Other·September 13, 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 Health Licensing and Certification during an ABBREVIATED survey for entity reported incident (ERI): CA00531444. Representing the California Department of Public Health: Federal ID: 28531, HFEN. The ABBREVIATED survey was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for ERI: CA00531444.

F223 SS=G FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 09/08/2017 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(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: 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: XWZD11 Facility ID: CA040000064 If continuation sheet 1 of 5 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: _______________ 555935 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (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 Based on observation, interview, record review and administrative document review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Certified Nursing Assistant (CNA) 1 stabbed Resident 1 multiple times in the head with a ballpoint pen. As a result of this failure, Resident 1 experienced pain, emotional distress, and an injury to her head requiring transport to the general acute care hospital (GACH) for evaluation and treatment. Findings: Review of Resident 1's clinical record titled, "Record of Admission (record containing resident personal information)" indicated Resident 1 was admitted to the skilled nursing facility (SNF) on 4/17/17 and was 90 years old on the day of the incident. The "Record of Admission" indicated Resident 1 was admitted to the SNF for rehabilitation following surgery for a fractured (broken) hip and had diagnoses that included pain, hypertension (high blood pressure) and Alzheimer's disease (progressive mental disorder with gradual loss of memory and development of personality changes). On 4/24/17 at 12:40 p.m., during an interview, the Director of Nursing (DON) stated she received a text message from Licensed Nurse (LN) 1 on 4/19/17 at approximately 1:45 a.m. The DON stated LN 1 notified her CNA 1 had stabbed Resident 1 in the head with a pen at about 1:30 a.m. The DON stated she instructed LN 1 to call the police department (PD) to file a report against CNA 1. On 4/24/17 at 2:45 p.m., during an observation and concurrent interview, Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XWZD11 Facility ID: CA040000064 If continuation sheet 2 of 5 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: _______________ 555935 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (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 sitting in her wheelchair in the activities room at the SNF. Resident 1's hair was neatly combed and completely covered her scalp. Resident 1 did not respond to questions when asked about the altercation with CNA 1 on 4/19/17. Resident 1 did not interact with her surroundings or participate in the activity in progress. On 8/10/17 at 10:15 a.m., during a telephone interview, LN 1 stated she was the charge nurse on the night shift on 4/19/17. LN 1 stated on 4/19/17 Resident 1 had resided at the facility for a few days and was at the SNF for rehabilitation following a broken hip and also had Alzheimer's disease. LN 1 stated Resident 1 was alert but confused. LN 1 stated Resident 1 was very restless during the night on 4/19/17 and kept trying to climb out of bed. LN 1 stated she moved Resident 1 to a chair near the nurses' station and all staff took turns keeping an eye on her and reminding her not to get up out of the chair and attempt to walk by herself. LN 1 stated CNA 1 returned from her lunch break that night at 1:30 a.m. and she asked CNA 1 to sit with Resident 1 for safety reasons. LN 1 stated a few minutes later she heard Resident 1 yell, "OW! OW! Why are you doing this to me? What did I do to deserve this?" LN 1 stated she looked up from where she was at the nurses' station and saw CNA 1 stabbing Resident 1, more than once, in the head with a ball point pen. LN 1 stated she immediately got up and separated the two and pushed CNA 1 back toward the cabinets at the nurses' station. LN 1 stated Resident 1 was sitting in her wheelchair with both hands held over the top of her head and there was blood seeping through her fingers. LN 1 stated she called for CNA 2 to help her and she placed a bandage over Resident 1's head to stop the bleeding. LN 1 stated she asked CNA 1 why she jabbed Resident 1 in the head with a pen and CNA 1 told her Resident 1 had hit her on her face and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XWZD11 Facility ID: CA040000064 If continuation sheet 3 of 5 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: _______________ 555935 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (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 responded impulsively by jabbing Resident 1 in the head with her pen. LN 1 stated she did not see Resident 1 hit CNA 1. LN 1 stated she informed CNA 1 she would call the police and then CNA 1 left the immediate area. LN 1 stated she notified the DON of the incident and called for an ambulance to transport Resident 1 to the GACH for evaluation of the bleeding head wound caused by CNA 1's pen. LN 1 stated she also called the local police department (PD) and they responded within 10 minutes; located CNA 1 still sitting in the building and took CNA 1 with them when they left the building. LN 1 stated CNA 1 was an experienced CNA and had worked at the facility for almost one year. LN 1 stated CNA 1 should have responded differently to Resident 1's confusion and restlessness; her behavior was not appropriate. LN 1 stated Resident 1 returned to the SNF from the GACH on 4/19/17 about 7 a.m., transported by her Responsible Party (RP) and did not have any wound dressings on her head. Review of Resident 1's GACH clinical record titled, "Quick Registration" dated 4/19/17, indicated Resident 1 arrived at the GACH on 4/19/17 at 2:20 a.m. by ambulance. Resident 1's GACH clinical record titled, "Physician Notes, Final Report" dated 4/19/17 at 2:42 a.m., indicated, "This is a 90 y/o [year old] female BIBA [brought in by ambulance] s/p [status post - meaning afterward] being stabbed in the head by a pencil [ball point pen]. Pt [patient] lives at a SNF and was stabbed with pen by a staff member at the facility. Pt states that she has some pain around the area. She states that she also has some slight neck pain ...1 mm (millimeter, a measurement of length, one mm equals 0.04 inches) puncture wound to top of scalp ...Diagnosis: Alleged assault ...Superficial laceration of scalp." The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XWZD11 Facility ID: CA040000064 If continuation sheet 4 of 5 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: _______________ 555935 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (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 GACH "Physician Notes, Final Report" indicated Resident 1 had undergone a "Head Computed Tomography"(CT scan, specialized X-ray examination of the head) while at the GACH on 4/19/17 to screen for injury to Resident 1's brain. The CT scan indicated, "No acute [sudden and serious] intracranial [within the skull] abnormality." Review of (city) Police Report dated 4/19/17 indicated, "[CNA 1] ...struck the victim [Resident 1] in the head several times with an ink pen causing the victim to bleed in violation PC [penal code] 245(a)(1) - assault with a deadly weapon and PC 368(b)(1) - Elder abuse, causing injury. [CNA 1] was arrested for the above charges and booked at [local county jail]. Review of facility administrative document titled, "Resident Rights" dated 5/20/13 indicated, "Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated ...Patients shall have the right : ...( 9) to be free from mental and physical abuse." Review of facility administrative document titled, "Reporting Abuse" dated revised 2/13 indicated, "Definitions ...III. "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XWZD11 Facility ID: CA040000064 If continuation sheet 5 of 5