Inspection·January 17, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care which met professional standards when he was involved in an employee to resident abuse allegation, and it was not documented by nursing and social services department. Residents Affected - Few This failure resulted in inaccurate assessment documentation and had the potential to result in unmet nursing and psychosocial needs for Resident 1. Findings: A review of Resident 1 ' s admission record indicated he was last admitted in late 2024 with diagnoses including encephalopathy (brain dysfunction) and dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/23/24, indicated Resident 1 had severe memory impairment. A Skilled Services Documentation, dated 1/8/25 and 1/15/25, indicated no documented evidence of abuse allegation. Further review of document indicated no body check was done on Resident 1, no documented evidence of physician notification, and no documented evidence of nursing progress note on psychosocial well-being. Progress notes, dated 1/8/25 to 1/15/25, indicated no documented evidence of social services follow up for Resident 1. A care plan, dated 1/15/25, indicated that Resident 1 had a psychosocial wellbeing problem .recent verbal abuse from agency staff .Interventions .Assist Resident to process feelings .outcome . During an interview, on 1/17/25 at 12:49 p.m., with Licensed Nurse 1 (LN 1), LN 1 stated that a report was made to her on 1/9/25 of allegation of verbal and physical abuse between Registry Staff 1 (RS 1) and Resident 1. LN 1 confirmed there were no nursing assessment or nursing documentation done. During an interview, on 1/17/25 at 4:03 p.m., with Social Services Director (SSD), SSD confirmed that there were no follow up interviews, psychosocial support and interventions done with Resident 1 after facility was made aware of abuse allegation. During a concurrent record review and interview, on 1/17/25 at 4:23 p.m., the Director of Nursing (DON) stated she considered an employee-to-resident abuse allegation as a change of condition for the resident. DON's expectation was the LN needed to do an assessment with a body/skin check and 72 hour monitoring post incident. The DON further stated the MD needed to be notified. DON confirmed that there was no nursing assessment, no notification to MD and no follow up social services documentation regarding the abuse allegation involving Resident 1. During a review of Social Services Director ' s job description, the document indicated .job position is to .assure that the .emotional and social needs of the resident are met .interview residents/families .involve the resident/families in social services . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056109 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 056109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention Program, revised 12/1/22, the policy indicated, The facility shall examine the alleged victim for any physical signs of injury, including, but not limited to, psychological and psychosocial effect. During a review of the facility ' s P&P titled, Abuse Reporting and Investigation, dated 1/10/24, the policy indicated All allegations of abuse .will be reported to .the resident ' s Attending Physician. During a review of the facility ' s P&P titled, Change of Condition, revised March 2018, the policy indicated .the nurse shall assess and document .staff will monitor and document the resident/patient ' s progress .and the physician will adjust .accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056109 If continuation sheet Page 3 of 3