Health inspection·March 8, 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. Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from verbal abuse when Certified Nursing Assistant (CNA) yelled at Resident 1 I will knock you the 'F' out during a verbal altercation. This failure had the potential to result in psychosocial harm. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included vascular dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) with behavioral disturbance, adult failure to thrive and opioid dependence (Physical and psychological reliance on opioids, a substance found in certain prescription pain medications and illegal drugs like heroin). During a review of Resident 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 1/19/24, the MDS indicated Resident 1 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13 (A BIMS score of 13-15 is an indication of intact cognitive status). The MDS also indicated Resident 1 did not have any behaviors that were potential indicators of psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) and had no behavioral symptoms directed toward others. During a review of Resident 1's dementia Care Plan, with start date 1/12/24, the Care Plan indicated for staff to offer choices appropriate for resident's cognition and provide verbal cues to resident. During a review of the Investigation Summary, dated 3/8/24, the Investigation Summary indicated CNA was having a verbal altercation with Resident 1. The Investigation Summary indicated Resident 1 requested for extra cups of coffee. When CNA delivered coffee and went to remove the other coffee mug from Resident 1's table, Resident 1 started to yell and threw coffee at CNA, CNA responded in a manner that was not appropriate, which was witnessed and heard by facility staff. During an interview on 3/8/24 at 10 a.m. with Receptionist (REC), REC stated hearing a loud verbal altercation coming from Resident 1's room with Resident 1 saying No, you're not! REC stated hearing a man's voice that said, I'll knock you the f out!. REC stated Restorative Nursing Assistant (RNA) Page 1 of 2 555358 555358 03/08/2024 Fruitvale Healthcare Center 3020 East 15th Street Oakland, CA 94601

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stood by Resident 1's door and said, You can't talk to a resident like that! to someone inside Resident 1's room. REC stated after a few moments, CNA walked out of Resident 1's room saying Ok, ok. and walked away. During an interview on 3/8/24 at 10:21 a.m. with RNA, RNA stated hearing an argument coming from Resident 1's room. RNA stated going to the room and stood by the door, where CNA and Resident 1 could be seen and heard yelling at each other. RNA stated CNA had just brought two cups of coffee for Resident 1 and was going to take a previously used coffee mug from Resident 1's table, but Resident 1 wanted to keep it. RNA stated Resident 1 told CNA to Get the f .out of my room!, to which CNA yelled back I'll knock you the f . out! to Resident 1. RNA stated telling CNA to not talk to Resident 1 like that and CNA said a few words before leaving the room. RNA stated CNA was in a fighting stance during the altercation like going into a street fight. RNA stated staff should never talk to any resident like CNA did, it was inappropriate and very unprofessional. 555358 Page 2 of 2