Other·April 11, 2017

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. Complaint Number: 522436 Representing the Department: 35286, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint 522436.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 04/09/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and 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: 3NR911 Facility ID: CA040000028 If continuation sheet 1 of 4 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: _______________ 555125 (X3) DATE SURVEY COMPLETED 03/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINWOOD MEADOWS CARE CENTER 4444 W Meadow Ave 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 exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) and investigate an allegation of financial abuse for one of three sampled residents (1). This had the potential to expose the resident to further harm. Findings: The clinical record for Resident 1 was reviewed. The Minimum Data Set (MDS - a comprehensive assessment tool) dated 6/8/16, indicated under Brief Interview for Mental Status (BIMS) a score of 13 (a score of 13-15 indicates the resident was cognitively intact). The progress notes for Resident 1 dated 6/7/16, at 9:29 AM, indicated, "Resident is alert and oriented, with usual level of forgetfulness." The progress notes for Resident 1 dated 6/30/16, at 10:52 AM, indicated "SSD (Social Service Director) spoke with (District AttorneyDA) at Tulare County DA office today. (DA) states she also received allegations of financial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3NR911 Facility ID: CA040000028 If continuation sheet 2 of 4 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: _______________ 555125 (X3) DATE SURVEY COMPLETED 03/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINWOOD MEADOWS CARE CENTER 4444 W Meadow Ave 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 abuse from (Resident 1's son's name) and has forward the report to APS (Adult Protection Services)." The progress notes for Resident 1 dated 7/6/16, at 4:17 AM, indicated the DA was in the facility to speak to Resident 1 regarding the allegation of abuse from an old caregiver. There was no investigation regarding the financial abuse allegation or indication the allegation was report to the Department, found in Resident 1's clinical record. During an interview with the SSD, on 2/23/17, at 5:37 PM, the SSD stated the facility did not perform an investigation of the allegation of financial abuse and the abuse allegation was not reported to the required agencies. During an interview with the Director of Nurses, on 2/23/17, at 5:43 PM, she reviewed the clinical record and was unable to find documentation of financial abuse allegation investigation. She stated "We did not investigate...we didn't report it." The facility policy and procedure titled "Reporting Abuse to Facility Management" revised date 10/2009, indicated "It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc, to promptly report any incident or suspected incident of neglect or resident abuse, including injures of unknown source, and theft or misappropriation of resident property to facility management. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately within two hours for major injury and within twenty-four hours in case of minor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3NR911 Facility ID: CA040000028 If continuation sheet 3 of 4 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: _______________ 555125 (X3) DATE SURVEY COMPLETED 03/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINWOOD MEADOWS CARE CENTER 4444 W Meadow Ave 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 injury of the alleged incident or abuse shall notify the following persons or agencies of such incident: The State licensing/certification agency (CDPH) responsible for surveying/licensing the facility (and) The local/State Ombudsman." The facility policy and procedures titled "Abuse Investigation" revision date 4/2010, indicated under Policy, "All reports of resident abuse, neglect and injuries of unknown source, shall be promptly and thoroughly investigated by facility management. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3NR911 Facility ID: CA040000028 If continuation sheet 4 of 4