Health inspection·March 22, 2025

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, Page 1 of 2 555698 555698 03/22/2025 Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150

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 . 555698 Page 2 of 2