Other·August 14, 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 standard survey. Facility Reported Incident: 639091 Representing the Department: 16894, HFEN 41024, HFEN The inspection was limited to the facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of the facility reported incident 639091.

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

F607 07/31/2019 §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 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: WBGZ11 Facility ID: CA050000695 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: _______________ 555517 (X3) DATE SURVEY COMPLETED 07/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KERN VALLEY HEALTHCARE DISTRICT D/P SNF 6412 Laurel Ave Lake Isabella, CA 93240 (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 facility failed to ensure staff implemented their policy of reporting abuse, or suspected abuse, in a timely manner. This failure had the potential to place all residents in the facility at risk for abuse. Findings: During a review of the SOC 341 document sent by the facility to the Department on 5/24/19, it indicated "Reporter witnessed CNA [Certified Nursing Assistant] verbally abusing elderly resident [Resident 1] by repeating what resident had said in an obviously mocking tone. Reporter noticed resident distress after interaction." The document indicated the reporting party was Dietary Aide (DA), and the incident date was 5/16/19 at 11 AM. During an interview with DA, on 5/29/19, at 10:37 AM, he stated he witnessed the above incident with CNA speaking to Resident 1 in a mocking tone, causing her distress, on 5/16/19. DA stated he waited until 5/22/19 for his supervisor to return from being off work before reporting the incident. During an interview with Nutritional Supervisor (NS), on 5/29/19, at 10:39 AM, she stated that DA reported the allegation of abuse to her on 5/22/19. The NS stated she told DA it was abuse, and reported it to the Director of Nurses. During a review of a handwritten note from DA, dated 6/25/19, it indicated "On 5/16/19, I witnessed a CNA making mocking comments towards a Resident. My supervisor was on vacation at the time so I waited until she was back to inform her, as I was unsure of what I witnessed was abuse. This was on 5/22/19." The facility policy title "Abuse Prevention FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WBGZ11 Facility ID: CA050000695 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: _______________ 555517 (X3) DATE SURVEY COMPLETED 07/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KERN VALLEY HEALTHCARE DISTRICT D/P SNF 6412 Laurel Ave Lake Isabella, CA 93240 (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 Program" dated 12/7/16, indicated "Each resident will be free from abuse. . .verbal abuse (derogatory terms). . . ." The facility policy title "Abuse Prevention Program - Investigation" dated 12/7/16, indicated "An initial report must be completed and submitted to California Department of Public Health within 24 hours of the incident. . . ." The facility policy title "Abuse Prevention Program - Reporting" dated 12/7/16, indicated "If an incident or allegation is considered reportable, the licensed nurse will make a report to the California Department of Public Health and the Ombudsman within 24 hours." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WBGZ11 Facility ID: CA050000695 If continuation sheet 3 of 3