Other·July 18, 2018

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: 584169 Facility Reported Incident: 586170 Representing the Department: 39426, HFEN 34510, HFEN The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number 584169 and facility reported incident 586170.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 07/06/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the 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: 2UHO11 Facility ID: CA630013665 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 06/20/2018 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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to the proper agencies, the mistreatment for one of three sampled residents (Resident 1) when Resident 1's Family Member (FM) slapped her hand which had the potential to put Resident 1 at risk for physical and/or psychosocial harm. Findings: During an interview with the Case Worker (CW), on 5/8/18, at 3:15 PM, she stated the FM called her and admitted to slapping Resident 1 on the hand when Resident 1 reached for the FM's purse. The CW stated she informed the FM that the action was a form of abuse and had to be reported. During an interview with Certified Nursing Assistant 1 (CNA 1), on 5/9/18, at 1:45 PM, she stated she did not see the incident that happened on 4/24/18 between Resident 1 and the FM, but CNA 1 stated she transferred Resident 1 from the dining area to Resident 1's room after the fact. CNA 1 stated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UHO11 Facility ID: CA630013665 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 06/20/2018 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 was crying en route to her room and said, "Why would she do that to me". During an interview with the Administrator/Abuse Coordinator (AAC), on 5/9/18, at 2:15 PM, he stated he did not know about the incident that occurred between Resident 1 and the FM. He stated the staff did not report it to him. AAC stated he would report the incident to the proper agencies, and the facility would conduct their own investigation. During an interview with CNA 2, on 5/10/18, at 4:45 PM, she stated she was sitting across from Resident 1 and the FM in the dining room, and she saw Resident 1 grab the FM's hand. CNA 2 stated the FM had a purse lying on her leg. CNA 2 stated the FM smacked Resident 1's hand and made it drop towards the wheel of the wheelchair. CNA 2 stated she heard the noise of the smack. CNA 2 stated Resident 1 was agitated and said, "Ow, that hurts". CNA 2 stated she went to the nurse's station to inform someone and she was directed to speak to the Social Services Department staff. CNA 2 stated she reported the incident to both the social workers and she was questioned about what she saw. CNA 2 stated, "In my opinion, it was abuse. That's why I went to my charge nurse". The facility policy and procedure title "Abuse Prevention Program", dated 12/16, indicated, "As part of the resident abuse prevention, the administrator will: ...Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse...Investigate and report any allegations of abuse within time frames as required by federal requirements; Under Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UHO11 Facility ID: CA630013665 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: _______________ 555877 (X3) DATE SURVEY COMPLETED 06/20/2018 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 the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director...If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UHO11 Facility ID: CA630013665 If continuation sheet 4 of 4