident 2] had a room change .[Resident 2] stated she feels safe with changing her room. Residents Affected - Few In an observation on 11/15/24 at 11:15 a.m., Resident 1 was up in a reclining wheelchair inside her room and her eyes were closed. In an interview on 11/15/24 at 12:52 p.m., the Licensed Nurse 1 (LN 1) stated she was sitting at her usual spot at the desk in the nurse ' s station 1 when the incident occurred between Resident 1 and Resident 2. The LN 1 further stated she heard the yelling coming from the resident ' s room. The Certified Nursing Assistant (CNA) got to the residents ' room before her. The residents were near each other. The LN 1 pulled Resident 2 ' s wheelchair back and Resident 1 was by the bathroom door facing the television. The CNA told her [LN 1] it was Resident 1 who grabbed Resident 2 ' s wrists when Resident 2 accidentally bumped into Resident 1 ' s feet. Resident 2 told LN 1 she was hit by Resident 1 and Resident 1 also knew what she did with Resident 2. In a concurrent interview and record review on 11/15/24 at 1:11 p.m., LN 1 stated Resident 2 had MoCA (Montreal Cognitive Assessment- to assess cognitive function) score of 12 out of 30 on 10/28/24 which indicated Resident 2 had moderate cognitive impairment. The LN 2 further stated Resident 2 ' s MoCA score was 7 out of 30 on 10/21/24 which indicated severe cognitive impairment. In a concurrent observation and interview on 11/15/24 at 1:21 p.m., Resident 2 was inside her room lying in bed. Resident 2 was able to sit upright in bed with assistance when a female staff delivered her lunch tray. Resident 2 stated a month ago this resident slapped her 4 times on her cheek, twice on both cheeks. Resident 2 further stated she wacked her back because she got scared. Resident 2 added she did not know if she hit her, she just swung her hand. Resident 2 stated she did not feel scared as long as she did not see her again. In a telephone interview on 11/15/24 at 1:38 p.m., the CNA stated he was sitting at the nursing station when he heard the verbal exchange between Resident 1 and Resident 2. The CNA further stated it was Resident 2 who started the conflict. Resident 1 had her feet sticking out a little and then Resident 2 rolled in and bumped into Resident 1 ' s feet. Resident 1 started arguing with Resident 2, both residents exchanged some words. Resident 2 waved her hand close to the face of Resident 1 and that was when Resident 1 grabbed the hands of Resident 2 and shook it. Resident 2 got a little scared because Resident 1 grabbed her hands. The CNA further stated things happened pretty quick. The CNA stated there was a potential for the incident not to have happened if he intervened during the verbal altercation. In a telephone interview on 11/21/24 at 11:24 a.m., the LN 3 stated Resident 1 and Resident 2 were roommates at the time of incident. Resident 1 was in the room sitting in her wheelchair. Resident 2 was at the nurses ' station and then wheeled herself inside the room. The LN 3 heard Resident 2 yelling out and the CNA rushed in the room. The CNA told LN 3 Resident 1 grabbed Resident 2. The LN 3 stated Resident 1 had behaviors such as yelling and repetitiveness. The LN 3 further stated Resident 1 would yell not so nice language and both residents (Resident 1 and Resident 2) had memory problems. 555219 Page 2 of 3 555219 11/15/2024 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a telephone interview on 11/22/24 at 10:11 a.m., the Administrator (ADM) stated they try to keep residents free from abuse in their facility. A review of the facility ' s Policy and Procedure (P & P) revised December 2016 and titled, Abuse Prevention Program indicated, .residents have the right to be free from abuse .This includes but is not limited to freedom from .physical abuse .As part of the resident abuse prevention, the administration will .Protect our residents from abuse by anyone including .other residents . A review of the facility ' s P & P revised September 2022 and titled, Resident-to-Resident Altercations indicated, .All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .Behaviors that may provoke a reaction by residents or others include .screaming .grabbing .wandering into others .space . 555219 Page 3 of 3