Inspection·April 9, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its abuse reporting policy for one of four sampled residents (Resident 1). This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including major depressive disorder (a mental condition characterized by long-term loss of interest or pleasure in life) and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 1's Progress Notes, dated 4/29/23, indicated licensed nurse A (LN A) witnessed Resident 1 yelling and cursing at another resident. The Progress Notes indicated Resident 1 then pushed the other resident's wheelchair with such force that the wheelchair rolled approximately 20 feet before coming to rest. Resident 1 then yelled, And don't come back! There was no documentation that indicated LN A reported this incident to anyone. During an interview and concurrent record review with LN B on 4/9/24 at 10:50 a.m., LN B reviewed Resident 1's 4/29/23 Progress Notes. LN B confirmed Resident 1's documented actions were considered abuse and should have been reported. LN B explained incidents of abuse should be reported to the facility's abuse coordinator. LN B stated the abuse coordinator would then report the incident to the Ombudsman (resident advocate), the California Department of Public Health (CDPH, State licensing and certification agency), and if necessary, the police. During a follow-up interview with LN B on 4/9/24 at 1:58 p.m., in the presence of administrative staff C (AS C), LN B confirmed there was no documentation that the incident involving Resident 1 on 4/29/23 was reported to the facility's abuse coordinator, the Ombudsman, CDPH, or the police. During a telephone interview with LN A on 4/9/24 at 2:11 p.m., LN A indicated she vaguely remembered the incident involving Resident 1 on 4/29/23. LN A stated she did not remember if she reported the incident. The facility's policy titled Abuse Investigation and Reporting, revised 7/2017 indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055311 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)