Other·April 4, 2019

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 during an abbreviated survey for the investigation of facility reported incident #CA00541278. Representing the Department of Public Health: HFEN, 36244 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 04/03/2019 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents 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: OIBQ11 Facility ID: CA030000082 If continuation sheet 1 of 7 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: _______________ 055917 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HARVEST CROSSING POST ACUTE 469 E. North Street Manteca, CA 95336 (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 or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIBQ11 Facility ID: CA030000082 If continuation sheet 2 of 7 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: _______________ 055917 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HARVEST CROSSING POST ACUTE 469 E. North Street Manteca, CA 95336 (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 This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure an allegation of neglect was reported to the Department within the required 24 hours of the incident for Resident 1. This failure increased the risk for abuse without prompt investigation. Findings: On 6/26/19 the Department received a facility report indicating Resident 1 informed staff that on 6/23/17 at about 2:30 a.m., CNA 3 told Resident 1 that CNA 1 (who was assigned to Resident 1) would change the resident's brief when she returned from break. In a hand written letter that accompanied the facility report, CNA 1 indicated when Resident 1 called for assistance again at about 3:30, CNA 1 went to assist Resident 1 and "She was very upset and had soaked her entire bed." Resident 1 was admitted to the facility on 1/31/16. Resident 1's diagnoses included hemiplegia (one side of the body is paralyzed) and hemiparesis (weakness on one side of the body) on the left side. A Brief Interview for Mental Status (BIMS) was conducted on 4/28/17. Resident 1 had a BIMS score of 13 out of 15 indicating she was cognitively intact. The Medication Review Report included an order dated 1/31/16. The order indicated, "Resident is capable of making and understanding his/her own decisions [x] yes..." An undated hand-written letter written by Certified Nursing Assistant 1 (CNA 1) identified an allegation of neglect occurred on the night shift of 6/23/17. The letter indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIBQ11 Facility ID: CA030000082 If continuation sheet 3 of 7 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: _______________ 055917 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HARVEST CROSSING POST ACUTE 469 E. North Street Manteca, CA 95336 (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's routine included calling at 2:30 a.m. to be changed. The letter further indicated, "[Resident 1] was told by [CNA 2] that she would change her later, and she never came back. [Resident 1] called again [at] 3:30 a.m. When I [CNA 1] went in she...had soaked her entire bed." A report for suspected abuse indicated the date the form was completed received by the Department was 6/26/17. Section D of the report indicated the incident occurred on 6/23/18 at 2:22 a.m. An interview was conducted with the Director of Staff Development (DSD) on 7/11/17 at 1 p.m. The DSD stated CNA 1 placed the hand-written letter into the mailbox for Director of Nursing (DON), the Administrator (AD), and the DSD for Monday, 6/26/17. The DSD stated she could not answer why CNA 1 did not report the allegation properly. An interview was conducted with the AD on 7/11/17 at 3 p.m. After the AD informed CNA 1 she had not reported the allegation correctly, the AD stated CNA 1 felt she had reported the allegation correctly and accurately. A facility document regarding resident abuse, revised 11/15, was addressed to facility staff members and new employees from the Administrator. The document, dated 5/24/17, contained CNA 1's signature. The document indicated, "All employees must report any knowledge or observation of an incident that appears to be or is suspected of...neglect...Reports are to be made in writing on the [abuse reporting] form located at each nurse's station in the Abuse Binder and faxed to the California Department of Public Health...Employees with knowledge, observation or suspicion of abuse are also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIBQ11 Facility ID: CA030000082 If continuation sheet 4 of 7 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: _______________ 055917 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HARVEST CROSSING POST ACUTE 469 E. North Street Manteca, CA 95336 (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 responsible to notify the Administrator as soon as possible...I acknowledge that I have read the above information...and agree to report any knowledge, observation, or suspicion of abuse while working in this facility. I understand that I can be terminated if I fail to report any abuse as defined above." The facility's "Abuse Investigation and Reporting" policy, revised 12/16, indicated in pertinent part, "All reports of resident abuse, neglect...shall be promptly reported to local, state and federal agencies (as defined by current regulations)..."

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 04/19/2019 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record review, and facility document review, the facility failed to ensure residents' briefs were changed to prevent residents from lying in urine and feces for extended periods of time for Resident 1. This failure increased the risk for skin breakdown. Findings: On 6/26/19 the Department received a facility report indicating Resident 1 informed staff that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIBQ11 Facility ID: CA030000082 If continuation sheet 5 of 7 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: _______________ 055917 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HARVEST CROSSING POST ACUTE 469 E. North Street Manteca, CA 95336 (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 on 6/23/17 at about 2:30 a.m., CNA 3 told Resident 1 that CNA 1 (who was assigned to Resident 1) would change the resident's brief when she returned from break. In a hand written letter that accompanied the facility report, CNA 1 indicated when Resident 1 called for assistance again at about 3:30, CNA 1 went to assist Resident 1 and "She was very upset and had soaked her entire bed." According to the clinical record, Resident 1 was admitted to the facility on 1/31/16. Resident 1's diagnoses included hemiplegia (one side of the body is paralyzed) and hemiparesis (weakness on one side of the body) on the left side. A Brief Interview for Mental Status (BIMS) was conducted on 4/28/17. Resident 1 had a BIMS score of 13 out of 15 indicating she was cognitively intact. The Medication Review Report included an order dated 1/31/16. The order indicated, "Resident is capable of making and understanding his/her own decisions [x] yes..." According to Resident 1's Nurse's Notes, dated 6/26/17 at 8:30 a.m., "Per Resident's assigned CNA on 6/23/17 NOC [night] shift while she went for her break resident has requested another CNA to change her brief and the CNA didn't change her on time." The facility's Investigation Report, dated 6/28/17, indicated the facility had several surveillance cameras throughout the hallways. The report indicated, CNA 1 was assigned to Resident 1 for night shift on 6/23/17. CNA 1 went to lunch at 2:22 a.m. on 6/24/17 for a half an hour. At 2:23 a.m. CNA 3 was seen coming out of Resident 1's room. CNA 3 then went to the nurses station and washed her hands, entered the medication room for a few moments, then exited and sat at the nurses station with her coworker for 15 minutes. CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIBQ11 Facility ID: CA030000082 If continuation sheet 6 of 7 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: _______________ 055917 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HARVEST CROSSING POST ACUTE 469 E. North Street Manteca, CA 95336 (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 3 then stood and went toward another hallway. An observation of Resident 1 was conducted on 7/6/17 at 9:35 a.m. Resident 1 was fully dressed and sat in a wheelchair in her room. No odors were noted. An interview was conducted with Resident 1 on 7/6/17 at 9:35 a.m. Resident 1 stated she was not changed at 2:30 a.m. and had to wait. Resident 1 stated it had upset her and "I had cried." An interview was conducted with Licensed Nurse 1 (LN 1) on 7/11/17 at 10:10 a.m. LN 1 stated Resident 1 set her cell phone alarm for every two hours. The alarm woke Resident 1 up and she was able to see if she needed to be changed. LN 1 stated, "Resident [1] usually does this all the time." The facility's 'Quality of Life - Dignity' policy, revised 8/09, indicated, "Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by:...Promptly responding to the resident's request for toileting assistance..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIBQ11 Facility ID: CA030000082 If continuation sheet 7 of 7