Other·January 24, 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 during a standard abbreviated survey regarding investigation of an entity reported incident conducted on 1/22/19. For Entity Reported Incident CA00618198 regarding Quality of Care/Treatment, Resident Safety, a federal deficiency was identified (see

F600). Also, a "B" Citation was issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 32276, Health Facilities Evaluator Nurse.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 01/24/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation 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 medical symptoms. §483.12(a) The facility mustLABORATORY 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: 4TQ211 Facility ID: CA070000084 If continuation sheet 1 of 3 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 01/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 E Romie Ln Salinas, CA 93901 (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 §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to protect one of two sampled residents (Resident 1) from verbal abuse when Housekeeper A (HSK A) swore at Resident 1. This failure had the potential to cause emotional distress for Resident 1. Findings: During an interview with the Administrator (ADM) on 1/7/19 at 9:09 a.m., he stated he investigated an allegation of verbal abuse against Resident 1. He had been notified Resident 1 and HSK A had a verbal argument which resulted in HSK A calling Resident 1 a [profane language]. He stated HSK A admitted to calling Resident 1 a [profane language]. During an interview with Resident 1 on 1/7/19 at 11:25 a.m., he stated on 1/2/19, HSK A swore at him and called him a [profane language]. During a review of the clinical record for Resident 1, the IDT (Interdisciplinary Team) Progress Notes dated 1/2/19 at 2:36 p.m., indicated " ...resident and member of housekeeping were engaged in a conversation which became heated and resulted in housekeeper using unprofessional language directed at resident." The facility's policy and procedure, "Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a crime in the Facility Policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4TQ211 Facility ID: CA070000084 If continuation sheet 2 of 3 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 01/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 E Romie Ln Salinas, CA 93901 (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 Procedure" dated 3/2018, indicated "This facility prohibits and prevents abuse ...Each resident has the right to be free from ...mental/emotional ...verbal ...Residents must not be subjected to abuse by anyone, including but not limited to, facility staff ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4TQ211 Facility ID: CA070000084 If continuation sheet 3 of 3