Other·November 19, 2018

PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA040000590 (X3) DATE SURVEY COMPLETED 11/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH HEALTH SKILLED NURSING CENTER 1633 S Court St Visalia, CA 93277 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A000 The following reflects the findings of the California Department of Public Health during the investigation of one facility reported incident. Facility Reported Incident: 609833 Representing the Department: 39602, HFEN One State Citation was written as a result of facility reported incident 609833. Citation number 12-39602-0014571-S. A064 1418.91(a) Health & Safety Code 1418 A064 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. This Statute is not met as evidenced by: A065 1418.91(b) Health & Safety Code 1418 A065 (b) A failure to comply with the requirements of this section shall be a class "B" violation. This Statute is not met as evidenced by: On 10/31/18 at 11 AM, an unannounced abbreviated survey was initiated at the facility. During the course of the survey, an incident of alleged resident abuse was identified and investigated. Based on observation, interview, and record review, the facility failed to report an allegation Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 UYWF11 TITLE (X6) DATE If continuation sheet 1 of 3 PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA040000590 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 11/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH HEALTH SKILLED NURSING CENTER 1633 S Court St Visalia, CA 93277 (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 of abuse for one resident (Resident 1) to the Department within 24 hours. This failure had the potential for Resident 1's allegation to not be appropriately investigated. Resident 1 was a 74-year-old female with diagnoses of S/P (status post - after) lumbar laminectomy (spinal surgery), impaired functional mobility, arthritis, hypertension (high blood pressure), chronic back pain, and history of bilateral knee replacement surgery. Resident 1 was non-English speaking. During an interview with the Nurse Manager (NM), on 10/31/18, at 11 AM, the NM stated she was informed on 10/25/18, at approximately 11 AM, Resident 1 had made an allegation of abuse. The NM stated she immediately spoke to Resident 1, who alleged on 10/24/18, at 9 PM, a Certified Nurse Assistant (CNA) pulled her leg while transferring her, causing her to cry out, and the CNA then told her to "shut up". The NM stated she wanted to further investigate the allegation and did not report the abuse allegation to the Department until 10/29/18. During an interview with the Administrator, on 11/2/18, at 11:45 AM, she stated she was made aware of the abuse allegation on 10/29/18, after the NM reported the allegation to the Department. During a review of the SOC 341 (form utilized by facilities to report abuse allegations to the Department) submitted to the Department, the space labeled Date Completed indicated "10/29/18". The facility policy and procedure titled "Abuse Prevention and Reporting in SNF [Skilled Nursing Facility]" dated 5/24/18, indicated ". . . Reporting. . . F. The DON [Director of Nursing] ensures the written reports are completed to the State L&C [Department]. . . after telephone Licensing and Certification Division STATE FORM 6899 UYWF11 If continuation sheet 2 of 3 PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA040000590 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 11/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH HEALTH SKILLED NURSING CENTER 1633 S Court St Visalia, CA 93277 (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 reports are made: SOC 341 (Suspected Dependent Adult/Elder Abuse) . . . G . . . This includes the SOC 341 which is to be sent within 24 hours. . ." The allegation of abuse was not reported to the Department within 24 hours. In accordance with Health and Safety Code section 1418.91, this is a class B violation. Licensing and Certification Division STATE FORM 6899 UYWF11 If continuation sheet 3 of 3