Other·February 12, 2019

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 a Standard Abbreviated Survey. Complaint CA00616618 - Substantiated Representing the Department: 33720 - HFEN The inspection was limited to the investigation of the Complaint and does not reflect the findings of a full inspection of the facility.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement abuse policies and procedures according to the regulations when: 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: 4Z2M11 Facility ID: CA050000043 If continuation sheet 1 of 6 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: _______________ 055861 (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OJAI HEALTH & REHABILITATION 601 N Montgomery St Ojai, CA 93023 (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. The facility policy and procedure was not implemented and allegation of abuse were not reported to the Department of Public Health within 24 hours; and 2. The facility policy and procedure was not implemented when the, licensed nurse did not notify Resident 1's attending physician regarding alleged incident and physical findings; and 3. The facility failed to implement its policy and document objective data in the medical record and initiate a care plan to reflect Resident 1's condition and measures to be taken to prevent reoccurrence. These failures to implement establish facility policy and procedures have the potential to affect the resident's safety and protection from harm. Findings: 1. The facility policy and procedure titled, "Abuse Prevention," dated 12/31/15, page 6 of 17, indicated in part, "The administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours..." During an interview with a Resident 1, on 12/20/18, starting at 8 a.m., Resident 1 stated, "About one week ago the nurse refused to take me out for my 11 p.m., cigarette, she threw me down on my bed and punched me in my eye, it was black and blue." Resident 1 indicated he spoke to the police, nursing staff and his sister about the incident. During a review of the facility file, no report of alleged abuse had been filed with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4Z2M11 Facility ID: CA050000043 If continuation sheet 2 of 6 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: _______________ 055861 (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OJAI HEALTH & REHABILITATION 601 N Montgomery St Ojai, CA 93023 (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 Department of Public Health for that allegation. During an interview with the Administrator (ADM), on 12/20/18, at 10:30 a.m., ADM indicated he was aware of allegation of abuse on 12/09/18, ADM acknowledged he did not report the allegation to the Department of Public Health . 2. The facility policy and procedure titled " Abuse Prevention," dated 12/31/15, page 7 of 17, indicated in part..."The Licensed Nurse shall be responsible for notifying the residents' attending physicians regarding the alleged incident and the physical assessment findings."... During an interview with ADM on 11/20/18, at 11:30 a.m., while concurrently reviewing the nurses notes from 12/7/18 through 12/9/18, when asked if there was any indication Resident 1's physician was notified of the allegation of abuse, ADM stated, "No, it doesn't look like that occurred." 3. The facility policy and procedure titled " Abuse Prevention," dated 12/31/15, page 8 of 17, indicated in part..."The Licensed Nurse shall document objective data in the medical record and initiate a care plan to reflect the resident's condition and measures to be taken to prevent reoccurrence..." During an interview with ADM on 11/20/18, at 11:30 a.m., while concurrently reviewing the nurses notes from 12/7/18 through 12/9/18 and Resident 1's current care plan, when asked if there was documentation of nursing notes reflecting Resident 1's allegations and care plan revisions, ADM acknowledged there was none. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4Z2M11 Facility ID: CA050000043 If continuation sheet 3 of 6 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: _______________ 055861 (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OJAI HEALTH & REHABILITATION 601 N Montgomery St Ojai, CA 93023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F609 Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of abuse of one of two sampled residents (Resident 1). This failure resulted in delayed investigation of the allegation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4Z2M11 Facility ID: CA050000043 If continuation sheet 4 of 6 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: _______________ 055861 (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OJAI HEALTH & REHABILITATION 601 N Montgomery St Ojai, CA 93023 (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 Findings: The facility policy and procedure titled "Abuse Prevention" dated 12/31/15, indicated in part "The administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours." Record review on 12/20/18 revealed Resident 1 was admitted to the facility with diagnosis including acute pyelonephritis (inflammation of the kidney due to a bacterial infection), difficulty in walking and muscle weakness. The facility's most recent comprehensive assessment dated 11/28/18, indicated Resident 1 had minimal cognitive memory problems. During an interview with a Resident 1, on 12/20/18, starting at 8 a.m., Resident 1 stated, "About one week ago the nurse refused to take me out for my 11 p.m. cigarette, she threw me down on my bed and punched me in my eye, it was black and blue." Resident 1 indicated he spoke to the police, nursing staff and his sister about the incident. Review of facilities "Allegation of Abuse Investigation" indicated in part, "A report was received on 12/9/18, at 8:30 p.m., by administrator from nurse (LN1) that resident (name of Resident 1) reported to him that he was hit on the right side of face by a "nurse" staff member the previous night on 12/8/2018. The nurse immediately assured the residents safety and conducted an interview with the residents' sister present..." During a review of the facility file, no report of alleged abuse had been filed with the Department of Public Health for that allegation. During an interview with the Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4Z2M11 Facility ID: CA050000043 If continuation sheet 5 of 6 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: _______________ 055861 (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OJAI HEALTH & REHABILITATION 601 N Montgomery St Ojai, CA 93023 (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 (ADM), on 12/20/18, at 10:30 a.m., ADM indicated he was aware of allegation of abuse on 12/09/18, ADM acknowledged he did not report the allegation to the Department of Public Health. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4Z2M11 Facility ID: CA050000043 If continuation sheet 6 of 6