Other·September 18, 2017

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 HealthLicensing and Certification, during a RECERTIFICATION survey. Representing the California Department of Public Health-Licensing and Certification by Federal ID Number: 38060 RN, HFEN, 35737 RN, HFEN, 37398 RN, HFEN and 39233 RN, HFEN Capacity: 99 Census: 92 Sample: 19 Random: 1 Entity Reported Incident (ERI) investigated during the Recertification survey: ERI CA00511409: Substantiated with a deficiency issued, F224.

F224 SS=G PROHIBIT

F224 MISTREATMENT/NEGLECT/MISAPPROPRIA TN CFR(s): 483.12(b)(1)-(3) 09/25/2017 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(b) The facility must develop and 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: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 implement written policies and procedures that: (b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (b)(2) Establish policies and procedures to investigate any such allegations, and (b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property for one of 19 sampled residents (Resident 19) when the facility Social Services Director (SSD) withdrew funds from Resident 19's bank account without Resident 19's permission and in violation of facility policy. As a result of this failure, Resident 19's personal funds were not protected by the facility and her bank account was debited $2,280.18 dollars without authorization. Resident 19 suffered a loss of trust in facility staff to care for her financial needs and expressed sadness and emotional distress as a direct result of the unauthorized withdrawal of funds. Findings: Review of Resident 19's clinical record titled, "Admission Record (document containing resident personal information)" indicated Resident 19 was 62 years old and was admitted to the skilled nursing facility (SNF) on 7/29/16 with diagnoses that included Acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 Respiratory Failure (sudden onset of serious illness affecting the lungs ability to function normally), Heart Failure (serious illness of the heart affecting the capability to pump blood to body's tissues ), and Generalized Anxiety Disorder (mental disorder resulting in feelings of dread, apprehension and uneasiness). Resident 19's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool used to plan care) dated 10/26/16, indicated Resident 19's Brief Interview for Mental Status score was 15 points out of a possible 15 points which indicated Resident 19 was cognitively (pertaining to judgement, memory and reasoning ability) intact. On 11/22/16 at 9:42 a.m., during an observation and concurrent interview at the SNF, Resident 19 was sitting in a wheelchair. Resident 19 conversed freely and was alert and oriented to person, place and time. Resident 19 stated in early October 2016 she asked the SSD to take her to a nearby Automated Teller Machine (ATM) so that she could withdraw money from her account. Resident 19 stated the SSD had been holding her debit card in the SSD office for safe keeping and on 10/9/16 the SSD accompanied her to the ATM where she withdrew money. Resident 19 stated the SSD stood behind her while she withdrew $200 from the ATM. Resident 19 stated she gave her debit card back to the SSD for safe keeping, but she did not give the SSD her Personal Identification Number (PIN) or permission to use her debit card for purchases. Resident 19 produced three ATM receipts dated 10/9/16 as follows: Date: 10/9/16, Time: 10:46 a.m. Balance from checking: $1728.64 Date: 10/9/16, Time: 10:46 a.m. Balance from savings: $17.00 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 Date: 10/9/16, Time: 10:48 a.m. Withdrawal from checking Amount Requested: $200.00 Amount Dispensed: $200.00 Terminal fee: $3.50 Total Amount: $203.50 Resident 19 stated on 11/18/16 she received her bank statement dated 10/12/16 to 11/8/16. Resident 19 stated she noticed some withdrawals from her account on the statement that she had not made. Resident 19 stated at approximately 3 p.m. on 11/18/16, she presented her bank account statement for the period of 10/12/16 to 11/8/16 to the facility Administrator (ADM). Resident 19 stated she informed the ADM because she was worried about the many ATM charges that appeared on the bank statement. Resident 19 stated she was aware the SSD had kept her bank card for safekeeping and showed the ADM the many ATM charges on the bank statement that occurred after the withdrawal of money on 10/9/16. Resident 19 stated she had provided no one with the authority to withdraw money from her account and had not authorized anyone to use her bank card at any retailer. Resident 19 provided her bank statement dated 10/12/16 to 11/8/16 and stated the following ATM withdrawals were not done by her except for the recurring charges listed on 11/3/16 totaling $58.65 for insurance and the recurring charge listed on 11/7/16 of $71.34. Resident 19 stated she had not made or authorized the remaining charges on the bank statement indicating a total amount of $1769.68 (including ATM fees of $2.50 for each transaction). The bank statement dated 10/12/16 to 11/8/16 indicated: 10/14/16 303.00 (ATM) 10/17/16 203.00 (ATM) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 10/20/16 202.95 (ATM) 10/20/16 22.25 (ATM) 10/21/16 62.00 (ATM) 10/24/16 2.00 (ATM balance inquiry fee) 10/24/16 20.79 (purchase at food and liquor store) 10/24/16 103.50 (ATM) 10/24/16 203.00 (ATM) 10/27/16 30.28 (purchase at clothing store) 10/27/16 14.18 (purchase at liquor store) 10/27/16 42.95 (ATM) 10/28/16 2.00 (ATM balance inquiry fee) 10/31/16 42.25 (ATM) 10/31/16 28.96 (purchase at grocery store) 11/1/16 2.00 (ATM balance inquiry fee) 11/1/16 42.50 (ATM) 11/2/16 15.98 (purchase at variety store) 11/2/16 16.18 (purchase at fast food restaurant) 11/2/16 55.92 (purchase at liquor store with $40 cash back) 11/2/16 10.24 (purchase at liquor store) 11/3/16 32.07 (purchase at fast food restaurant) 11/3/16 28.64 (purchase at food and liquor store) 11/3/16 9.20 (recurring insurance charge authorized by Resident 19) 11/3/16 49.45 (recurring insurance charge authorized by Resident 19) 11/4/16 11.64 (purchase at a convenience market) 11/4/16 41.34 (purchase at a variety store) 11/7/16 2.00 (ATM balance inquiry fee) 11/7/16 71.34 (recurring charge authorized by Resident 19) 11/7/16 103.00 (ATM) 11/8/16 12.81 (purchase at food and liquor store) 11/8/16 82.25 (ATM) Resident 19 stated she was very ill when she was admitted to the SNF on 7/29/16 and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 facility Social Services Director (SSD) helped her with her personal affairs and held some of her cash, about $140, in the SSD office as well as her debit card. Resident 19 stated the SSD told her it was the usual practice to lock up a debit card in the SSD office and Resident 19 felt she could trust the SSD with her card. Resident 19 stated after she realized money was missing from her checking account the ADM called the fraud department at the bank and then placed a call to the SSD's home. Resident 19 stated together with the fraud department at the bank she (Resident 19) identified additional withdrawals from her checking account on dates that began before 10/12/16 and after 11/8/16. Resident 19 stated the following amounts withdrawn from her checking account were identified by her and the bank fraud department as unauthorized withdrawals: 10/11/16 - $204.50 11/9/16 - $ 42.25 11/14/16 - $ 143.50 11/14/16 - $ 42.50 11/17/16 - $ 62.75 Resident 19 stated on 11/18/16 the ADM left a message on the SSD's answering machine requesting a return call to discuss problems with Resident 19's bank account. Resident 19 stated the local police department (PD) was contacted on 11/18/16 and an officer contacted her at the facility the morning of 11/19/17. Resident 19 stated the officer took her statement, reviewed available evidence, provided a case number and filed a police report. Resident 19 stated the officer told her approximately $3,000 had been withdrawn from her account without her permission. Resident 19 stated she felt someone at the facility had withdrawn the money and she lost trust in the facility and the facility staff. Resident 19 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 she felt sad and upset that she could not trust the facility staff because she had always felt she had a good relationship with the staff; especially the SSD. Review of Resident 19's document titled, "[Bank] Claims Assistance Center" dated, 11/21/16, indicated, "Subject: Temporary credit for your account ending in [number] ...Dear [Resident 19]: While we research your inquiry, as a courtesy, we have temporarily credited $2,227.18 to your account above..." On 11/22/16 at 11:20 a.m., during an interview, the Assistant Social Services Director (ASSD) stated on 11/18/16 at approximately 4:45 p.m., she was informed by the ADM that Resident 19's bank account had unauthorized withdrawals. The ASSD stated she visited Resident 19 fifteen minutes later and found her to be tearful, emotional, and upset. The ASSD stated Resident 19 expressed that she was very upset because it seemed the SSD had used her debit card to take money from her bank account. The ASSD stated Resident 19 said she felt emotionally hurt because she thought she had a good relationship with the SSD. On 11/22/16 at 1:05 p.m., during an interview, the ADM stated on 11/18/16 at approximately 3 p.m., Resident 19 reported she had discovered withdrawals on her local bank account statement which she had not authorized or done. The ADM stated she and Resident 19 called the fraud department at the bank and the bank representative went over Resident 19's account and identified multiple unauthorized transactions. The ADM stated Resident 19 was very clear on which transactions were not authorized. The ADM stated, the bank canceled the debit card used to access the account, issued a new card to Resident 19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 opened an investigation and issued an event identification number. The ADM stated the SSD called her on 11/18/16 and stated she did not have Resident 19's debit card. The ADM stated she contacted the PD on 11/19/16 in the afternoon and was given a case number. The ADM stated the PD came to the facility on 11/20/16, spoke with her (ADM) and Resident 19, made copies of Resident's 19's bank statement and the facility's policies and procedures for handling resident's funds. The ADM stated the PD returned to the facility on the morning of 11/21/16 with video from Resident 19's bank where unauthorized transactions had occurred. The ADM stated that she (ADM) and Resident 19 were able to positively identify the facility's SSD at the ATM window in two separate videos. The ADM stated, she received a telephone call on 11/21/16 from the SSD stating, she (SSD) had $1400 at her house that belonged to Resident 19. The ADM stated the SSD's family member arrived at the facility at approximately 2 p.m. and presented a sealed envelope to the ADM which contained $1400 and indicated the money belonged to Resident 19. On 11/23/16 at 11:15 a.m., during an interview Resident 19 stated, she had filed charges of fraud and identity theft against the SSD. On 11/23/16 at 12 p.m., The ADM stated Resident 19 received a letter from the bank indicating $2,227.18 had been credited to her account because of evidence of fraud. Review of a document titled, "Law Enforcement Report Form" dated "approved" on 11/29/16, indicated, "On 11/23/16, at 0800 hours, I [Local Police Officer, LPO] assembled an arrest team and went to the residence of suspect [SSD] ...I contacted [SSD] and arrested her at her home ...Suspect [SSD] committed several crimes as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 outlined in this investigation. Those crimes include identity theft, the possession of another person's credit card/bank card account information with the intent to defraud, and multiple acts of theft committed through the fraudulent use of the victim's credit/bank card to obtain cash and through unlawful ATM withdrawals and merchandise through unlawful point of sale purchases ...The victim [Resident 19] is out $2,280.18 after the suspect [SSD] committed 30 plus fraudulent cash withdrawals and purchases using the victims bank card." The report was completed by the LPO. On 12/8/16 at 2:46 p.m., during a telephone interview, the SSD stated, in October 2016, Resident 19 gave her debit card and wallet to her to keep in the SSD office. The SSD stated it was not unusual for residents to give her purses or wallets to store in her office. The SSD stated she had been doing this "for years" for many residents. The SSD stated that she had taken Resident 19 to a local bank ATM two times in the past to withdraw money from her account. The SSD stated she was involved with Resident's 19's financial transactions including a withdrawal of $1,400 in cash. The SSD stated, "We have been doing this forever." The SSD stated that she had held wallets, purses and monies for other residents over the years. The SSD stated the business office would ask her to hold residents money and property. The SSD stated she currently had three residents' property locked up in her office. The SSD stated it was not unusual to run "financial errands" for residents. The SSD stated, she was unsure of the facility's policy and procedures and she had been doing business this way for years. On 12/9/16 at 4:40 p.m., during an interview, the ADM stated, there was no policy or procedure that permits facility staff to access FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 residents' personal bank accounts. The ADM stated there was not a facility policy or procedure that permitted facility staff to access resident bank accounts without written permission. On 12/9/16 at 6:35 p.m., during a telephone interview with the LPO, the LPO stated the facility SSD had accessed Resident's 19's debit card and made multiple purchases for personal gain. The LPO stated a search of the SSD's office and car had resulted in six wallets and purses in the office and one wallet in the SSD's personal car. The LPO stated that the SSD had confessed to points of purchases identified using Resident 19's bank card. The LPO stated the SSD had been charged with Identity Theft, Credit Fraud, and three counts of Actual Use. The facility policy and procedure titled, "INVENTORY OF PERSONAL PROPERTY" dated 03/2010, indicated"...7. Send money and valuables to business office for safe keeping. Give receipt to resident or relative. Use valuables envelope..." The facility policy and procedure titled, "ABUSE PREVENTION" dated 03/2010, indicated "Purpose: To ensure that resident's rights are protected through implementation of the Abuse Prevention policy and procedure. Policy: Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff...TRAINING...2. The Director of Staff Development will also provide twice a year and as needed in-services to review with facility staff the Abuse Prevention Policy and Procedure...DEFINITIONS...Misappropriation of resident property...is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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, "Course Completion History" dated 08/09/16, indicated the SSD completed "Abuse and Neglect of the Elderly-An Overview" on 07/09/15 and "Preventing, Recognizing and Reporting Abuse" on 07/20/16. The facility document titled "[Facility] EMPLOYEE HANDBOOK" dated October 2015, indicated, "Gross Misconduct: Gross Misconduct infractions are a direct violation of the Company's standards of conduct. These infractions include, but are not limited to: 1. Abuse...fiduciary...abuse of a resident. 2. Theft: Theft, attempted theft, fiduciary malfeasance or abuse...ELDER ABUSE ...The residents of this facility each have the right to be free from...fiduciary abuse...Definitions: Fiduciary Abuse means misappropriation of a resident's private funds ..."

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 09/25/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, and record review, the facility failed to store food under sanitary conditions in accordance with the facility policy and procedures when: 1. One bag of dry cereal was opened and in an unsealed container in the dry food storage area. 2. One dented can was in the dry food storage area. 3. A dry rice container was beside two sanitizer (cleaning) buckets in a food preparation area. 4. Resident 20's bedside had four opened unsealed cereal boxes at the bedside. These failures placed the residents at risk for foodborne illness. Findings: 1. On 8/21/17 at 7:20 a.m., during the initial kitchen observation in the dry food storage closet and a concurrent interview, the Dietary Cook (DC) stated all opened packages were required to be dated and placed in a sealed bag or container. The DC identified a bag of dry cereal with a broken seal and stated the opened bag of dry cereal was not properly stored. On 8/21/17 at 9:42 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 Dietary Service Supervisor (DS) stated the dry cereal bag should have been placed inside a sealed bag or a sealed container. The DS stated the bag of dry cereal was improperly stored. The facility policy and procedure titled, "SANITATION AND INFECTION CONTROL ...CANNED AND DRY GOODS STORAGE" dated 2012, indicated, "7. Metal, plastic containers (with tight fitting lids ...), or resealable plastic bags will be used for staples and opened packages of items such as ...dry cereals..." 2. On 8/21/17 at 7:21 a.m., during an observation and concurrent interview, the DC identified a dented can of marinara sauce and stated all dented cans were supposed to be removed from the storage area and should not be used. On 8/21/17 at 9:42 a.m., during an interview, the DS stated the dented can of marinara sauce should have been removed by the "stock person." The DS stated dented cans could not be used in the preparation of a meal. The facility policy and procedure titled, "SANITATION AND INFECTION CONTROL ...CANNED AND DRY GOODS STORAGE" dated 2012, indicated, " 8. Canned food items should be routinely inspected for damage such as dented, bulging or leaking cans. These items should be set aside in a designated area ..." 3. On 8/21/17 at 10:50 a.m., during an observation in a food preparation area, a container of uncooked rice sat next to two buckets filled with sanitizing chemicals. On 8/21/17 at 11:10 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 observation and concurrent interview, the DS stated the container of uncooked rice was ok to be next to the two buckets of sanitizing chemicals. The DS stated the chemical were food grade chemicals and would be ok if the chemicals were stored next to food as long as the chemicals were not being ingested. On 8/21/17 at 11:12 a.m., during an observation and concurrent interview, the Registered Dietician (RD) stated, "The chemicals need to be at a lower level and not next to the food." The RD stated the chemicals could potentially contaminate the food. The facility policy and procedure titled, "SAFETY ...CHEMICAL SAFETY AND STORAGE" dated 2012, indicated, " ...8. All soaps, detergents, cleaning compounds or similar substances will be stored in an area separate from food supplies..." 4. On 8/21/17 at 7:55 a.m., during an initial tour observation in Resident 20's room and a concurrent interview, four opened unsealed dry 12 ounce cereal boxes were at the bedside. Licensed Nurse (LN) 1 stated the boxes needed to be in sealed containers. LN 1 stated the cereal boxes need to have a date to indicate the opened date. LN 1 stated, "Sometimes the residents bring in food from outside and do not tell us." On 8/21/17 at 3:05 p.m., during an interview, Resident 20 stated the nurses knew when he brought food in from outside because the boxes of cereal were visible to everyone entering the room. Resident 20 stated no one in the facility had offered to store his cereal in a sealed container or resealable bag. The facility policy and procedure titled, "FOODS BROUGHT BY RESIDENT, FAMILY FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 MEMBER & VISITOR" dated 3/10, indicated, "It is the policy of this facility that food(s) brought by a resident, family member/visitor must be inspected... Foods brought into the facility by the resident, family members or visitors must be checked by a Charge Nurse... 4. Non-perishable foods permitted to be retained in the resident's room must be stored in plastic containers with tightfitting lids ..."

F518 SS=E TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 09/25/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provide effective emergency preparedness training for staff when Licensed Nurses (LN) 1 did not know how to access and demonstrate shut off of the domestic water and LN 2 did not know how to shut off the emergency gas. These failures placed residents, staff and visitors at risk for harm during an emergency. Findings: On 8/21/17 at 11:20 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 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: _______________ 555866 (X3) DATE SURVEY COMPLETED 08/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA HEALTHCARE 1715 S Cedar Ave Fresno, CA 93702 (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 observation and concurrent interview outside, LN 1 was asked to demonstrate the domestic water shut off. LN 1 stated the domestic water shut off was under a locked steel cage. LN 1 stated she did not know how to access the shut off because she did not know how to remove the steel cage. On 8/21/17 at 3:15 p.m., during an interview, LN 2 was asked about how to shut off the domestic gas utility during an emergency. LN 2 stated, "I do not know how to shut it off..." On 8/25/17 at 8:30 a.m., during an interview, the Director of Nurses stated all the staff was expected to locate emergency shut off for the facility utilities and know how to shut them off during an emergency. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LBCD11 Facility ID: CA040000037 If continuation sheet 16 of 16