The Pines At Placerville Healthcare Center

Resident 2 has memory impairment with short and long term problem. risk for behavioral problems.During a review of Resident 2's NN dated 9/18/25 at 9:46 p.m. indicated, Resident noted involved in attempted physical altercation with another resident.

Both parties separated immediately and kept apart.During a review of Resident 3's AR, dated 9/23/25 (print date), the AR indicated that Resident 3 was admitted to the facility in late 2022 with diagnoses which included low back pain and depression.During a review of Resident 3's MDS, dated [DATE], the MDS indicated that Resident 3 had intact cognitive abilities.During a review of the facility's security camera footage video titled Hall 2 (Man Cave) time stamped yesterday [9/18/25] 8:43-8:45 p.m., the video recording showed Resident 2 sitting on the wheelchair in the hallway. Resident 2 extended her right arm, blocking Resident 1's passage as he walked down the hallway and grabbed Resident 1 on his right hand, and Resident 1 reacted and pulled back his right hand and reached for Resident 2's neck not completely making contact with the neck as his hand moved down to Resident 2's upper chest area. Resident 1 swung his arms around, contacting Resident 2's arms a few times before the staff were able to pull both residents apart.During a concurrent observation and interview on 9/23/25 at 2:50 p.m. with Certified Nurse Assistant (CNA 1) in the facility's hallway, CNA 1 pointed out facility locations and described an incident that happened between Resident 1 and Resident 2 on 9/18/25. CNA 1 stated that initially, she was in room [ROOM NUMBER] as Resident 1 wandered into the room (room [ROOM NUMBER]), and she had to ask him to get out of the room because it was not his room. CNA 1 further stated that Resident 1 became agitated and responded with foul language and went out walking down the adjacent hallway towards the area close to room [ROOM NUMBER] and room [ROOM NUMBER], where Resident 1 was sitting on the w/c in the hallway. CNA 1 further stated that she saw how Resident 1 hit Resident 2 in the chest area.

During an interview on 9/23/25 at 3:19 p.m. with Resident 2, Resident 2 stated that there was a guy in the hallway who twisted her hand and hit her on the chest, and it did hurt.During an interview on 9/23/25 at 4:39 p.m. with Resident 3, Resident 3 stated that few days ago she was in the hallway next to Resident 2 as she saw how Resident 1 approached Resident 2. Resident 3 further stated that during the incident, Resident 2 moved her arm out, blocking the passage to Resident 1, and Resident 1 pushed back on her and then hit her on the arm and chest. Resident 3 stated it was an audible hard hit by Resident 1.During a video call interview on 9/24/25 at 11:30 a.m. with the Director of Nursing (DON), the DON confirmed that she expected facility residents to be free from abuse, including physical abuse and undesirable touching.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/20/21, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.

The resident abuse, neglect and exploitation prevention program consists of a facility -wide commitment and resource allocation to support the following objectives: 1.

Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents.

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