Other·May 4, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED TO ACCURATELY REFLECT THE 3/24/17 EXIT DATE. The following reflects the findings of the California Department of Public HealthLicensing and Certification during a RECERTIFICATION survey. Representing the California Department of Public Health by Federal ID: 31279 RN, HFEN, 36080 RN, HFEN, and 20362 RN, HFEN. Capacity: 65 Census: 52 Sample: 13 Random: 4 Entity Reported Incident (ERI) Regulatory Grouping investigated for the following ERI's during the Recertification survey: ERI CA00511997: Substantiated with deficiency F 223. ERI CA00506149: Substantiated with deficiency F 223. ERI CA00527124: Substantiated without deficiency.

F161 SS=E SURETY BOND - SECURITY OF PERSONAL F161 FUNDS CFR(s): 483.10(c)(7) 04/15/2017 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: IFYI11 Facility ID: CA040000018 If continuation sheet 1 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, and administrative document review, the facility failed to purchase a surety bond to assure the security of all personal funds of residents deposited with the facility when the surety bond was less than the amount of the residents funds. This failure had the potential for resident's to lose funds entrusted to the facility for safeguard. Findings: On 3/21/17 at 11:20 a.m., during a concurrent observation and interview, the Business Office Manager (BOM) stated the bond was valued at $7,000.00. The BOM stated according to the facility bank statement dated 2/17, the resident's funds totaled $16,708.92. The BOM stated the current bond was insufficient to cover the residents accounts. The BOM stated this should not happen because the bond protects the residents funds. On 3/21/17 at 12:00 p.m., during an interview, the Administrator (ADM) stated he believed the facility bond was enough to cover the resident's accounts. The ADM stated he was unaware the bond amount was insufficient to protect the residents. The ADM stated the business office was responsible for assuring that the residents funds were fully protected. The ADM stated the BOM should have adjusted the bond. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 2 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 The facility document titled, "Surety Bond Verification" dated 9/18/15, indicated an amount of $7,000.00. The facility bank statement dated 2/1/17 through 2/28/17, indicated an ending balance of $16,708.92. The facility policy and procedure titled, "Resident Trust Fund Policies,"..."The Executive Director will ensure that a surety bond adequately insures the Resident Trust Fund... of the total trust fund...."

F223 SS=H FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.13(b), 483.13(c)(1)(i)

F223 04/24/2017 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record and administrative document review, the facility failed to protect two of two random sampled residents (Residents 15 and 16) from abuse when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 3 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 1. Resident 15 was inappropriately touched by Resident 14 when Resident 14 was observed with his finger inside Resident 15's vagina. 2. Resident 16's crotch was groped by a visitor who was a registered sex offender certified by Megan's Law when staff failed to effectively supervise the location of the offender at all times as instructed by the Administrator (ADM). These failures had the potential to cause psychological harm to Residents 15 and 16. Findings: 1. On 11/29/16 at 3:35 p.m., during a concurrent observation and interview, Resident 15 sat in a wheelchair in the hallway and held a teddy bear. Resident 15 became tearful and stated, "I've been bad." Resident 15 was unable to answer coherently additional questions. On 11/29/16 at 3:45 p.m., during a telephone interview, Certified Nurse Aide (CNA) 1 stated she was aware Resident 14 was on every 15 minute checks (staff observe resident every 15 minutes) due to his behaviors of touching residents and staff inappropriately. CNA 1 stated staff were to visualize and document every 15 minutes Resident 14's activities. CNA 1 stated on 11/23/16 around 4 p.m., she was across the hall from Resident 14's room and noticed the stop sign (a cloth with a red stop sign in the middle with Velcro on both ends that extended across the door opening) hung down one side of the door. (The absence of the sign going across the door would have allowed others to go in and out of the room without the presence of a visual barrier.) CNA 1 stated as she had entered Resident 14's room, Resident 15 sat in a wheelchair beside Resident 14's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 4 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 bed. CNA 1 stated Resident's 14 hand was clearly on Resident 15's crotch with his middle finger of the left hand inserted into Resident 15's vagina. CNA 1 stated Resident 15's pants had been pulled down enough to access the brief (disposable underwear) which was pushed to one side. CNA 1 stated she pulled Resident 15's pants up, removed her from the room to the large dining room, and reported the incident to Licensed Nurse (LN) 1. CNA 1 stated the ADM called her into his office where she provided a full verbal report on what she had observed during this incident. Resident 15's face sheet (a facility form that contained resident identifying information on admission) indicated she was diagnosed with Dementia (cognition deficit that may include memory loss). Resident 15's Minimum Data Set Assessment (MDS) (a tool which is used to assess functional and cognitive abilities) assessment, dated 8/14/16, indicated under the area of "Cognitive Skills For Daily Decision Making," Resident 15 was moderately impaired cognitively, decisions poor and cues/supervision required. On 11/29/16 at 4:11 p.m., during an interview, CNA 2 stated Resident 15 was quieter than usual since the incident with Resident 14. CNA 2 stated she had worked two days with Resident 15 since the incident and had noted Resident 15 would "stare off" more and did not seem as happy as before the incident. On 11/29/16 at 4:40 p.m., during a concurrent observation and interview CNA 2 stated Resident 14 was Spanish speaking and staff would provide a language interpreter. Through the interpreter Resident 14 was asked about the incident with Resident 15. Resident 14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 5 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 stated he didn't "know anything." Resident 14 stated he watched television, slept, or walked in his room when he was bored. Resident 14 further stated, he didn't know "that woman." Resident 14's affect and behavior changed as the interview progressed. Resident 14 appeared angry, his relaxed sitting posture changed to a standing position, waved his arms while speaking, and the volume of his speech became louder. Resident 14 moved his face next to the face of the female interpreter and stated, "he didn't know anything." Resident 14's face sheet indicated a diagnosis of Dementia. Resident 14's MDS assessment, dated 11/6/16, indicated a Brief Interview for Mental Status (BIMS) score of 6 of 15 which indicated severe cognitive impairment. On 11/29/16 at 6:05 p.m., during an interview, the ADM stated on 11/23/16, CNA 1 reported she had been across the hall from Resident 14's room and noticed the stop sign was down. The ADM stated CNA 1 then went into Resident 14's room. The ADM stated CNA 1 saw Resident 14 on his bed and Resident 15 sat in a wheelchair next to the bed. CNA 1 stated she observed Resident 14's hand down Resident 15's pants. On 1/3/17 at 12:55 p.m., during a telephone interview, the Social Service Director (SSD) stated Resident 14 had a known behavior of inappropriate touching of others. The SSD stated she had been aware of Resident 14's sexual behaviors towards other residents and staff prior to the incident with Resident 15 on 11/23/16. On 1/6/17 at 12:55 p.m., during a telephone interview, Resident 14's Primary Care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 6 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 Physician (PCP), PCP 1 stated he was aware of the resident's long history of sexual behaviors. On 1/10/17 at 10 a.m., during a telephone interview, CNA 1 stated the time of the incident was around 3:30 p.m. CNA 1 stated she provided a clear description of the incident to the ADM, which included Resident 14's finger in Resident 15's vagina. On 1/13/17 at 3:50 p.m., during an interview, the SSD stated, for the last year, Resident 14 had continual monitoring for sexual behaviors. The SSD stated Resident 14 had a history of exposing himself and groping both staff and residents. On 1/17/17 at 5:30 p.m., during an interview, LN 2 stated she was on duty when the incident between Resident 14 and Resident 15 occurred (on 11/23/16). LN 2 stated CNA 1 initially gave report to LN 1 and later reiterated her report to both LN 1 and LN 2. LN 2 stated CNA 1 told her, "That is one visual I never want to see again." LN 2 stated she, CNA 1 and CNA 2 went to Resident 15's room where she performed an assessment of Resident 15. LN 2 stated Resident's 15 cognition was impaired to the point where she was almost child like and unable to recognize boundaries or danger. LN 2 stated Resident 14 was higher functioning than Resident 15 and knew right from wrong. LN 2 stated Resident 15 had become quieter with less rummaging and wandering behaviors since the incident. LN 2 stated Resident 15 sat in one spot for periods of time staring into space for about two days, which was unusual for her. LN 2 stated, in her opinion, the incident should have been avoided. On 3/17/17 at 8:40 a.m., during an interview, the Director of Nursing (DON) stated for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 7 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 last eleven months, Resident 14 had been on one to one monitoring by staff for his sexual behaviors. The DON stated she had spoken to Resident 14's PCP about the possibility of prescribing medication to treat Resident 14's sexual behaviors. The DON stated the Interdisciplinary Team (IDT) (a team of professionals which included the SSD, who met a minimum of quarterly to discuss resident care and issues related to residents) notes dated 11/5/15 and 3/11/16, lacked an entry from the SSD. The DON stated the SSD should have revised Resident 14's care plan to add an action to protect the other residents from Resident 14's sexual behaviors and unwanted advances. The DON stated quarterly psychiatric evaluations for Resident 14 would have been appropriate, but none were done. The DON stated a psychiatric consult after every inappropriate physical contact with another resident by Resident 14 should have been done, but was not. The DON stated Resident 15's SSD and IDT notes dated 11/10/16 failed to address behaviors of Resident 14 and safety of other residents. On 3/22/17 at 4:00 p.m., during an interview, the SSD stated if the IDT had followed up on Resident 14's behavior monitoring data five times a week, as stated under corrective actions on the document, the IDT could have assessed whether staff actually complied with the one to one and every 15 monitoring of Resident 14. The SSD stated the care plan written by herself had not addressed Resident 15's behavior. Resident 14's record titled, "Q (every) - 15 Minutes Visual Monitoring" dated 11/23/16, indicated, columns for time, "Activities/Observations," and staff initials. The columns timed from 2:15 p.m. to 3:45 p.m. did not indicate documentation of Resident 14's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 8 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 activities, and did not include staff initials to signify staff had made an observation of Resident 14 during those times. Resident 14's nursing progress note dated 11/23/16 at 11:02 p.m., indicated, "Res (Resident 14) on alert charting for 15 min (minute) checks. Was an incident of sexual aggression today at 1515 (3:15 p.m.). A female resident (Resident 15) with dementia... they were found with his hand (Resident 14) in her crotch (Resident 15)..." Resident 14's nursing care plan dated 9/9/16, indicated, "RESOLVED: I sometimes have behaviors which include... hypersexual behaviors, i.e... inappropriate touching." On 3/23/17 at 1:40 p.m., during an interview, the Medical Director stated he was not made aware of the incident with Resident 14 and Resident 15 until 12/14/16 (three weeks after the incident). Resident 14's "Psychologist Consultation/Followup" form dated 6/29/16, indicated Resident 14 was on one-to-one monitoring for sexual behavior towards female peers. Resident 14's "Psychologist Consultation/Followup" form dated 10/17/16, indicated under recommendations staff were to continue to monitor for sexually inappropriate behavior. The facility policy and procedure titled, "Abuse Policy," undated, indicated, "It is the policy of the Company to prevent the occurrence of abuse..." 2. On 10/7/16 at 12:30 p.m., during an interview, the facility Ombudsman (a volunteer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 9 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 program who assists residents and the facility with concerns of residents and families) stated CNA 4 had reported seeing a visitor put his hands down Resident 16's pants. CNA 4 separated the visitor from Resident 16, escorted him to the ADM's office, and phoned the local police department to report an abuse occurrence. Resident 16's nursing progress notes dated 10/7/16 at 12:42 p.m., indicated, "CNA witnessed visitor groping resident between legs..." On 10/10/16 at 11:45 a.m., during a concurrent observation and interview with the SSD and Resident 16, the SSD stated Resident 16 had a diagnosis of Dementia and Alzheimer's Disease (chronic disorder that affects cognitive and functional abilities). On 10/11/16 at 11:38 a.m., during an interview, CNA 4 stated (on 10/7/16) Resident 16 sat in her wheel chair in the main corridor. CNA 4 stated she had been working in another room when she observed a visitor walk toward Resident 16 and put his hand between Resident 16's legs. CNA 4 stated she then yelled across the room for him to stop. CNA 4 and LN 5 then escorted the visitor to the ADM who escorted the visitor outside and told him to never come back. CNA 4 stated the staff were previously told the visitor had a history of sexual assault, but the visitor would be allowed in the building from 10 a.m. to 12 p.m. (noon) as long as the visitor was within sight by the staff. CNA 4 stated staff were told if staff were not directly with the visitor, they were to keep him in their line of sight at all times. CNA 4 stated a process was set up which included the visitor was to first check himself in with the business office staff and sign the visitor registration book. CNA 4 stated the visitor was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 10 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 then to go to the nurses station to check in, then the staff would bring the resident he came to visit, and escort the visitor and the resident to the activity room where they could visit. On 12/19/16 at 4:32 p.m., during an interview, the ADM stated the visitor was not allowed to go into the residents' room whom he came to visit, and he could only visit from 10 a.m. to 12 p.m. The ADM stated staff were aware the visitor was to be supervised. On 1/4/17 at 12:15 p.m., during an interview, LN 5 stated on (on 10/7/16 at 9:50 a.m.) she heard CNA 4 yell, after the visitor came into the facility. LN 5 stated she went to help CNA 4 separate the visitor from Resident 16. LN 5 stated she had escorted the visitor to the ADM who escorted the visitor out the door and told him never to come back. LN 5 stated from the area where the visitor had entered the building, staff were able to observe his actions. Resident 16's MDS assessment dated 9/14/16, indicated Resident 16 rarely or never understood (conversations) and was unable to be understood (during conversations). The MDS assessment indicated Resident 16's memory was severely impaired. Resident 1 required extensive assistance with transfers (required staff assistance to get out of chair). The police report dated 10/7/16, indicated a report made by the facility of a visitor sexually assaulting a resident. The report indicated a member of the care center was sexually assaulted on 10/7/16. The report indicated the policeman spoke to CNA 4 (the witness), the ADM, and the visitor accused. The police were unable to converse with Resident 16. The visitor was a registered sex offender certified by Megan's Law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 11 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 On 1/4/17 at 1:30 p.m., during an observation and interview, Resident 16 laid in bed covered with bed linen. Resident 16's eyes were open, but she would not answer any questions. Resident 16's nursing progress notes dated 10/7/16 indicated, "CNA witnessed visitor groping resident between legs..." The facility policy and procedure titled, "Abuse Policy," undated, indicated, "It is the policy of the Company... to prevent the occurrence of abuse..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 12 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F368 FREQUENCY OF MEALS/SNACKS AT BEDTIME CFR(s): 483.35(f)

F368 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/21/2017 Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided below. The facility must offer snacks at bedtime daily. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served. This REQUIREMENT is not met as evidenced by: Based on interview and administrative document review, the facility failed to offer evening snacks to all residents according to the facility policy and procedure. This failure had the potential to impact quality of life and resident health and nutrition. Findings: On 3/16/17 at 4:15 p.m., during an interview, the Registered Dietitian (RD) stated the Certified Nursing Assistants (CNAs) were to go to the resident's rooms and offer evening snacks. The RD stated, "CNAs should be communicating verbally with them (residents)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 13 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 On 3/20/17 at 3:20 p.m., during an interview, Resident 5 stated she can ask for alternate snacks and she told the dietary manager what she liked and the CNA would not bring it (the preferred snacks) to her. Resident 5's nursing care plan dated 6/9/16, indicated the resident was on a regular diet, staff was to monitor meal consumption daily, and obtain monthly weights. The care plan indicated the resident was at a nutritional risk due to her diagnoses and her weight was to remain stable. On 3/20/17 at 4:00 p.m., during an interview, Resident 8's family member (FM) 1 stated her mother liked popcorn and she occasionally brought her some (popcorn). FM 1 did not know if popcorn was offered to her mother for a snack or not (by the CNAs). On 3/20/17 at 4:30 p.m., during an interview, Resident 6's FM 2 stated her grandmother "loves snacks." FM 2 did not know if they (CNAs) offered her grandmother a snack. On 3/25/17 at 4:55 p.m., during an interview, CNA 5 stated, "We do offer snacks but we do not go down the halls with the carts. We put the (snack) carts by the nurses station. We do not go around and offer snacks to each resident." The facility policy and procedure titled, "Nourishments" undated, indicated, "Nourishments are foods and beverages offered to all patients on a routine basis at hour of sleep (H/S) unless contraindicated by diet. Nourishments may also be provided to patients between meals at the patient's request." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 14 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F371 FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.35(i) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/21/2017 The facility must (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions This REQUIREMENT is not met as evidenced by: Based on observation, resident and staff interview, and administrative document review, the facility failed to store foods in accordance with professional standards when two plastic bags of white cake mix and one container of creamy hot rice mix were were expired, according to their "use by" dates, in the dry storage room. This failures had the potential for food contamination. Findings: On 3/15/17 at 12:00 p.m., during a kitchen observation, two plastic bags of white cake mix FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 15 of 16 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 03/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 and a container of rice mix sat on a dry storage shelf. One cake mix indicated a "use by" date of 2/24/17. The second cake mix indicated a "use by" date of 2/20/17. The container of rice mix indicated a "use by" date of 3/7/17. On 3/16/17 at 3:55 p.m., during an interview, the Administrator stated, "We have a received date and a "use by" date on our dating and labeling. We use the "use by" date as our expiration date." On 3/17/17 at 2:00 p.m., during an interview, the DM stated foods should be labeled and dated with the "use by" date. The DM stated they (the cake mixes and the rice mix) should have been discarded. The facility policy and procedure titled, "Storing Prepared Foods" dated 2/11, indicated, "Food or potentially hazardous food ingredients not stored in original containers must be... Discarded if not used within "use by" date." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IFYI11 Facility ID: CA040000018 If continuation sheet 16 of 16