Health inspection·June 11, 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. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s safety, when Resident1's Family Representative (FR) 1 slapped Resident 1 on the face while attempting to feed Resident 1. This failure to protect Resident 1 from abuse violated Resident 1's right to a safe environment and resulted in redness on the left cheek. Findings: A review of Resident 1's Physician Progress Notes, dated 5/16/25, indicated Resident 1 was admitted to the facility in May 2025 with diagnoses including 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) and dysphagia (difficulty swallowing) related to history of stroke. A review of Resident 1's Progress Notes, dated 6/9/25, indicated Resident 1 was discharged from the facility on 6/9/25. 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 5/20/25, the MDS indicated a Brief Interview for 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 zero indicating severe cognitive impairment. The MDS indicated Resident 1 was completely dependent on staff for all activities of daily living (ADLs, those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) including eating. During a phone interview on 6/11/25, at 11:18 a.m., with the housekeeper, assisted by interpreter (ID number 405919), housekeeper stated that on the morning of 5/21/25, she saw Resident 1's FR 1 slapping at Resident 1 on the left side of the face while attempting to feed them, when Resident 1 did not open their mouth. After slapping Resident 1's left cheek, the FR 1 ran out of Resident 1's room. During an interview on 6/11/25, at 10:30 a.m., with Licensed Practice Nurse (LVN) 1, the charge nurse on the day of the incident, LVN 1 stated that on 5/21/25, at about 8:45 a.m., after receiving a message that FR 1 slapped Resident 1, he went into Resident1's room. LVN 1 stated he noted redness on Resident 1's left cheekbone, but Resident 1 was not able to provide any information about the incident. LVN 1 stated FR 1 had already left the room. LVN 1 stated that he had previously spoken with the FR 1, but the FR 1 never listened to him. LVN 1 stated he was not aware of the FR 1's mental Page 1 of 2 555376 555376 06/11/2025 Danville Post-Acute Rehab 336 Diablo Road Danville, CA 94526

F 0600 Level of Harm - Minimal harm or potential for actual harm condition, as Resident1's Family Representative (FR 2) always accompanied the FR 1 whiling visiting Resident 1, in the past. During a record review of Resident 1's Progress Notes, dated 5/21/25, the Progress Notes indicated (Resident 1) still with redness on the left cheek, slight swelling noted . Residents Affected - Few During a review of the facility's Policy and procedure (P&P) titled, Elder/Dependent Adult Abuse, revised on 12/17/19, indicated, The facility will protect residents' privacy and protect from any type of abuse. 555376 Page 2 of 2