Health inspection·April 29, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for one of five sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 hit Resident 1 in the shoulder during transfer from the bed to the wheelchair. This failure violated Resident 1's right to be free from abuse. Findings: During a review of Resident 1's admission Record (a document containing demographic information), indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Diagnosis Report (a document listing resident's diagnoses) dated 4/8/24, indicated Resident 1 was admitted to the skilled nursing facility with diagnoses which included, .Dementia (progressive or persistent loss of intellectual functioning) .Parkinson (a brain disorder that causes unintended or uncontrollable movements) .Type 2 Diabetes Mellitus (high blood sugar) . During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 8 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderate impairment, and 00-07 indicates sever impairment) which indicated Resident 1 had moderate cognitive impairment. During a concurrent interview and record review on 4/29/24 at 8:45 am., with the Administrator (ADM), Resident 1's Facility Reported Event dated 4/8/24, was reviewed. The ADM stated CNA 1 was providing care to Resident 1. The ADM stated Resident 1 became combative with staff while care was being provided and bit CNA 1. The ADM stated CNA 1 hit Resident 1 on the back. The ADM stated CNA 1 should have not hit Resident 1. The ADM stated it was a staff to resident abuse. During a telephone interview on 4/29/24 at 9:05 am., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/8/24 CNA 4 notified me Resident 1 was uncooperative during care and CNA 1 hit Resident 1 in the back. LVN 1 stated it was an abuse to resident and should have never happened. During a telephone interview on 4/29/24 at 9:17 am., with CNA 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 was uncooperative with care and verbally aggressive. CNA 1 stated she was helping another CNA transfer Resident 1 from the bed to the wheelchair and Resident 1 bit Page 1 of 2 555485 555485 04/29/2024 Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her. CNA 1 stated she reacted and hit Resident 1 on her back. CNA 1 stated it was not appropriate to hit residents. CNA 1 stated what she did was physical abuse to Resident 1. During an interview on 4/29/24 at 11:35 am., with Director of Staff Development (DSD), the DSD stated she was made aware of the incident on 4/8/24 by the ADM. The DSD stated it was reported CNA 1 hit Resident 1 while providing care. The DSD stated when Resident 1 became agitated, nursing staff should have stopped the care immediately. The DSD stated CNA 1 abused Resident 1 by hitting her on the back. The DSD stated residents have the right to be free from any types of abuse. During a telephone interview on 5/1/24 at 10:05 am., with CNA 4, CNA 4 stated she was assigned to Resident 1 on 4/8/24 on the night shift. CNA 4 stated she was in Resident 1's room with CNA 1 and a CNA orientee. CNA 4 stated CNA 1 helped her transfer Resident 1 from bed to wheelchair and had sat Resident 1 up on the side of the bed. CNA 4 stated during the transfer CNA 1 called out Resident 1 had bit her and immediately afterwards she heard a slap but did not see it happen. CNA 4 stated when staff hits a resident it was considered elder abuse. Review of facility P&P titled, Abuse-Prevention, Screening, &Training Program dated 07/2018 the P&P indicated, .To address the health, safety, wellness, dignity and respect of residents by preventing abuse .and mistreatment .The facility does not condone any form of resident abuse .and or mistreatment . and to provide a environment free from abuse .The Administrator as the abuse coordinator is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program .Abuse is defined as the willful, deliberate infliction of injury, .it includes verbal abuse, physical abuse .Physical Abuse is defined as .hitting, slapping, punching and/or kicking . 555485 Page 2 of 2