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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 056109 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 056109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Post-Acute 678 3rd Street Woodland, CA 95695 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)