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). Page 1 of 2 555125 555125 05/23/2025 Linwood Meadows Care Center 4444 West Meadow Visalia, CA 93277

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 2's IDT Note (Interdisciplinary note-multidisciplinary team meeting regarding resident's care), dated 5/26/25 indicated, [Resident 2] has not received shower from [CNA 1] in more than 30 days. The IDT Note indicated the abuse incident happened over 30 days ago. During an interview on 5/20/25 at 12:20 p.m. with Resident 3, Resident 3 stated, [CNA 1] was rough with me when she [CNA 1] gave me a shower. She [CNA 1] rubbed my back so bad it hurt me. I will never have her [CNA 1] give me shower again. So from the last six to seven months, she [CNA 1] has not showered me. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had a BIMS score of 15. During an interview on 5/20/25 at 2:30 p.m. with CNA 1, CNA 1 stated, His [Resident 3's] wife told me that he [Resident 3] does not want shower from me because he [Resident 3] does not like me. During a review of Resident 3's IDT Note, dated 5/26/25 indicated, [Resident 3] has not received shower from [CNA 1] in more than 30 days. The IDT Note indicated the abuse incident happened over 30 days ago. During an interview on 5/21/25 at 2:17 p.m. with CNA 1, CNA 1 stated there has been complaints about her being rough couple months ago, a resident (2) was not happy about the shower she (CNA 1) gave. CNA 1 stated she reported the allegation of physical abuse to the Director of Staff Development (DSD). CNA 1 stated she showered Resident 1 on 5/14/25 and was not happy and started screaming Rape! Rape! During an interview on 6/4/25 at 8:57 a.m. with DON, DON stated she was not aware of all of the three allegations of abuse prior to the survey on 5/19/25 and were not reported to the CDPH. During an interview on 6/4/25 at 9:53 a.m. with DSD, DSD stated she did not receive a report from CNA 1 regarding the allegations of abuse. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022, the P&P indicated, Reporting Allegations to the Administrator and Authorities: 3. Immediately as defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 555125 Page 2 of 2