Health inspection·July 9, 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 interview and record review, the facility failed to protect the right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1's plate of food onto her chest and landed in her lap which affected Resident 1's emotional well-being. This failure resulted in Resident 1 not free from abuse by Resident 2. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted in July 2017 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular diseases (stroke) affecting left non-dominant side (decreased ability to move and muscle weakness on left side), dementia (a progressive state of decline in mental abilities) and anxiety disorder (any group of mental conditions characterized by excessive fear of real or perceived threats). Review of Resident 1's Minimum Data Set (MDS-A federally mandated resident assessment too), dated 6/13/25 indicated Resident 1 had moderately impaired cognition. Review of Nurse's note for Resident 1 dated 7/7/25 indicated, .around 1850H [6:50 p.m.] when CNA [ Certified Nursing Assistant] reported another resident [ 2] swung resident [1] and was hit at the chest area. During an interview on 7/9/25 at 11:34 a.m. with Resident 1, Resident 1 stated that she was eating, and Resident 2 was trying to get her food. Resident 1 stated Resident 2 pushed her plate onto her lap. Resident 1 stated, It made me mad. Review of Resident 2's admission Record indicated Resident 2 was admitted [DATE] with diagnoses including metabolic encephalopathy (a change in how a brain works due to an underlying condition which can cause confusion and memory loss) and Alzheimer's Disease (a disease characterized by progressive decline in mental abilities). Review of Resident 2's MDS indicated Resident 2 had severely impaired cognition. During an interview on 7/9/25 at 12:36 p.m. with CNA 3, CNA 3 stated she witnessed the altercation between Resident 1 and Resident 2. CNA 3 stated that there were three CNAs in the room and these two residents were in the dining room at that time. Resident 2 was being touchy with Resident 1. Resident 2 took a swing at Resident 1 and her plate of food hit her chest and landed in her lap. Page 1 of 2 555219 555219 07/09/2025 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 During an interview on 7/9/25 at 2 p.m. with the Director of Nursing (DON), the DON stated that residents do have the right to be free from abuse in the facility. Review of the facility's policy and procedures (P&P) titled, Abuse and Prevention Program, dated December 2016, the P&P indicated, .our residents have the right to be free from abuse . Protect our residents from abuse by anyone including but not necessarily limited to facility staff, other residents . 555219 Page 2 of 2