Health inspection·May 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to maintain dignity for one of four sampled residents (Resident 1) when two Certified Nursing Assistants (CNA) had an argument regarding a staffing assignment while providing a shower to Resident 1. This failure resulted in Resident 1 crying and feeling afraid and decreased the facility's potential to protect residents' dignity. Findings: During a review of Resident 1's admission record, Resident 1 was admitted to the facility in May of 2024 with multiple diagnoses which included nontraumatic intracerebral hemorrhage (a condition in which a ruptured blood vessel causes bleeding inside the brain), hemiplegia and hemiparesis (weakness on one side of the body) affecting right dominant side, dysarthria (weakness in the muscle used for speech), aphasia (loss of ability to understand or express speech), muscle weakness, and major depressive disorder (persistently depressed mood or loss of interest in activities). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of a document titled, Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 5/4/24, the document indicated, Resident 1 received a cold shower by CNA 1 and newly assigned CNA 2 took Resident 1 into the communal shower room and finished off with warm water. During a review of a document submitted to the Department titled, Investigative Summary Report, dated 5/8/24, the document indicated, [Resident 1] was in the shower room crying because he received a cold shower .On the morning of 5/4/23, [CNA 1] placed Resident 1 in the shower chair in the room and put on the water so it can start to warm up .While waiting for the water to warm up, she was approached by another CNA stating that the assignment was changed and that the patient is no longer in her assignment. CNA 1 went to see CNA 2 who was at the station and asked her to give the shower instead. After repeated calls, CNA 2 then went in .On 05/06/2024 at 9:40 AM [morning], [CNA 2] stated that since the assignment was changed, CNA 1 and the other CNA complained that there will be more people .While arguing about the assignment in the resident's room, [CNA 2] heard [Resident 1] crying and when [CNA2] checked in the bathroom, she saw [Resident 1] crying in the chair, hair was dry, but the body was wet .Conclusion: Whether or not a cold shower was intentionally or unintentionally given, the fact remains that the misunderstanding leading to an argument between [CNA 1] and [CNA 2] (because of the change in assignment), had unintended consequences that affected the resident . During a concurrent observation and interview on 5/16/24 at 11:30 a.m. with Resident 1 in his room, Resident 1 was observed awake, sitting on a wheelchair by the door of the bathroom. Resident 1 Page 1 of 4 555450 555450 05/16/2024 American River Center 3900 Garfield Avenue Carmichael, CA 95608

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated he cried when he was at the shower on the day of the incident and stated it was because the water was cold. Resident 1 further stated he was afraid it might happen again. Resident 1 was not able to clearly identify the staff involved in the incident. During an interview on 5/16/24 at 1:15 p.m. with the Director of Nursing (DON), the DON stated, There was nothing about abuse here, but because of the bickering, the resident didn't feel right that's why he cried .the problem is the interpersonal relationship of employees .the bickering was not appropriate during that time .they should have communicated separately where the [resident] cannot hear .they should professionally discuss the changes . During an interview on 5/16/24 at 2:02 p.m. with the Social Services Director (SSD), the SSD stated, It was more like drama between CNAs, but a resident was involved. During an interview on 5/16/24 at 2:29 p.m. with the Administrator, the Administrator stated, They [CNAs] feel they are overwhelmed. We've been telling staff and management to not discuss anything in front of the residents .As leaders, we are saddened with the situation because they [residents] might feel they are responsible for causing the argument. A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2021, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . A review of the facility's P&P titled, Dignity, revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .1. Residents are treated with dignity and respect at all times .10. Staff protect confidential clinical information. Examples include the following: a. Verbal staff-to-staff communication (e.g., change of shift reports) are conducted outside the hearing range of residents and the public. 555450 Page 2 of 4 555450 05/16/2024 American River Center 3900 Garfield Avenue Carmichael, CA 95608

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to revise the care plan for one of four sampled residents (Resident 2) when Resident 2 had repeated falls. Residents Affected - Some This failure resulted in Resident 2 to have unmet care needs for falls and could have contributed to the thigh bone fracture during her stay in the facility. Findings: Review of Resident 2's clinical record, admission RECORD, indicated the resident was admitted to the facility in March of 2024 for aftercare of right hip replacement surgery. Resident 2's diagnoses included diabetes and memory problems. Review of Resident 2's most recent MDS (Minimum Data Set, an assessment tool) indicated the resident had severely impaired cognitive function with a score 3/15 in the BIMS (Brief Interview for Mental Status) assessment. Review of Resident 2's clinical record, eINTERACT Change in Condition Evaluation-V 5.2 included the following 3 fall incidents in a month: a. 4/12/24-Staff member noted Patient sitting on the floor. Patient stated that she tried to get up to go outside. b. 4/25/24- .found resident sitting on the floor next to her w/c[wheelchair]. Per pt[patient] she tried to get up and sit on her w/c, but she fell .Pt c/o [complaint of] pain to right hip . c. 4/30/24- .to the activity room and found pt sitting on the floor, w/c is behind her, per pt she was trying to stand up and go to the other ladies to play with them. Review of Resident 2's clinical record included an x-ray taken on 4/25/24 and reviewed by the physician the next day with no new orders. No x-rays were not taken post 4/12/24 and 4/30/24 falls. Review of Resident 2's clinical record, Orthopedic Hospitalist Clinic Note, dated 5/14/24, indicated the resident sustained a new fracture to the right thigh bone after the admission to the facility. The Orthopedic Hospitalist Clinic Note documented, She [Resident 2] had x-rays done today .she has had a fracture in her greater trochanter [outside edge of the femur, near the hip joint] that is displaced about a cm[centimeter] .probably related to 1 of her postoperative falls. The immediate postoperative x-rays and once a month ago do not show that fracture. Review of Resident 2's clinical record, a care plan for at risk for falls, dated 3/20/24, identified the resident was at risk for falls due to diagnoses with dementia, with poor safety awareness, history of falls, disorientation and confusion, poor safety judgement, impaired balance, and unsteady gait. The care plan goal was, Resident will have no falls with injury x 90 days, including multiple interventions that were implemented 3/20/24; however, the care plan was not revised after the first two falls on 4/12/24 and 4/25/24. The care plan did not identify what caused the falls or what current resident needs to prevent future falls at the time of the falls. The care plan had no new goals or additional interventions implemented after each fall. 555450 Page 3 of 4 555450 05/16/2024 American River Center 3900 Garfield Avenue Carmichael, CA 95608

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of the facility's 8/25/21 policy and procedure, Care Plan Comprehensive, stipulated, Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change .The interdisciplinary Team is responsible for evaluation and updating of care plans: a. when there has been a significant change in the resident's condition. b. When the desired outcome is not met. Residents Affected - Some In a concurrent interview and record review on 9/4/24 at 11:05 a.m. with the Director of Nursing (DON) in the conference room, the DON stated the facility did not create a fall care plan after the resident had an actual fall, instead the facility revised and updated the existing at risk for falls care plan to implement new interventions to prevent further falls. The DON reviewed Resident 2's care plan for at risk for falls and verified it was not revised after the falls on 4/12/24 and 4/25/24. The DON stated, We did not update the care plan and acknowledged residents' care needs could change quickly as well as interventions. The DON indicated the care plan should have been revised based on a change in conditions and in response to current interventions. The DON acknowledged Resident 2's care plan should have been revised after each of the resident's falls. 555450 Page 4 of 4