Other·February 21, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey for Complaint CA 00603236. Inspection was limited to the abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #35362, Health Facilities Evaluator Nurse. One class B citation # 11-2888-14741 at Federal Tag F 550 was written as a result of complaint investigation CA00603236.

F550 SS=G Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 01/18/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055919 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE APPLE VALLEY POST-ACUTE REHAB 1035 Gravenstein Ave Sebastopol, CA 95472 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: The facility failed to treat one of three sampled residents (Resident 1) with dignity and respect, and ensure Resident 1 was free from retaliation when the facility parked the facility van (cargo van) permanently right in front of Resident 1's window blocking Resident 1's view and creating a glare. This failure resulted in Resident 1, an outdoors and gardening enthusiast who treasured the view out her window, being tearful and feeling "disrespected and demeaned" by the facility. This failure also resulted in Resident 1 being very depressed and feeling "like nothing; like a bag of potatoes." Findings: During an interview on 9/17/18 at 10:09 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055919 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE APPLE VALLEY POST-ACUTE REHAB 1035 Gravenstein Ave Sebastopol, CA 95472 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Complainant X stated Resident 1 had been admitted to the facility for Rehabilitation. Resident 1 needed to stay in the facility for long term care due to medical issues after the end of Rehabilitation. Resident 1's payment source had changed at the end of rehabilitation, and facility staff had wanted her to move to the "long term care" side of the building. Resident 1 had been in a room in a bed next to a window. Resident 1 did not want to move because she enjoyed the view. After Resident 1 refused to move, facility management had decided to park the facility cargo van in front of her window blocking her view. Complainant X stated facility management had given the explanation it was for 'advertisement' purposes. Complainant X stated it blocked Resident 1's view completely, and caused a glare when the sun hit the van's windshield. Complainant X stated the fact the facility parked the van right in front of Resident 1's window felt like retaliation to both of them because Resident 1 had not wanted to move to the "long term care" side and give up the view. Complainant X stated having the van block her view had caused Resident 1 to be very depressed. A document titled "Record of Admission", not dated, revealed Resident 1 was admitted to the facility on 2/8/18. Resident 1 had diagnoses of cellulitis (infection of the skin) in both legs, difficulty walking, and muscle weakness. A document titled "Discharge/Transfer Instructions" signed and dated 2/8/18 by a physician in the acute care hospital and sent to the facility, revealed Resident 1 had additional diagnoses of Depression and Anxiety. The document also revealed Resident 1 was prescribed two different medications (Lexapro and Abilify) to treat her depression and one medication (Ativan) to treat her anxiety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055919 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE APPLE VALLEY POST-ACUTE REHAB 1035 Gravenstein Ave Sebastopol, CA 95472 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation on 9/19/18 at 7:50 a.m in the facility parking lot, a large cargo van was parked in front of the building towards the end of the west side parking lot. It was parked in front of a resident room's window. Other parking spaces were empty. During an observation on 9/19/18 at 8:40 a.m., Resident 1 was observed in her bed, eating breakfast. The facility van was parked in front of her window blocking the view. During an observation on 9/19/19 at 9:45 a.m., the facility van was parked in the same location in front of Resident 1's window. There were empty parking spaces in front of the building. During an observation on 10/9/18 at 9:35 a.m., the facility van was parked in the same location in front of Resident 1's window. Parking spaces were available in front of the building. During an interview on 10/9/18 at 10:20 a.m., Resident 1 was observed in her bed. The facility van was not parked in front of her window. Resident 1 stated she was 94 years old and could no longer walk. She stated she liked to look out the window, pointing to the window and the view and stating "that's all I have left." At 10:22 a.m., the facility van was driven into the parking spot in front of her window blocking her view. Resident 1 became very tearful when the van was parked and her view blocked. Resident 1 stated "it's very demeaning...they are treating me like a thing." Resident 1 stated she was very depressed, and they "make you feel like nothing...like a bag of potatoes." Resident 1 pointed to a photograph of her yard at home and stated she looked at the photograph when she could not look outside. Resident 1 stated it "means a lot to me to have a view... now they block it." Resident 1 stated she had declined to move to another FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055919 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE APPLE VALLEY POST-ACUTE REHAB 1035 Gravenstein Ave Sebastopol, CA 95472 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE side of the building when she finished rehabilitation and give up the window bed. Having the van parked in front of her window made her very depressed. Despite her grievances, the facility declined to move the vehicle. Review of Resident 1's MDS (Minimum Data Set) (an assessment tool) dated 3/10/18, 5/18/18, and 8/17/18 revealed BIMS (Brief Interview for Mental Status) scores of 13, 15 and 15 respectively (a score of 13-15 reveals a resident is cognitively intact; 15 is the highest score). A facility document titled "Discharge Care Conference Summary" dated 3/9/18 revealed .... " (family) wants to keep her in her room and bed (needs window)." A facility document titled [Resident 1's name], dated 4/26/18 and signed by four department managers, revealed "...she enjoys being outdoors..." A facility document titled "Interdisciplinary Progress Notes" dated 8/21/18 at 2:39 p.m., revealed "She refuses to change rooms to longer term care." During an interview on 10/9/18 at 1:40 p.m., Licensed Staff A stated he was very much aware of the issue with the facility van parked in front of Resident 1's window. Licensed Staff A stated it caused Resident 1 to be "upset a lot." Licensed Staff A stated facility management had been informed multiple times about how the van affected Resident 1. Licensed Staff A stated Resident 1 used to be an outdoors person, a poet who did not enjoy watching TV. Licensed Staff A stated it was understandable Resident 1 was upset about it. Licensed Staff A stated "I feel for her." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055919 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE APPLE VALLEY POST-ACUTE REHAB 1035 Gravenstein Ave Sebastopol, CA 95472 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 10/9/18 at 1:50 p.m., Unlicensed Staff B stated she had heard about the van bothering Resident 1. Unlicensed Staff B stated she was not sure what was bothering Resident 1 more, the van blocking her view or the glare it created. During an interview on 10/9/18 at 2:55 p.m., Management Staff C, in charge of social services, stated Resident 1 had been "warned" the van would be parked there. Management Staff C stated social services had not been involved in the decision to park the facility van in front of Resident 1's window. During an interview on 10/16/18 at 2:40 p.m., Management Staff D stated Resident 1's family has requested a bed next to a window when Resident 1 was admitted because Resident 1 "likes to look out.". Management Staff D stated none was available at that time, but one opened up a couple of days later and Resident 1 was moved to a bed next to the window. Management Staff D stated moving Resident 1 "made sense since she likes to look out the window." During an interview on 10/16/18 at 11:35 a.m., Management Staff E stated he was the driver for the facility van. Management Staff E stated the facility van had been parked in another spot but residents, who liked to sit outside, had complained that it was "blocking the sun." Management Staff E stated where it was parked now had "more room for the ramp to go down" and "made it easier to load and unload patients." Management Staff E stated he had been told to park the van in front of the window (Resident 1's room) about a month or two ago (around the time Resident 1 refused to change rooms). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055919 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE APPLE VALLEY POST-ACUTE REHAB 1035 Gravenstein Ave Sebastopol, CA 95472 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 10/16/18 at 3:35 p.m., Management Staff F stated the facility had decided to park the facility van permanently when not in use in front of the window because resident had complained it was "blocking the sun" during outdoor activities when it was parked in the old spot. Management Staff F stated the new spot was the only spot that allowed the ramp to be lowered "without blocking traffic." Management Staff F stated the van was used for "customer service." Management Staff F stated the facility had no policy for the van. During an interview on 11/14/18 at 12:08 p.m., Physician A stated Resident 1 was a "talented poet" who treasured a "view of trees and the sky all her life." Resident 1 was very involved in nature. Physician A stated having the van parked in front of the window made her "depressed" and "impacted her quality of life." A document titled "Quality of Life--Dignity", dated 2001, revised August 2009, revealed the policy statement "Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality."The document revealed 1. Residents shall be treated with dignity and respect at all times. 2. "Treated with dignity" means the resident will be assisted in maintaining and enhancing his or her selfesteem and self-worth. The above violation caused significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80F911 Facility ID: CA010000026 If continuation sheet 7 of 7