Health inspection·June 28, 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 observation, interview and records review, the facility failed to ensure one Resident's (of four sampled residents) right to be free from abuse when staff witnessed Resident 1 punch Resident 2. This failure resulted in Resident 1 having experienced physical abuse by Resident 2. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses which included paranoid schizophrenia (feeling afraid and unable to trust others), bipolar disorder (intense mood, energy, and activity changes), and psychological and behavioral factors with disorders. Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool), dated 3/29/24, indicated he had a very severe cognitive (the mental process of obtaining knowledge and understanding through thought, experience, and the senses) decline. A review of Resident 1's Order Summary Report, dated 5/4/24 indicated, risperiDONE [antipsychotic] ORAL Tablet 1MG (milligram, dose) .for PARANOID SCHIZOPHRENIA AEB Aggressive behavior. A review of Resident 1's Care Plan (CP) dated 6/6/24 indicated, .AGGRESSIVE COMBATIVE BEHAVIOR . [Resident 1] Noted With Aggressive-Combative Behavior AEB [as evidenced by]: Punching . Verbal Foul Language Outburst .BEHAVIOR CARE PLAN . has altered behavior with potential to disrupt resident and/others R/T [related to]: Dx[diagnoses] of bipolar and schizophrenia . The CP indicated the following interventions, Anticipate needs on resident .Provide distraction: music, activity, TV, walks/pushing in wheelchair outdoors to calm . A review of Resident 1's IDT (InterDisciplinary Team) Note, dated 6/14/24 indicated, .Resident [1] does have a hx [history] of agitation and verbal aggression .become[s] more agitated when the resident is spoken to in a harsh tone. The tone of the other resident [2] may have caused the resident [1] to react . A review of an admission record indicated Resident 2 was admitted to the facility on early 2022 with multiple diagnoses which included abnormal gait and mobility, right leg pain, difficulty swallowing following stroke, anxiety, and mood disorder. Resident 2's MDS dated [DATE] indicated mild cognitive decline. A review of Resident 2's IDT Note dated 6/14/24 indicated, .HX OF VERBAL AGGRESSION .Resident [2] can be forceful with words .and can be loud and this can be a trigger for others . Page 1 of 2 055497 055497 06/28/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 6/28/24 at 12:12 p.m., in Resident 2's room, Resident 2 was in bed watching television. When asked regarding the incident with Resident 1, Resident 2 stated, Yes I know him, but I don't want to talk about him and to you . Resident 2 became quiet, his face displayed sadness and he did not want to talk anymore. During a concurrent observation and interview on 6/28/24 at 12:12 p.m., in Resident 1's room, Resident 1 was sitting in wheelchair, staring at the wall doing nothing. Resident 1 stated, .Yes, I know [Resident 2] .What about him? [verbalizing in an angry tone] . When asked regarding the incident between him and Resident 2, Resident 1 became verbally abusive, angrier, verbalizing derogatory words. Resident 1 became aggressive towards this surveyor, tried to physically charge at this surveyor with his wheelchair, and yelled, Get out, call the cops if you want! During an interview on 6/28/24 at 12:38 p.m., the Certified Nurse Assistant 1 (CNA 1) stated, .[Resident 1 was] assigned to me .I was working in this hallway when I heard the argument, the yelling, something was going on in room [CNA 2's name] was there . During an interview on 6/28/24 at 1:22 p.m., the Director of Nursing (DON) confirmed and stated, .It happened during the day shift .I participated in the first part of the investigation. Talk to [CNA 2] because she saw it . During an interview on 6/28/24 at 1:47 p.m., the Administrator (ADM) confirmed and stated, .Yes it happened . During an interview on 6/28/24 at 2 p.m., the DON stated, .Yes, the residents have the right to be free from any abuse from anyone . During an interview on 6/28/24 at 2:05 p.m., the CNA 2 confirmed the physical altercation between Resident 1 and Resident 2. The CNA 2 stated, .Yes, the incident between Resident 1 and Resident 2 happened on 6/13/24 .I was passing by [the room] with the lift machine when I saw Resident 1 punching Resident 2 in the stomach. I was like, 'Oh my god!' I witnessed it! I asked [Resident 1] why you do that and he just yelled at me .I confirmed everything I wrote in the [initial report] . A review of the facility's policy and procedures titled, Abuse Prevention Program, revised August 2011, indicated, Our resident have the right to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including .other residents . 055497 Page 2 of 2