Health inspection·May 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 observation, interview and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 ' s right shin with a front wheel walker (a walker is an assistive device used to aid in walking, providing stability and reducing weight bearing on the lower extremities of an individual). This failure resulted in Resident 1 sustaining redness on his right leg, pain, and a transfer to Acute Care Hospital (ACH 1) for follow-up care. Findings: During a record review of Resident 1 ' s Face Sheet (A Face Sheet is a summary document that provides essential resident information), the record showed Resident 1 was admitted to the facility in November 2021. The record indicated Resident 1 had diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified Dementia (a condition that affects memory, thinking, and reasoning, interfering with daily life). During a record review of Resident 1 ' s Minimum Data Set (MDS is an assessment tool used to evaluate residents' health, functional status, and care) assessment dated [DATE], the assessment indicated Resident 1 had BIMS Score of 9 (nine) out of 15, indicating the moderate cognitive impairment. During a record review of Resident 2 ' s Face Sheet, the record showed Resident 2 was admitted to the facility in January 2024. The record indicated Resident 2 had multiple medical diagnosis including Alcohol dependence with withdrawal (a condition falls within substance use disorders. The characteristics of Alcohol dependence include loss of control over drinking and strong cravings or urges to drink). During a record review of Resident 2 ' s MDS dated [DATE] the assessment indicated, Resident 2 had BIMS score of 15 out of 15, indicating intact cognition. During an observation and interview on 04/17/25 at 09:58 a.m. with Resident 1, Resident 1 was sitting in his bed. Resident 1 stated on the day of the incident he was sitting in the smoking area at the back of the facility, Resident 2 was drunk, walked towards him, grabbed Resident 1 ' s walker and threw it across the table. Resident 1 stated he got hurt in his leg with the walker and that incident made him feel very sad. During an interview on 04/17/25 at 10:10 a.m. with Resident 2, Resident 2 stated, he did not want Page 1 of 2 555358 555358 05/09/2025 Fruitvale Healthcare Center 3020 East 15th Street Oakland, CA 94601

F 0600 to talk about the incident on 3/25/2025 or anything. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/17/25 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/25/25 around lunch time, Certified Nursing Assistant (CNA) 1 came to the nursing station to inform her that there was a noisy argument between Resident 1 and Resident 2 in the smoking area. LVN 1 saw Resident 1 and Resident 2 were separated by the staff. LVN 1 saw the alcohol bottle in a plastic bag on the floor. Resident 2 became agitated when LVN 1 wanted to confiscate the alcohol bottle. The staff notified the Administrator (Admin) and Oakland Police. Resident 2 became pleasant when the police arrived. Residents Affected - Few During an interview on 04/17/25 at 10:57 a.m. with CNA 1, CNA 1 stated she heard the yelling in the smoking area at the back of the facility. When she arrived at the smoking area, she saw Resident 2 was in front of Resident 1 and Resident 2 picked up the walker and smashed Resident 1 ' s legs. CNA 1 asked the other staff to separate both residents and called for help. CNA 1 said this was not the first time that she saw Resident 2 drunk and become combative and aggressive. During an interview on 04/17/25 at 11:19 a.m. with Director of Nursing (DON), DON stated Resident 1 refused assessment after the altercation between Resident 1 and Resident 2. The DON stated he observed the redness on Resident 1 ' s right shin related to the altercation. During a record review of Resident 1 ' s, Progress notes dated 3/25/25 at 1:22 pm, the Progress notes indicated, Resident 1 was noted at the smoking area in the parking lot when an altercation between Resident 1 and Resident 2 occurred. Staff witnessed that Resident 1 was arguing with Resident 2 and Resident 2 striking and kicking Resident 1 in his right shin. Skin assessment noted the redness on Resident 1 ' s right shin. Resident 1 complained of moderate pain and wanted to transfer to the hospital. During a review of Resident 1 ' s, Emergency Department After Visit Summary from Acute Care Hospital (ACH 1), dated 3/25/25, the summary indicated Resident 1 ' s reason for visit was fall with the diagnosis of right leg pain. Resident 1 was given acetaminophen and Flexeril (Flexeril is a muscle relaxant to relieve pain). During a record review of Resident 1 ' s Progress Note, dated 3/25/25, the notes indicated, Resident 1 came back from emergency room (ED) with new medication orders for cyclobenzaprine for muscle spasm up to 10 days, and lidocaine patch 5% on right lower leg to relieve pain. During a review of Resident 2 ' s Emergency Department After Visit Summary, from Acute Care Hospital, dated 3/25/25, the summary indicated, Resident 2 was evaluated for Violent behavior with the diagnosis of Agitation. During a review of facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, the P&P documented, the administration will protect the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors or any other individual. 555358 Page 2 of 2