Inspection·July 30, 2024

F 0689 Resident 1 should be 1:1 continuously for the safety of other residents. CNA 1 stated, all residents including Resident 1 had the right to be free from physical abuse. Level of Harm - Actual harm Residents Affected - Few During a concurrent interview and record review on 7/30/24 at 9:20 a.m. with Licensed Vocational Nurse (LVN) LVN 1. Resident 1 ' s (AM SHIFT) document dated 7/12/24 1:1 document was reviewed. LVN 1 stated, Resident 1 liked to go up to other residents and shake their hand. LVN 1 stated, Resident 1 has had altercations with other residents. LVN 1 stated, we were in charge of assigning CNAs to a 1:1 daily, for Resident 1 starting at 6:00 a.m. to 10:00p.m. in 30- minute increments. LVN 1 stated Resident 1 was on a 1:1 due to his multiple altercations with other residents. LVN 1 stated, Resident 1 was a danger to other residents. LVN 1 stated, Residents have the right to be free from physical abuse from other residents. LVN 1 stated, Resident 1 and Resident 2 had an altercation in the large dining room on 7/12/24 at 2:30 p.m. LVN 1 stated, Resident 2 had a skin tear and was bleeding from his left hand. LVN 1 stated Resident 1 hit Resident 2 with a closed fist. LVN 1 stated 1:1 document dated 7/12/24 showed Resident 1 was on 1:1 on 7/12/24 at 6:00 am till 10:00 pm. LVN 1 stated the assignment sheet indicates at 2:00 p.m. to 2:30 p.m. and 2:30 p.m. to 3:00 p.m. a CNA was not assigned to provide 1:1 for Resident 1. LVN stated, because of the missing assignments on 7/12/24 placed other residents in danger. During a record review of Resident 1 ' s Care Plan (CP) undated, the CP indicated, .Focus .resident will be free of being involved in any resident to resident altercation .goal .resident will be free of physical altercation .intervention .one on one .CNA .date initiated 7/12/2024 . During an interview on 7/30/24 at 10:25 a.m. with LVN 2, LVN 2 stated, Resident 1 was on a 1:1 on 7/12/24 from 6:00 am to 10:00 pm. LVN 2 stated, Resident 1 was not on a 1:1 at the time of the incident. LVN 2 stated, the altercation took place on 7/12/24 at 2:30 p.m. in the dining room. LVN 2 stated, LVNs were responsible to complete the 1:1 log sheet for CNA assignments daily. LVN 2 stated LVN ' s were responsible to monitor and observe CNAs were providing the 1:1. LVN 2 stated, Resident 1 was on a 1:1 due to his behavior and aggression towards other residents. LVN 2 stated, Resident 1 was a danger to others because his aggression could escalate quickly, and he would become verbally and physically aggressive. LVN 2 stated, residents had the right to be free from physical abuse by other residents. During an interview on 7/30/24 at 10:40 a.m. with CNA 2, CNA 2 stated, she was assigned to Resident 1 to provide 1:1 from 6:00 a.m. to 12:00 p.m. on 7/12/24. CNA 2 stated, Resident 1 was on a 1:1 due to his aggression, especially towards other male residents. CNA 2 stated, residents had the right to be free from abuse from other residents. CNA 2 stated, Resident 1 was danger to other residents. During an observation on 7/30/24 at 11:00 a.m. in the patio, Resident 2 was sitting in his wheelchair. Resident 2 had a large bandage to the back of his left hand. Resident 2 was unable to recall how or what happened to his hand. During a review of Resident 4 ' s admission Record (AR), dated 7/30/24, the AR indicated, Resident 4 was admitted on [DATE] with diagnoses that included, Schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave) and muscle weakness. During a review of Resident 4's MDS Assessment dated 05/24/24, indicated Resident 4's BIMS assessment score was 15. The BIMS assessment indicated Resident 4 was cognitively intact. During an interview on 7/30/24 at 11:15 a.m. with LVN 1, LVN 1 stated, a CNA did not witness the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055047 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center 1010 Ventura Avenue Chowchilla, CA 93610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 altercation. LVN 1 stated, if Resident 1 was on a 1:1 at the time of the incident, the assigned CNA would be the witness. LVN 1 stated, Resident 4 witnessed the incident. Level of Harm - Actual harm Residents Affected - Few During an interview on 7/30/24 at 11:30 a.m. with Resident 4, Resident 4 stated, he was in the dining room watching a movie when he saw Resident 1 hit Resident 2 on his left hand several times with a closed fist. During a concurrent interview and record review on 7/30/24 at 1:00 p.m. with Director of Nursing (DON), Resident 1 ' s 1:1 document dated 7/12/24 was reviewed. The DON stated, the incident happened on 7/12/24 at 2:30 pm in the dining room. The DON stated, Resident 1 was on a 1:1 due to his physical aggression towards other residents. The DON stated the 1:1 log dated 7/12/24 indicated there were no CNAs assigned to Resident 1 on 7/12/24 from 2:00 p.m. to 3:00 p.m. The DON stated, because Resident 1 was not on the 1:1, the incident took place. The DON stated, Resident 1 should be on 1:1 always. The DON stated, if Resident 1 had been on 1:1 the CNA assigned would be a witness. The DON stated, there was no documentation of a CNA as a witness. The DON stated residents in the facility had the right to be free from physical harm from other residents. The [NAME] stated any injury to another resident from a resident-to-resident altercation was considered harm. The DON stated, Resident 2 sustained injuries to his left hand. The DON stated it was the facilities responsibility to keep residents safe. During an interview on 7/30/24 at 1:35 p.m. with CNA 3, CNA 3 stated, she was familiar with Resident 1 who could be aggressive with other residents. CNA 3 stated Resident 1 is currently on a 1:1 due to his behavior and is a danger to other residents. CNA 3 stated all residents had the right to be free from physical abuse from other residents. During a concurrent interview and record review on 7/30/24 at 1:55 p.m. with the DON, the facility Policy and Procedure (P&P) titled Abuse, Neglect and Exploitation dated 2024 was reviewed. The P&P indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The DON stated, We did not follow our P&P. The DON stated we failed to protect Resident 2 from a resident who we knew was a danger to others in the facility. During a telephone interview on 07/31/24 at 10:52 a.m. with Administrator (ADM), The ADM stated the facility was responsible for the safety of all of their residents. The ADM stated Resident 1 was on a 1:1 because of his aggressive behavior and was danger to other residents. The ADM stated all residents had the right to be free from abuse per the facility P&P. During a review of the facility ' s P&P titled Abuse, Neglect and Exploitation dated 2024, the P&P indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .abuse means the willful infliction of injury .resulting in physical harm or mental anguish .Instances of abuse of all residents .cause physical harm, pain, or mental anguish It includes verbal abuse, physical abuse .the facility will implement policies and procedures to prevent and prohibit all types of abuse .the facility will make efforts to ensure all residents are protected from physical harm .increased supervision of .residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055047 If continuation sheet Page 3 of 3