Other·November 30, 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. Facility Reported Incident: 557698 Representing the Department: 39356, HFEN 35286, HFEN The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as a result of facility reported incident 557698.

F223 SS=D FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 11/30/2017 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s 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: QHV411 Facility ID: CA630013665 If continuation sheet 1 of 7 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 11/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIDGECREST REGIONAL TRANSITIONAL CARE AND REHABILITATION UNIT 1081 N China Lake Blvd Ridgecrest, CA 93555 (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 symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from neglect which resulted in Resident 1 being subjected to physical neglect and psychosocial harm by a staff member. Findings: During an observation and concurrent interview with Family Member 1 (FM 1), on 10/26/17 at 11:25 AM, Resident 1 was asleep, with the nurse call button ( a button found around a bed that allows patients in health care settings to alert a nurse or other health care staff member remotely of their need for help) located underneath his left hand. At his bedside were two family members. FM 1 stated Resident 1 was alert and oriented and would be able to be interviewed however, had become very hard of hearing in the last few years, but was able to communicate via his phone (speaking into the phone translated the speech into written words and transcribes it on the screen of the phone). FM 1 stated Resident 1 preferred this method to communicate. FM 1 stated his father told him CNA 1 had taken the nurse call button and urinal (urine collecting container) away from Resident 1 after responding to his call light for the second time in the evening. FM 1 stated his, "Father now has a death grip on the call alarm". During an interview with Resident 1, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QHV411 Facility ID: CA630013665 If continuation sheet 2 of 7 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 11/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIDGECREST REGIONAL TRANSITIONAL CARE AND REHABILITATION UNIT 1081 N China Lake Blvd Ridgecrest, CA 93555 (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 assistance of FM 1's phone, on 10/26/17, at 11:40 AM, Resident 1 stated the second time he pressed the nurse call button, CNA 1 walked in angrily and with disgust, flipped back the sheets of his bed, and checked to see if he needed changing. At this point, CNA 1 took his nurse call button and urinal away. Resident 1 stated he felt like a burden. During a review of clinical record for Resident 1, the Record of Admission, indicated Resident 1 was 89 years old and had diagnoses of pain in right hip, muscle weakness (lack of muscle strength), unspecified atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atria), chronic obstructive pulmonary disease (obstructive lung disease characterized by long-term breathing problems and poor airflow). During review of Minimum Data Set (MDS - an assessment tool) for Resident 1, dated 10/9/17, the MDS indicated Resident 1 had clear speech, was able to make himself understood, and he had the ability to understand others. The MDS indicated Resident 1 was able to recall staff names and faces and was frequently incontinent of urine. During interview with Licensed Vocational Nurse 1 (LVN 1), on 10/26/17, at 2 PM, LVN 1 stated at the beginning of her shift on 10/8/17, she heard hollering coming from Resident 1. LVN 1 stated this was an unusual behavior from Resident 1, as she had taken care of Resident 1 previously. LVN 1 stated upon entering Resident 1's room, the nurse call button and urinal was on the floor. LVN 1 stated Resident 1 was very angry and upset. Resident 1 told her he could not use his nurse call button because CNA 1 had taken his nurse call button and urinal away from him. Resident 1 explained that he had to "pee in cups". LVN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QHV411 Facility ID: CA630013665 If continuation sheet 3 of 7 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 11/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIDGECREST REGIONAL TRANSITIONAL CARE AND REHABILITATION UNIT 1081 N China Lake Blvd Ridgecrest, CA 93555 (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 stated she noticed an ultra sorb pad (a pad used to draw in moisture to help keep the skin dry) was underneath Resident 1 with a large round circled wet spot below the pad. LVN 1 stated she notified the Director of Nursing (DON). During interview with the Administrator, and the DON, on 10/26/17, at 1:10 PM, the Administrator and the DON verified the incident of neglect had occurred. The facility policy and procedure titled, "Abuse and Neglect - Clinical Protocol", dated 4/2007, indicated "Neglect refers to refusal or failure to fulfill any part of one's obligations or duties to an individual...The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect including the Buddy system for staff to utilize while giving are to prevent a potential abusive situation occurring." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QHV411 Facility ID: CA630013665 If continuation sheet 4 of 7 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 11/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIDGECREST REGIONAL TRANSITIONAL CARE AND REHABILITATION UNIT 1081 N China Lake Blvd Ridgecrest, CA 93555 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F224 PROHIBIT

F224 MISTREATMENT/NEGLECT/MISAPPROPRIA TN CFR(s): 483.12(b)(1)-(3) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/22/2017 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(b) The facility must develop and implement written policies and procedures that: (b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (b)(2) Establish policies and procedures to investigate any such allegations, and (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 facility failed to follow its own policies and procedures for: 1. Reporting allegations of neglect. 2. Suspending staff members accused of abuse or neglect. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QHV411 Facility ID: CA630013665 If continuation sheet 5 of 7 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 11/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIDGECREST REGIONAL TRANSITIONAL CARE AND REHABILITATION UNIT 1081 N China Lake Blvd Ridgecrest, CA 93555 (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 These failures resulted in delayed reporting, investigation, and resolution of neglect by the alleged perpetrator (Certified Nursing Assistant 1-CNA 1), which resulted in CNA 1 providing care to residents before the completion of the facility's investigation of the incident, which had the potential for further neglect by CNA 1 to the facility's residents. Findings: During an on interview with the Director of Nursing (DON) and the Administrator, on 10/26/17, at 2:45 PM, the DON verified an allegation of neglect was reported to him by Licensed Vocation Nurse 1 (LVN 1) on 10/8/17, in the early morning. The DON denied reporting the incident to the Administrator or proper authorities (the Ombudsman or to the Department). The DON stated, "My fault. It slipped my mind". The Administrator verified the findings. During a record review of "Intake Information", the Facility Reported Incident of resident neglect was reported to the California Department of Public Health on 10/20/17 at 3:34 PM. This report was 12 days after the incident. During interview with the Assistant Director of Nursing, (ADON), on 10/26/17, at 1:10 PM, the ADON stated she had heard about the incident of neglect sometime in the morning of 10/08/17. The ADON verified knowledge of Resident 1's report of neglect. The ADON stated "I should have reported it [the allegation of resident neglect]." During a concurrent interview with the Administrator, the DON and the ADON on 10/26/17, at 2:35 PM, the time card for CNA 1 dated 10/8/17-10/21/17, was reviewed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QHV411 Facility ID: CA630013665 If continuation sheet 6 of 7 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 11/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIDGECREST REGIONAL TRANSITIONAL CARE AND REHABILITATION UNIT 1081 N China Lake Blvd Ridgecrest, CA 93555 (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 time card indicated CNA 1 worked her shift on 10/12/17, from 10:29 PM to 10/13/17 at 7:28 AM. The time card indicated CNA 1 worked after the incident with Resident 1 and before the facility' investigation of the incident was completed. The Administrator, the DON and the ADON verified the findings. The facility policy and procedure titled, "Abuse Investigation and Reporting" dated, 12/2016, indicated "All reports of resident abuse, neglect...shall be promptly reported to local , state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported." The policy also indicated..."The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QHV411 Facility ID: CA630013665 If continuation sheet 7 of 7