Other·June 20, 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 Licensing and Certification during the investigation of an ABBREVIATED SURVEY for the following Facility Reported Incident (FRI): CA00580714. Representing the California Department of Public Health: 28531 HFEN 38831 HFEN The inspection was limited to the specific FRI investigated and does not represent the finding of a full inspection of the facility. Because of the serious actual harm to Resident 1, the potential serious harm to all residents assessed for being at risk of wandering and elopement and the failure to have an effective system in place to ensure the safety of residents with elopement behaviors an Immediate Jeopardy (IJ) Situation was called on 4/2/18 at 5:35 p.m. The facility administrator (Admin), the Director of Nursing (DON) and the Director of Maintenance (DOM) were present and were verbally notified of the IJ situation. The facility submitted an Action Plan (AP) which addressed wandering risk assessment, checking placement and function of the Residents' PAS and staff response to all exit door alarms. The facility's AP was reviewed, revised, and formally accepted on 4/3/18 at 2:25 p.m. The determination was made that the facility implemented the AP and trained or retrained staff sufficiently to remove the immediacy. The IJ was removed during an onsite visit on 4/3/18 at 5:06 p.m. with the Admin and the DON present. 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: GJWX11 Facility ID: CA040000018 If continuation sheet 1 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 One deficiency was issued for CA00580714.

F689 SS=K Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/31/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to prevent one of three residents, Resident 1, from leaving the facility on 4/2/18 in her wheelchair, unnoticed and unsupervised. Prior to the incident Resident 1 was assessed as a cognitively (pertaining to reasoning, memory and judgement) impaired individual with known elopement behavior. The facility failed to ensure Resident 1's personal alarm system (PAS - an alarm system to alert staff when residents try to leave the facility or wander into restricted areas) device and/or the alarm system component at the lobby exit door were functioning properly. The facility failed to implement an individualized monitoring plan to address Resident 1's known elopement behavior. These failures resulted in Resident 1 leaving the facility unassisted and unsupervised, falling off the sidewalk curb in her wheelchair on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 2 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 4/2/18 at 8:40 a.m., landing face down on the city street, and sustaining a two centimeter (cm) laceration (cut) and large hematoma (solid swelling of clotted blood) in the soft tissues in the area around the left eye. Resident 1 required transportation by ambulance to the General Acute Care Hospital (GACH) for evaluation. The facility failed to have a system in place to ensure the safety and protection of five of 59 residents assessed as having behaviors of wandering and elopement. Staff did not respond to door alarms intended to prevent residents from eloping. The facility did not have a system in place to ensure door alarms and PAS devices functioned properly and staff responded appropriately. Because of the serious actual harm to Resident 1, the potential serious harm to all residents assessed for being at risk of wandering and elopement and the failure to have an effective system in place to ensure the safety of residents with elopement behaviors an Immediate Jeopardy (IJ) Situation was called on 4/2/18 at 5:35 p.m. The facility administrator (Admin), the Director of Nursing (DON) and the Director of Maintenance (DOM) were present and were provided verbal notification of the IJ situation. The facility submitted an Action Plan (AP) which addressed wandering risk assessment, checking placement and function of the Residents' PAS and staff response to all exit door alarms. The facility's AP was reviewed, revised, and formally accepted on 4/3/18 at 2:25 p.m. The determination was made that the facility implemented the AP and trained or re-trained staff sufficiently to remove the immediacy. The IJ was removed during an onsite visit on 4/3/18 at 5:06 p.m. with the Admin and the DON present. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 3 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 Findings: Resident 1's Admission Record (AR - record containing personal information) indicated Resident 1 was 72 years old and was admitted to the skilled nursing facility (SNF) on 11/11/14. The AR indicated Resident's 1 diagnoses included: Alzheimer's (progressive disorder marked by memory loss, personality changes, and impaired reasoning), history of falls, psychosis (mental health disorder characterized by difficulty in telling what is real and what is not), convulsions (seizures), and anxiety. The AR indicated Resident 1 was her own Responsible Party (RP - decision maker). Resident 1's clinical record titled, "Minimum Data Set (MDS - a resident assessment tool used to plan resident care) Assessment" dated 2/1/18, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 9 points out of a possible 15 points, which indicated moderate cognitive impairment. On 4/2/18 at 2:10 p.m., during an interview and concurrent record review, the DON stated on Saturday, 3/31/18 at 6:20 p.m., the Licensed Nurse (LN) 1 learned from a visitor that Resident 1 was outside self-propelling her wheelchair down the street. The DON stated, "Then, this morning [4/2/18] at 8:40 a.m., a visitor called staff and made them aware that a resident was outside in the street with a wheelchair flipped over off the curb." The DON stated staff ran out to the street and found Resident 1 face down with a two cm laceration above her left eyebrow. The DON stated Resident 1 left the facility on 4/2/18, unnoticed and unsupervised for the second time in three days. The DON stated it was unknown which door Resident 1 had exited from. The DON stated it was unknown whether or not alarms sounded, whether staff did not hear alarms, or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 4 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 if staff did hear the alarms and did not respond. The DON stated Resident 1 was transported to the GACH by ambulance and had not returned to the facility. Resident 1's GACH clinical record indicated Resident 1 was transferred to the GACH on 4/2/18 for evaluation following the fall and remained in the GACH for eight days for medical follow-up, not directly related to the elopement and fall. The GACH clinical record indicated Resident 1 was transferred back to the SNF on 4/10/18. Resident 1's GACH clinical record titled, "History and Physical" dated 4/2/18 indicated, "[Resident 1] is a 72 y/o [year old] female with a history of mental health issues...She presented [arrived in the emergency department] after tipping over in her wheelchair and falling and was found to have a left-orbital [area around the eye] hematoma..." The GACH "Radiology Report" indicated a Computed Tomography [CT - a computer assisted specialized X-Ray] imaging of the head was performed on 4/2/18 with the following results: "There is a large hematoma noted in the soft tissues in the left periorbital region. The orbit in the left appears to be intact ...No evidence of acute intracranial (within the skull) hemorrhage ...mass or bleeding ..." On 4/2/18 at 2:35 p.m., during a joint interview with the DON and LN 1, LN 1 stated she arrived at work on Saturday 3/31/18 at 6:03 p.m. LN 1 stated a resident's family member (FM) was standing near the front door in the lobby. LN 1 stated, "He [FM] said one of your patients is getting away." LN 1 stated Resident 1 was outside on the sidewalk a short distance from the facility. LN 1 stated she went outside and brought Resident 1 back into the building in her wheelchair. LN 1 stated Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 5 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 wearing a PAS (a bracelet which should trigger an alarm if Resident 1 was close to the lobby exit door). LN 1 stated the PAS alarmed when she brought Resident 1 through the lobby door. LN 1 stated, "I didn't know she had a [PAS] until I brought her back inside through the front door and it went off [alarmed]." The DON stated on 3/31/18 Resident 1 had a PAS on without a physician order and no one was checking to ensure it was functioning properly. The DON stated Resident 1's current PAS order was obtained after the first elopement on 3/31/18. LN 1 and the DON both stated they did not know how Resident 1 got out of the building unnoticed and unsupervised while wearing a PAS on both 3/31/18 and 4/2/18. On 4/2/18 at 3 p.m., during a joint interview with the DON and LN 2, LN 2 stated Resident 1 had a PAS, since she started working at the SNF approximately two months ago. LN 2 stated she did not check the PAS to ensure it was working properly. LN 2 stated, "I check to see if it's [PAS] attached to her [Resident 1]. If there was damage I would think it might not work, but if it's there and it looks okay I expect it to work. I just assume." LN 2 stated she routinely checked to ensure the PAS was in place on Resident 1's wrist. LN 2 stated she documented the placement of the PAS on Resident 1 in the Medication Administration Record (MAR). The DON stated she checked Resident 1's MAR from 3/1/18 to 4/2/18 and there was no documentation Resident 1's PAS was checked for placement. The DON stated the only documentation of checking placement or function of the PAS was in the Treatment Administration Record (TAR), dated 4/1/18 and at midnight on 4/2/18. The DON stated, "No one was checking the doors to make sure the alarm triggered and alarmed." Resident 1's clinical record titled, "Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 6 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 Summary Report" dated 3/31/18 indicated, "May have [PAS] every shift to prevent elopement." The "Order Summary Report" indicated 4/1/18 was the start date for the PAS. On 4/2/18 at 3:30 p.m., during an interview, the DOM stated he had worked for the facility for about two months. The DOM stated he had never worked with the PAS devices prior to his employment at the facility. The DOM stated about a month before Resident 1 eloped, the PAS devices did not always cause the door alarm to sound. The DOM stated at that time (a month ago) he took three residents with a PAS to the lobby door and the alarm did sound when they neared the exit. On 4/2/18 at 3:40 p.m., during an observation and joint interview with the DOM and the Admin, the DOM attempted to demonstrate the PAS alarm system by wheeling Resident 5 up to the front lobby door which was equipped with PAS alarming system, but the alarm did not go off. The DOM stated he had used Resident 5's PAS earlier to check the alarm and it worked well. The DOM patted down Resident 5's forearms checking for a bracelet with the PAS tag attached. The Admin stated facility staff determined there was no physician order for Resident 5's PAS, so they had taken it (the PAS tagged bracelet) off without the DOM's knowledge. The DOM then brought Resident 2, who was wearing a PAS tag, to the lobby door to test the alarm system. A very loud alarm sounded when Resident 2 was pushed up to and through the lobby door. A staff member approached the hall doorway into the lobby and requested information unrelated to the alarm. No staff members came forward to investigate why the PAS was alarming and rule out the possibility of an elopement. On 4/2/18 at 4:40 p.m., during an interview, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 7 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 Admin stated, "It [the PAS system] works at least part of the time." Because of the serious actual harm to Resident 1, the potential serious harm to all residents assessed for being at risk of wandering and elopement, and the failure to have an effective system in place to ensure the safety of residents with elopement behaviors an IJ Situation was called on 4/2/18 at 5:35 p.m. The facility Admin, the DON and the DOM were present and were provided verbal notification of the IJ situation. The facility submitted an AP which addressed wandering risk assessment, checking placement and function of the Residents' PAS, and staff response to all exit door alarms. The facility's AP was reviewed, revised, and formally accepted on 4/3/18 at 2:25 p.m. The determination was made that the facility implemented the AP and trained or retrained staff sufficiently to remove the immediacy. The IJ was removed during an onsite visit on 4/3/18 at 5:06 p.m. with the Admin and the DON present. On 4/3/18 at 3 p.m., during an interview and concurrent review of the facility Wander Risk Assessment forms, the DON stated an error had been identified in the computerized Risk Assessment form. The DON stated all wander risk assessments would be reviewed and recalculated because they inaccurately measured residents' wander risk lower than they actually were. Resident 1's risk assessment completed on 3/31/18 at 9:11 p.m. resulted in a score of 8, which placed her at low risk for wandering. The risk assessment completed on 4/2/18 at 12:30 p.m., indicated a score of 13. Another risk assessment also completed on 4/2/18 at 12:30 p.m., indicated a score of 16. An assessment score of 11 and above indicated a high risk to wander. The DON stated residents were evaluated to better FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 8 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 plan their care and heighten staff awareness of the residents' risk to wander. On 4/11/18 at 9:20 a.m., during a telephone interview, LN 3 stated on 4/2/18 at 8:35 a.m., he had seen Resident 1 on the south hallway. LN 3 stated at 8:40 a.m., a visitor phoned that Resident 1 was outside. LN 3 stated multiple staff members ran outside and found Resident 1 face down in the street near the gutter, bleeding from a two cm laceration above her left eye. LN 3 stated, "She [Resident 1] was yelling, I hurt." LN 3 stated Resident 1's PAS was in place on her wrist. LN 3 stated, "We think she went out the front lobby door because all the other doors are perimeter doors which automatically alarm, PAS or not." LN 3 stated, "Residents at risk for elopement have a [PAS] on for their safety. I know she was at risk for elopement. She was already wearing a [PAS]." LN 3 stated Resident 1 had a PAS in place since she was admitted on 11/11/14. LN 3 stated the PAS alarm was loud and if it had alarmed it would have been heard at the nurses' station. LN 3 stated, "I did not hear the alarm the morning she [Resident 1] eloped. The business office staff did not hear the alarm. The visitor who alerted us she [Resident 1] was outside in the street, said the door alarm was not alarming when she [the visitor] left. All the other doors [perimeter doors] would have alarmed." On 4/12/18 at 10 a.m., during a phone interview and concurrent record review, the DOM stated only the front lobby door was equipped with the PAS system. The DOM stated all other exit doors alarmed unless a code was entered before opening, except the exit door located on the service hallway (which was behind another locked door). On 4/12/18 at 11:30 p.m., during a telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 9 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 interview, the Corporate Director of Maintenance (CDOM) stated he did not know if the SNF had developed policies that outlined which personnel were authorized to test the PAS or a procedure which outlined the steps to test the PAS system and door alarms. On 4/16/18 at 2:15 p.m., an observation and concurrent interview with Resident 1 was conducted in the hallway near the nurses' station. Resident 1 was sitting in her wheelchair and rubbed both sides of her face repeatedly with her open palm. Her left cheek and the area above her left eye was red and abraded (scraped). Resident 1 hesitated, and then stated she did not recall which door she used to leave the facility on 3/31/18 and 4/2/18. On 4/25/18 at 8:45 a.m., during a telephone interview, the DOM stated he had no knowledge of the PAS being checked and/or any documentation of the PAS checks prior to his hire date of 1/22/18. The DOM stated prior to Resident 1's elopement on 4/2/18, "I was checking the alarm, but not daily, maybe weekly... and I was not documenting the test results." The DOM stated he created a log and began documenting the PAS testing on 4/3/18, after the Immediate Jeopardy was called, due to Resident 1's elopements. The DOM stated the first time he documented Resident 1's PAS test was 4/11/18, after Resident 1 returned to the SNF from the GACH. On 5/1/18 at 9:30 a.m., during an interview, the DON stated the staff were expected to respond immediately when a door alarm went off. The DON stated by staff she meant licensed and unlicensed staff, to include all staff employed by the facility. The DON stated staff would need to identify which door was alarming and look to ensure that a resident had not gone out without permission and unsupervised. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 10 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 DON stated if the alarm went off and a resident was not near the door, staff should look outside to see if a resident had left the facility unsupervised. The DON stated if staff did not see a resident and could not determine why the alarm had sounded they should report to a charge nurse to get a head count in order to ensure there had not been an elopement. The DON stated this expectation was not new and had always been the expectation for staff employed by the facility. Review of the facility PAS purchase and product information from the supplier, dated 10/18/16, described the essential part of the PAS worn by residents at risk for elopement, as a one inch square shaped "tag" attached to an arm or ankle strap. The "Specification Sheet [PAS] Tag" indicated, "The [PAS] Tag provides protection to wander-prone residents. Each tag is identified by its own unique code. The system generates an Exit alarm if the tag is brought near to an exit protected by a Door Controller [PAS alarm sensor equipment at the door] ...When attached, the tag provides additional tamper-resistant protection for the residents." The "Specification Sheet [PAS] Door Controller" indicated, "[PAS] Door Controller monitors an exit in a facility using the [PAS] wander prevention system. The system provides freedom of mobility to residents in senior care facilities, while helping to ensure that they remain safe. The Controller generates an exciter field, which defines the door coverage area for resident tags. When a tag enters the Controller's exciter field while the door is open a Wander alarm is generated..." The Pocket Tag Reader (PTR - hand held testing device for the PAS) User Guide, dated 4/11, indicated, "...Important Recommendation [name of alarm company] systems are designed to assist staff in providing a high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 11 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 degree of safety for people and assets and therefore should be used as a component of a comprehensive security program of policies, procedures, and processes. As with every security system, you must perform regular system operational checks to verify functional integrity...Introduction...The PTR is a test tool for reading, testing and configuring...active Radio Frequency...Used improperly, the PTR can compromise the security system. Ensure that adequate procedures and precautions are in place to control the movement of this device; and to prevent the use of this device by unauthorized personnel. ...PTR Operation Overview For best results, place skin sensing tags on a shielded (e.g. metal) surface when testing...The type of tag and radio frequency (RF) noise may affect the performance of the PTR, RF noise radiates from notebook computers, PC [personal computer] monitors, and other devices..." The facility's policy and procedure (P&P) titled, "Wandering, Unsafe Resident" dated 8/14, indicated "...The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement... 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included..." Resident 1's Care Plan, initiated 3/31/18, indicated "FOCUS At Risk for elopement r/t [related to]: Impaired safety awareness... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 12 of 13 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: _______________ 055047 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALMS CARE CENTER 1010 Ventura Ave Chowchilla, CA 93610 (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 wanders aimlessly. GOAL: Resident's safety will be maintained through the next review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Wander Alert: Device [PAS]." The Care Plan did not include a detailed monitoring plan. The facility's undated P&P titled, "WANDERING RISK SCALE" indicated "STANDARD: A safe environment is provided for patients/residents who are at risk to wander ..." The facility's undated P&P titled, "... [PAS]" indicated, "POLICY: The [PAS] would be used for residents at risk for elopement. PURPOSE: For each resident to reach his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience. PROCEDURE: 1. Nursing Assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for falls or elopement. 2. A plan off care must be formulated...5. The [PAS] bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed...7. The [PAS] bracelets are checked daily on the night shifts by the Supervisor and are documented in the treatment book on the units and the [PAS] Folder in Peach Treatment Room." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJWX11 Facility ID: CA040000018 If continuation sheet 13 of 13