Other·July 26, 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 Entity Reported Incident investigation. Entity Reported Incident number: CA00510290. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN), Federal ID: 35973. Inspection was limited to the specific entityreported incident investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for Entity Reported Incident: CA00510290.

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

F223 07/27/2017 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(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 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: KUHJ11 Facility ID: 630014894 If continuation sheet 1 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 This REQUIREMENT is not met as evidenced by: Based on staff interviews, the facility failed to prevent physical and verbal abuse and maintain safety for six of six sampled Residents: (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6), when Certified Nurse Assistant (CNA 1) subjected them to verbal and physical abuse. This failure resulted in pain and injury to the residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6). Findings: On 2/04/2017 at 7:05 AM during an interview, CNA 4 stated, on 11/04/2016 she had witnessed and reported four allegations of abuse to Supervising Registered Nurse (SRN 2). CNA 4 further stated she had witnessed CNA 1 act like she was going to spit on Resident 1, stating "I can do that too. Don't hit me I have military background too." CNA 4 witnessed CNA 1 bend Resident 3's hand and Licensed Vocational Nurse (LVN 1) witnessed the event as well. CNA 4 witnessed CNA 1 tell Resident 5, "Get the fuck out of my way." During shift report, and upon learning assigned nursing personnel will need to do "Alert Charting" (assessment and documentation of injuries of unknown origin), CNA 1 stated to CNA 4, "You better not say anything because you know we do stuff like that.", referring to the bruising of the hand and fingers of Resident 1 caused by the bending of his hand the day before. On 2/05/2017 at 1:20 AM, during an interview, CNA 2 stated that on 11/3/2016 she was informed by an unidentified CNA of a suspected abuse allegation committed by CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 2 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 1. On 11/04/2016 she verbally reported 2 allegations to SRN 3 and a Registered Nurse (RN 1), as well as emailing a detailed account of the allegations to SRN 3. The first allegation indicated CNA 1 used mouth wash to clean the perineal area, "So that he (Resident 1) could feel the burn when she (CNA 1) cleaned him." The second allegation indicated CNA 1 stated "Good, now he can feel pain", after Resident 2 suffered a fall. CNA 2 stated she considered both allegations as abuse. On 2/05/2017 at 10:45 AM, during an interview SRN 3 stated on 11/04/16 he was notified by CNA 4 via email and by SRN 2 verbally of 2 suspected abuse allegations committed by CNA 1 against Resident 1 and Resident 2. The first allegation indicated CNA 1 used mouth wash to clean the perineal area of Resident 1, "So that he can feel the burn when I (CNA 1) clean him (Resident 1)." The second allegation indicated CNA 1 stated "Good, now he can feel pain.", after Resident 2 suffered a fall. SRN 3 stated he considered both allegations as abuse. On 2/06/2017 at 8 PM, during an interview CNA 5 stated on 11/04/2016 she reported an allegation of abuse to SRN 2 that occurred on 8/28/2016 in which CNA 1 bent the pinky fingers of Resident 3 "Far and back" to get him to release his grip on her (CNA 5). CNA 5 stated she considered that allegation as abuse. On 2/6/2017, at 11 PM, during an interview, CNA 3 stated she witnessed CNA 1 using mouthwash on wipes to remove and clean a bowel movement from Resident 4. CNA 3 stated she reported the event to SRN 2 on 11/4/2016. On 2/17/2017, at 2 PM, during an interview, CNA 7 stated, on a date unknown to CNA 7, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 3 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 CNA 1 appeared to have done something to get Resident 6 to release his firm grip on her, because she noticed Resident 6 react and release his grip. When asked, CNA 1 stated "You have to pull hair." CNA 1 positioned herself to the side and rear of Resident 6, raised her hand up close to the Resident's hair on the back lower area of Resident 6's head, and pretended to pull it. CNA 7 stated she considers pulling a Resident's hair for any reason abuse and reported the incident to the Charge Nurse. CNA 7 was unable to recall which Charge Nurse. CNA 7 did not complete the "Confident Report", or notify the required agencies (local Law Enforcement, the Ombudsman and CDPH).

F225 SS=F INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 07/27/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 4 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 5 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 by: Based on staff interviews, and administrative record review, the facility failed to report the allegations of abuse for six of six sampled Residents; (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) when Certified Nurse Assistant (CNA 1) subjected them to verbal and physical abuse. This failure had the potential for allowing more verbal and physical abuses to be committed by CNA 1. The earliest confirmed knowledge of the suspected abuse was on 8/28/2016 (as stated by CNA 5). The first confirmed report made to a licensed nurse occurred on 11/3/2016 (as stated by CNA 2). The first documented investigative interviews occurred on 11/4/2016 (as stated by Supervising Registered Nurse [SRN 2]). The form required to be completed as a mandated reporter titled "Confident Report" was initiated on 11/8/2016. The first notifications required within 24 hours were made on 11/9/2016 to Local Law Enforcement, the Ombudsman, and CDPH (California Department of Public Health); 73 days after the first confirmed allegation, and 5 days after supervision was notified. On 2/4/2017, at 7:05 AM, during an interview, CNA 4 stated that on 11/4/2016 she reported four allegations of abuse to SRN 2. CNA 4 stated she considered these behaviors as abuse, and understood her responsibility as a mandated reporter, but did not report to local Law Enforcement, the Ombudsman, or CDPH. On 2/5/2017, at 1:20 AM, during an interview, CNA 2 stated that on 11/4/2016 she verbally reported allegations of abuse to a Registered Nurse (RN 1) and SRN 3. CNA 2 stated that on 11/4/2016 she emailed a detailed account of the suspected abuse allegations to SRN 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 6 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 SRN 2 and SRN 3. CNA 2 stated she considered the allegations as abuse. CNA 2 stated she understood her responsibility as a mandated reporter, but did not generate a "Confident Report", notify Law Enforcement, the Ombudsman, or CDPH. On 2/5/2017, at 1:35 AM, during an interview, SRN 3 stated that on 11/4/2016 he was notified by CNA 4 via e-mail and by SRN 2 verbally of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. SRN 3 stated he considered both allegations as suspected abuse, and as a mandated reporter should have reported them within 24 hours. SRN 1 stated he did not generate a "Confident Report", notify Law Enforcement, the Ombudsman, or CDPH. On 2/5/2017, at 10:45 AM, during an interview, SRN 1 stated that on 11/4/2016 he was notified, by CNA 2 via e-mail and by SRN 2 verbally of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. SRN 1 stated he considers both allegations as abuse and as a mandated reporter he should have reported them within 24 hours. SRN 1 stated he did not generate a "Confident Report", notify Law Enforcement, the Ombudsman, or CDPH. On 2/6/2017, at 8 PM, during an interview, CNA 5 stated that on 11/4/2016 she reported an allegation of abuse that occurred on 8/28/2016 to SRN 2. CNA 5 stated she considers these acts as abuse and she understood her responsibility as a mandated reporter but did not report the incident to facility personnel, generate a "Confident Report", or notify local law enforcement, the ombudsman or CDPH. On 2/6/2017, at 11 PM, during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 7 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 CNA 3 stated she witnessed CNA 1 using mouthwash on wipes to remove and clean a bowel movement from Resident 4. CNA 3 stated she reported the event to SRN 2 on 11/4/2016. On 2/7/2017, at 10 AM, during an interview, the Medical Director (MD 1) stated mouthwash should not be used for perineal care and has never been ordered by him for that purpose. MD 1 stated that if mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse. On 2/7/2017, at 10 AM, during an interview, the Director of Nurses (DON) stated if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse. On 2/7/2017, at 7:30 PM, during an interview, CNA 6 stated on 11/4/2016 she reported 2 allegations of abuse to SRN 2. CNA 6 stated she considered both allegations as abuse and she understood her responsibility as a mandated reporter but did not generate a "Confident Report", notify local Law Enforcement, the Ombudsman, or CDPH. On 2/8/2017, at 10:10 AM, during an interview, SRN 2 stated on 11/4/2016 she was notified, by CNA 4 via e-mail of 2 suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. SRN 2 stated she subsequently interviewed CNA 2, CNA 3, CNA 5, and CNA 6 on 11/4/2016 regarding their knowledge of suspected abuse committed by CNA 1. SRN 2 stated the allegations should be considered suspected abuse, and should have been reported within 24 hours. SRN 2 also stated she did not generate a "Confident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 8 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 Report", notify Law Enforcement, the Ombudsman, or CDPH. On 2/10/2017, at 8 AM, during an interview, Staff 1 stated anyone employed by the facility should report any suspicion of abuse within 24 hours, including completing the "Confident Report" and notifying the required agencies. Staff 1 stated there should have been more than 10 "Confident Reports" generated to reflect all those involved in the allegations involving CNA 1, and there is only one report she is aware of (referring to the Confident Report generated on 11/8/2016). On 2/17/2017, at 2 PM, during an interview, CNA 7 stated on a date unknown to CNA 7, CNA 1 appeared to have done something to get Resident 6 to release his firm grip on her, because she noticed Resident 6 react and release his grip. When asked, CNA 1 stated " You have to pull hair. " CNA 1 positioned herself to the side and rear of Resident 6, raised her hand up close to the Resident's hair on the back lower area of Resident 6's head, and pretended to pull it. CNA 7 stated she considers pulling a Resident's hair for any reason abuse and she reported the incident to the Charge Nurse. CNA 7 was unable to recall which Charge Nurse. CNA 7 did not complete the "Confident Report", or notify the required agencies (local Law Enforcement, the Ombudsman and CDPH). On 2/4/2017, at 8 AM, during an interview, SRN 4 stated "Mandated Reporter" documents are posted in every nurse station in each building (1&5) of the facility. SRN 4 also stated every witness, or those having knowledge of abuse should complete the Confident Report and report to all required agencies. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 9 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 A review of the Administrative document, "Elder Abuse, Reporting (All Homes)", reviewed 9/26/2016, indicated "All Veterans Homes of California employees are, by law, "mandated reporters" required to report any known or suspected incidents of elder abuse." It also indicated "Physical abuse not resulting in serious bodily injury must be reported: a) by telephone to local law enforcement within 24 hours of obtaining knowledge. b) in writing to local law enforcement, the ... Ombudsman, and ... CDPH ... within 24 hours of obtaining knowledge (Use form SOC 341 [titled "Confident Report"])." A review of the Administrative document, "Confident Report", indicated local law enforcement, the Ombudsman, and CDPH were notified of the alleged abuses on 11/9/2016; 5 days after the allegations of abuse were reported to SRN 1, SRN 2 and SRN 3. A review of the Administrative document, "Mandated Reporter", dated 1/1/2013, indicated what is to be reported, to whom notifications should be made, and in what time frame the notifications should occur. A review of the Administrative document, "New Employee Orientation Agenda" (NEO), dated 6/1-6/2016, indicated "Mandated Reporting" and "Internal Incident Reporting" are presented as educational components on day 2 of NEO. A review of the Administrative document, "Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders" (a form new employees are required to read and sign upon receiving NEO), not dated, indicated definitions of abuse, "Persons who are required to report abuse.", "Reporting responsibilities and time frames." and "Penalty for failure to report abuse." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 10 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

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

F226 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/27/2017 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 11 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 prevention. This REQUIREMENT is not met as evidenced by: Based on staff interviews and Administrative document review, the facility failed to protect six of six sampled Residents; (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) when the facility was made aware of allegations of abuse by CNA 1 and continued to assign CNA 1 to patient care. This failure had the potential for continued and increased victim abuses to occur by the alleged perpetrator, CNA 1. The facility has a licensed bed capacity of 120. Each licensed unit has the capacity of 30 beds. After the allegations of abuse were made to Supervising Registered Nurses, CNA 1 was assigned 9 Residents on 11/5/2016, 10 Residents on 11/6/2016, 8 Residents on 11/7/2016, and 11 Residents on 11/8/2016; a total of 38 Residents of which CNA 1 was providing direct care for. On each day CNA 1 was assigned Residents for care on a specific unit, 11/5-8/2016, she had access to all Residents residing on that unit, a potential of 30 Residents, each shift CNA 1 worked; a potential of 120 Residents after allegations of abuse were made known to Supervisory. Findings: On 11/23/2016, at 8:45 AM, during an interview, the Assistant Director of Nurses (ADON) stated upon learning of suspected abuse, the priority is to provide safety for, and "remove" the potential danger to, the Residents. During interviews conducted on 2/4/2017 (CNA 4), 2/5/2017 (CNA 2, SRN 1, SRN 3), 2/6/2017 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 12 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 (CNA 3, CNA 5), 2/7/2017 (CNA 6), and 2/8/2017 (SRN 2), it was confirmed by all facility staff interviewed that allegations of abuse were made, implicating CNA 1, to facility Supervisors (SRN 1-3) on 11/4/2016, and 11/7/2016. On 2/5/2017, at 1:35 AM, during an interview SRN 3 stated he did not know when CNA 1 was removed from patient care. On 2/5/2017, at 10:45 AM, during an interview, SRN 1 stated that on 11/5/2016 CNA 1 was redirected to laundry. On 2/8/2017, at 10:10 AM, during an interview, SRN 2 stated CNA 1 "... was removed from patient care by other personnel." She did not provide the date. A review of the Administrative document, "Nursing Daily Staff Assignments", dated 11/5/2016, 11/6/2016, 11/7/2016, and 11/8/2016, indicated CNA 1 was assigned Residents to provide care and therefore had direct access to a total of 60 Residents. Thirty in building 1 and 30 in building 5 after allegations of abuses were made on 11/4/2016; a period of 4 days. On 11/5/2016, CNA 1 was assigned rooms 131-135 and 146-149, in building 1; on 11/6/2016 CNA 1 was assigned rooms 531-535 and 546-550, in building 5; on 11/7/2016 CNA 1 was assigned rooms 131-134 and 146-149, in building 1; and on 11/8/2016 CNA 1 was assigned rooms 150-160, in building 1. Each room is single occupancy. A review of the Administrative document, "Laundry Sign In", for "November 2016", indicated CNA 1 was assigned to Laundry duties from 11/10/2016 - 11/30/2016. A review of the Administrative document, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 13 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 "Memorandum" (a letter with the intent of officially reassigning CNA 1 to laundry), dated 11/10/2016, addressed to CNA 1, from Laundry Supervisor I. In the section titled "Subject", it indicated "Reassignment - (Perform tasks assigned while in Laundry Department)." The document contained information on Elder Abuse Reporting, and a General Administrative Policy, from the Administrative Manual, page 14, revised 11/2012, which contained information on Standards of Conduct, and Courtesy and Respect of clients and colleagues. The document was signed on 11/10/2016 by CNA 1 and the Laundry Supervisor I. On 2/10/2017, a request was made from Staff 1 for a general "Abuse" policy. Staff 1 indicated the policy "Elder Abuse Reporting (All Homes)" was the facility's only policy on the subject. There are no references in the "Elder Abuse Reporting (All Homes)" Policy that indicated administrative personnel to redirect a suspected abuser, to an area separate from patient care.

F241 SS=F DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 07/27/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 14 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on staff interviews and Administrative document review, the facility failed to provide six of six sampled Residents; (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) the dignity and respect they were afforded under law. This failure resulted in a diminished demonstration of dignity and respect when Certified Nurse Assistant (CNA 1) was witnessed by 6 CNAs (CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7) making disrespectful statements to colleagues in the presence of the Residents, making disrespectful statements to the Residents, and abusing them physically. The facility has a licensed bed capacity of 120. Each licensed unit has the capacity of 30 beds. After the allegations of abuse were made to Supervising Registered Nurses, CNA 1 was assigned 9 Residents on 11/5/2016, 10 Residents on 11/6/2016, 8 Residents on 11/7/2016, and 11 Residents on 11/8/2016; a total of 38 Residents of which CNA 1 was providing direct care for. On each day CNA 1 was assigned Residents for care on a specific unit, 11/5-8/2016, she had access to all Residents residing on that unit, a potential of 30 Residents, each shift CNA 1 worked; a potential of 120 Residents after allegations of abuse were made known to Supervisory. Finding: On 2/4/2017, at 7:05 AM, during an interview, CNA 4 stated she had witnessed CNA 1 act like she was going to spit on Resident 1, stating "I can do that too. Don't hit me, I have military FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 15 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 background." CNA 4 stated she witnessed CNA 1 bend Resident 3's hand and Licensed Vocational Nurse (LVN 1) witnessed the event as well. CNA 4 stated she witnessed CNA 1 tell Resident 5, "Get the fuck out of my way." CNA 4 stated that during shift report, and upon learning assigned nursing staff will need to do "Alert Charting" (assessment and documentation of injuries of unknown origin), CNA 1 stated to her "You better not say anything, because you know we do stuff like that.", referring to the bruising of the hand and fingers of Resident 1 caused by the bending of his hand the day before. CNA 4 stated she considered these behaviors as abuse. On 2/5/2017, at 1:20 AM, during an interview, CNA 2 stated on 11/4/2016 she reported 2 allegations of abuse to Supervising Registered Nurse (SRN 1), SRN 2 and SRN 3 via email and included a detailed account of the suspected abuse allegations. The first allegation indicated that CNA 1 used mouthwash to clean the perineal area "So that he (Resident 1) could feel the burn when she (CNA 1) cleaned him." The second allegation indicated that CNA 1 stated "Good, now he can feel pain." after Resident 2 suffered a fall. CNA 4 stated she considered both allegations as abuse. On 2/6/2017, at 8 PM, during an interview, CNA 5 stated that on 8/28/2016 CNA 1 bent the pinky fingers of Resident 3 "far and back" to get him to release his grip on her (CNA 5). CNA 5 stated upon Resident 3 releasing his grip he held his hands to his chest and moaned. CNA 5 stated she considers these allegations as abuse. On 2/6/2017, at 11 PM, during an interview, CNA 3 stated she witnessed CNA 1 using mouthwash on wipes to remove and clean a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 16 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 bowel movement from Resident 4. On 2/7/2017, at 10 AM, during an interview, the Medical Director (MD 1) stated mouthwash should not be used for perineal care and has never been ordered by him for that purpose. MD 1 stated that if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse. On 2/7/2017, at 10 AM, during an interview, the Director of Nurses (DON) stated that if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse. On 2/7/2017, at 7:30 PM, during an interview, CNA 6 stated she witnessed CNA 1 using mouthwash on wipes to clean the perineal area of Resident 4. CNA 6 stated when she asked why CNA 1 was using mouthwash, CNA 1 responded, "So he will learn." CNA 6 stated that CNA 1 stated to her, "Don't let them hurt you. You get them first. Pull their finger first, and back, and hurt them." CNA 6 stated she considered both allegations as abuse. On 2/17/2017, at 2 PM, during an interview, CNA 7 stated on a date unknown by CNA 7, CNA 1 appeared to have done something to get Resident 6 to release his firm grip on her, because she noticed Resident 6 react and release his grip. When asked, CNA 1 stated "You have to pull hair." CNA 1 positioned herself to the side and rear of Resident 6, raised her hand up close to the Resident's hair on the back lower area of Resident 6's head, and pretended to pull it. A review of the Administrative document, "CalVet Information / Policy Memo", dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 17 of 18 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: _______________ 555900 (X3) DATE SURVEY COMPLETED 06/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (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 3/23/2015, regarding the subject "Standards of Conduct" (a form presented during New Employee Orientation (NEO) that new employees are required to read and sign), indicated "CalVet expects its employees to follow certain common rules that promote and protect their own safety and well-being, that of other employees, clients ... to be certain that all employees understand what conduct is expected and necessary." Under the section "Courtesy and Respect", it indicated "Employees are expected to behave courteously and respectfully at all times. Every person ... deserves our respect and our best efforts. Good service and a good attitude ... and the service expectation for CalVet is a caring, cheerful, and helpful attitude. It is important for all to make a positive impression on those you serve ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KUHJ11 Facility ID: 630014894 If continuation sheet 18 of 18