Health inspection·April 17, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 three sampled residents (Resident 1) from physical abuse when Certified Nursing Assistant 1 (CNA 1) raised her arm at Resident 1, as if she was to strike Resident 1. CNA 1 had previously exhibited aggressive verbal behavior towards Resident 4 and 5. This failure placed Resident 1 at risk for emotional and psychological distress. Findings: During a record review of Resident 1's admission record dated 4/17/24, indicated Resident 1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.). During a record review of Resident's 1's Minimum Data Set, (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) dated 3/1/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) was 0 out of 15, indicated severely impaired mental status. The MDS indicated Resident 1 required total care with Activities of Daily Living (ADL, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) and included full assistance with feeding. During an interview with Resident 1 on 4/16/24, at 9:53 a.m., Resident 1 was lying in bed, awake, able to talk, but confused with questions, stating she lived at the facility for one day. During a review of Resident 1's nursing progress note titled, Change of Condition (COC), dated 1/5/24, at 5:00 p.m., the COC indicated, [Resident 1]'s roommate [Resident 2] witnessed [CNA 1] hit [Resident 1] a few days ago, and told [Resident 1]'s roommate [Resident 2], not to tell anyone. The COC further indicated, Roommate [Resident 2] states that the curtains were wide-open, and [CNA 1] was feeding [Resident 1] then became combative and [CNA 1] struck [Resident 1] back. [CNA 1] then told roommate Shh, don't tell anyone. During a record review of Resident 2's MDS assessment, dated 12/2/23, the MDS indicated Resident 2's BIMS score was 15 out of 15, indicating intact mental status. Page 1 of 2 555287 555287 04/17/2024 Diamond Ridge Healthcare Center 2351 Loveridge Road Pittsburg, CA 94565

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a phone interview with the witness, Resident 2, on 4/22/24, at 3:00 p.m., Resident 2 stated she saw CNA 1 enter Resident 1's room and went to Resident 1. Resident 2 stated CNA 1 raised her arm and hand to Resident 1, as if to strike. Resident 2 stated CNA 1 then looked at her and said, You didn't see what happened. Resident 2 further stated it was a horrible experience, that left a mark on her. During a phone interview on 4/23/24, at 3:50 p.m. with the Director of Nursing (DON), the DON stated if a CNA raised his/her hand and arm towards a resident, she would not like it because this gesture looks like they are about to hit the resident. The DON also stated if the CNA said not to tell anyone, she would perceive this as a threat as if he/she is trying to cover up something. During a phone interview with CNA 2, on 4/18/24, at 8:25 a.m., CNA 2 stated, on 1/5/24, while assisting Resident 2 to the bathroom, Resident 2 told her that she witnessed CNA 1 hit her roommate. CNA 2 stated Resident 2 did not want CNA 1 as the nursing assistant caring for her. CNA 2 stated Resident 2 told her that she was afraid to tell anyone about what happened, as she was afraid of retaliation. CNA 2 further stated there have been instances where CNA 1 was rough with other residents. During an interview on 4/17/24, at 10:08 a.m., with the Director of Staff Development (DSD), the DSD stated CNA 1 has a history of being verbally and physically abusive to residents. DSD stated provided CNA 1 individual, one-on-one training, prior to the incident occurring on 1/5/24. During a concurrent interview and record review on 4/17/24, at 11:25 a.m., with Administrator (ADM), facility's undated document titled, Concern/Grievance Reporting Form, indicated, CNA 1 had verbally aggressive behavior toward Resident 4 and Resident 5 on 4/16/23 and 8/21/23, respectively. During a concurrent observation and interview on 4/17/24, at 11:45 a.m., Resident 4 was lying in the bed. Resident 4 stated CNA 1 was rough while providing ADL care to her and one time. Resident 4 stated she had bruises on her arms after the incident, pointing at both arms. Resident 4 stated it made her angry and she wondered what she did to make CNA 1 treat her this way. Resident 4 stated she told CNA 1 You are hurting me but she felt disregarded. During a concurrent observation and interview on 4/17/24, at 11:53 a.m., Resident 5 was sitting upright at the edge of her bed, facing the door to her room. Resident 5 stated that there was an incident with CNA 1 where she yelled at Resident 5 when Resident 5 asked to hand her the phone charger. Resident 5 stated that incident made her feel disrespected . During record review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 12/19/22, the P&P indicated, The facility will implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift . 555287 Page 2 of 2