Health inspection·January 17, 2025

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 one of three sampled residents (Resident 1) when an allegation of abuse was not reported per facility policy. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of a facility document, dated 1/15/25 and received by the Department on 1/15/25, indicated an allegation of suspected dependent adult/elder abuse had been made related to an employee to resident verbal and physical abuse between Registry Staff 1 (RS 1) and Resident 1. During an interview, on 1/17/25 at 12:49 p.m., Licensed Nurse 1 (LN 1) confirmed that the allegation was reported to her on 1/9/25 and she did not report it to the Administrator who is the Abuse Prevention Coordinator (APC). During an interview, on 1/17/25 at 1:33 p.m., Certified Nursing Assistant 1 (CNA 1) confirmed she heard the allegation of abuse on 1/9/25 at the nurse ' s station and acknowledged that it was not reported to the APC. During an interview on 1/17/25 at 2:18 p.m., CNA 2 confirmed that she heard the allegation of abuse on 1/9/25 and confirmed that it was not reported to the APC. During an interview, on 1/17/25 at 4:23 p.m., 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 confirmed the 1/9/25 allegation had not been reported to the Department until 1/15/25. During a review of the facility ' s policy and procedure titled, Abuse Reporting and Investigation, dated 1/10/24, the policy indicated To promptly report ALL allegations of abuse as required by law and regulations to the appropriate agencies .All allegations of abuse, neglect, mistreatment .shall be reported to the APC .All violations involving abuse .shall be reported .to local CDPH .within 2 hours after the allegation is made or reported . Page 1 of 3 056109 056109 01/17/2025 Woodland Post-Acute 678 3rd Street Woodland, CA 95695

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 . 056109 Page 2 of 3 056109 01/17/2025 Woodland Post-Acute 678 3rd Street Woodland, CA 95695

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. 056109 Page 3 of 3