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 protect the resident's right to be free from physical abuse
for one of three sampled residents (Resident 1) when Resident 2 hit Resident 1 on the face as witnessed
by Resident 2 ' s one-on-one sitter.
This failure reduced the facility's potential to protect Resident 1's right to be free from physical abuse and
had the potential for
Resident 1 to suffer physical and emotional injury.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted to the
facility on [DATE] with diagnoses including intestinal adhesions (scar-like tissue that form inside the
abdomen), severe protein-calorie malnutrition (lack of sufficient protein and calories), weakness,
hypertension (high blood pressure) and encounter for surgical aftercare following surgery on the digestive
system.
During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident
assessment tool), dated 2/2/25, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental
Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement
status of the resident) score of 11 out of 15, which indicated moderate memory impairment, with 15
indicating no memory impairment.
During a review of Resident 1 ' s Progress Note (PN), dated 2/20/25, the PN indicated, at approximately
0430 [4:30 a.m., after midnight] resident ' s roommate walked over and slapped her in the right side of the
face unprovoked .
During a review of Resident 2 ' s AR, the AR indicated Resident 2 was initially admitted to the facility on
[DATE] and re-admitted on [DATE] with diagnoses including dementia with other behavioral disturbance (a
progressive state of decline in mental abilities), hypercalcemia, unspecified psychosis not due to a
substance or known physiological condition (a severe mental condition in which thought, and emotions are
so affected that contact is lost with reality), anorexia (eating disorder that causes a severe and strong fear
of gaining weight) and Alzheimer ' s disease with late onset (a disease characterized by a progressive
decline in mental abilities.)
During a review of Resident 2 ' s PN from her initial admission, PN indicated that on 12/22/24,
(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 2
Event ID:
555698
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
555698
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Barton Hospital D/P Snf
2170 South Avenue
South Lake Tahoe, CA 96150
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 0600
Resident 2 struck staff on three separate occasions.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 2 ' s entry MDS, dated [DATE], cognitive patterns section assessment was not
completed.
Residents Affected - Few
During a review of Resident 2 ' s Discharge Return Anticipated MDS, dated [DATE] cognitive patterns
section assessment was not completed due to Resident 2 ' s unplanned discharge. Resident 2 ' s behavior
MDS dated [DATE], indicated Resident 2 exhibited physical and verbal behavioral symptoms directed
towards others, had rejected evaluation or care, and had been wandering, respectively.
During a review of Resident 2 ' s PN, dated 2/20/25, the PN indicated, Resident [2] while being supervised
by one-on-one sitter struck another resident/roommate [Resident 1] in the face unprovoked. Resident [1]
that was struck was sitting on bed .
During a telephone interview on 3/22/25 at 12:54 p.m. with Patient Safety Technician (PST, sitter), PST
stated Resident 2 was walking toward the hallway when Resident 2 suddenly turned and struck Resident 1
in the face. PST reported he was positioned behind and to the side of Resident 2 at the time. The PST
stated, Resident 1 ' s bed was near the doorway and Resident 1 was sitting upright at the foot of the bed.
The PST confirmed he witnessed Resident 2 strike Resident 1 in the face.
During an interview on 3/22/25 at 12:59 p.m. with Interim Director of Nursing (IDON), IDON stated that all
residents have the right to be free from abuse.
During an interview on 3/22/25 at 1:45 p.m. with Resident 1, Resident 1 stated that when Resident 2 struck
out, the motion caused the material of Resident 2 ' s clothing to hit her in the right eye, which she described
as painful at the time. Resident 1 stated that, at the time of the incident, she was sitting at the foot of her
bed. Resident 1 expressed frustration, stating she was upset because
Resident 2 was supposed to have a one-on-one staff monitor, yet Resident 2 was still able to strike her. She
added that Resident 2 had been heading toward the door when she suddenly turned and hit her.
During an interview on 3/22/25 at 2:34 p.m. with IDON, IDON confirmed the incident between Resident 1
and Resident 2 met the facility ' s definition of abuse, as outlined in their P&P.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Policy, dated 8/2024, the P&P
indicated, . It is the policy of the Skilled Nursing Facility to promote an environment free from any type of
abuse for all its residents .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555698
If continuation sheet
Page 2 of 2
