Health inspection·May 23, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of physical abuse to the California Department of Public Health (CDPH) within 24 hours for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for abuse allegations not being investigated and residents experiencing continued physical abuse. Findings: During an interview on 5/19/25 at 3:31 p.m. with Resident 1, Resident 1 stated during her last shower, a CNA (Certified Nursing Assistant 1) described as a big lady, put a lot of soap on her face, and was rubbing her face so hard she could not breathe. Resident 1 stated she tried to stop the CNA (1) but continued to rub soap on her face. Resident 1 stated the CNA did not stop until she screamed and yelled, Rape! Rape! Resident 1 stated, I could not do anything I was naked, and she was bigger than me, I am scared of her. Resident 1 stated she reported the incident to the head of the department and was informed, they were going to keep an eye on the CNA (1). Resident 1 stated CNA 1 still works in the facility and went to her room. During a review of Resident 1's Minimum Data Set (MDS-comprehensive assessment tool), dated 3/20/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 (score of 8-12 means moderate cognitive impairment). During an interview on 5/19/25 at 3:39 p.m. with Director of Nursing (DON), DON stated she was not aware of the abuse incident. During an interview on 5/20/25 at 8:29 a.m. with DON, DON stated she spoke with Resident 1 and the incident happened on 5/14/25 (six days ago). During an interview on 5/20/25 at 12:01 p.m. with Resident 2, Resident 2 stated the physical abuse happened two months ago. Resident 2 stated CNA 1 grabbed and pulled her right arm that was paralyzed (unable to move or feel certain part of the body due to a loss of nerve function) to get her out of the shower chair. Resident 2 stated, She [CNA 1] was very rough. Resident 2 stated couple of days after the incident, CNA 1 went to Resident 2's room and CNA 1 told Resident 2, I [CNA 1] know what you [Resident 2] did. You [Resident 2] reported me to the DON. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 3 had a BIMS score of 13 (score of 13-15 means cognitively intact). (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555125 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Linwood Meadows Care Center 4444 West Meadow Visalia, CA 93277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)