Health inspection·June 24, 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 one of four sampled residents (Resident 1) was free from abuse when he was struck in the head and chest several times by Resident 2. This failure had the potential to result in serious physical harm. Findings: According to Resident 1's admission record, he was admitted on [DATE] with diagnoses that included Degeneration of Nervous System Due to Alcohol (trouble with balance and body coordination due to chronic alcohol use) and anxiety. A Minimum Data Set (MDS, an assessment tool), dated 4/24/24, indicated Resident 1 had no memory impairment. A nursing note, dated 6/9/24, indicated Resident 1 had been involved in a resident to resident altercation on 6/8/24. The note indicated Resident 1 had been hit in the chest and head area 4-5 times by Resident 2. According to Resident 2's admission record, he was last admitted on [DATE] with diagnoses that included Antiphospholipid Syndrome (a disorder of the immune system that can cause blood clots) and stroke. A MDS, dated [DATE], indicated Resident 1 had no memory impairment. A nursing note, dated 6/9/24, indicated Resident 2 had been involved in a resident to resident altercation on 6/8/24. The note indicated Resident 2 was seen by staff having an altercation with Resident 1. In an interview, on 6/24/24 at 10:43 a.m., Resident 1 stated he was in the smoking area and Resident 2 was trying to bum cigarettes and a lighter from other residents. Resident 1 stated he told Resident 2 to, Knock it off, and Resident 2 began to swing and struck him in the head. Resident 1 denied hitting Resident 2. In an interview, on 6/24/24 at 10:48 a.m., Resident 2 confirmed he had hit Resident 1 but, stated Resident 1 had hit him first. Page 1 of 3 056109 056109 06/24/2024 Woodland Post-Acute 678 3rd Street Woodland, CA 95695

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview, on 6/24/24 at 10:57 a.m., Licensed Nurse 1 (LN 1) stated Resident 1 and Resident 2 had been in an altercation on 6/8/24 around 10 p.m., on the smoking patio. LN 1 stated Resident 2 had a history of aggressive behavior toward other residents, and she had heard cursing between the two and saw Resident 2 punch Resident 1 in the face twice. In an interview, on 6/24/24 at 12:11 p.m., the Social Services Director (SSD) confirmed that there was an altercation between Resident 1 and Resident 2. The SSD agreed that the altercation was abuse regardless of who started the altercation. In an interview, on 6/24/24 at 12:22 p.m., the Director of Nursing (DON) confirmed there had been a resident to resident altercation between Resident 1 and Resident 2 on 6/8/24. The DON agreed that it was abuse when Resident 2 punched Resident 1. A review of the facility's policy titled, Elder/Dependent Adult Abuse, revised 7/17, stipulated, This facility will protect the rights, safety and wellbeing of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, sexual, mental abuse . 056109 Page 2 of 3 056109 06/24/2024 Woodland Post-Acute 678 3rd Street Woodland, CA 95695

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the Department until the following day. This failure to report timely had the potential to compromise resident health and safety. Findings: A review of a facility document, Report Of Suspected Dependent Adult/Elder Abuse , dated 6/8/24 and received by the Department on 6/9/24, indicated an allegation of suspected abuse had been made related to a resident to resident altercation between Resident 1 and Resident 2. In an interview, on 6/24/24 at 12:22 p.m., the Director of Nursing (DON) stated it was the facility's policy to report an allegation of abuse to the Department within 2 hours. The DON 1 confirmed the 6/8/24 allegation had not been reported to the Department until 6/9/24. A review of the facility's policy titled, Elder/Dependent Adult Abuse, revised 7/17, indicated reports of physical abuse would be made within two hours to the Department. 056109 Page 3 of 3