Other·February 8, 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 HealthLicensing and Certification, during the investigation of Entity Reported Incident: CA00491420 Representing the California Department of Public Health-Licensing and Certification: HFEN 31651, 31506 . This inspection was limited to the specific Entity Reported Incident investigation and does not represent the findings of a full inspection of the facility. One deficiency issued for Entity Reported Incident CA00491420.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 02/09/2017 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, resident and staff interview, clinical record and administrative 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: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 document review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being for one of four sampled residents (Resident 1) when Resident 1 had multiple, repeated suicide attempts requiring hospitilization for evaluation and treatment of depression and suicidal ideations. The facility failed to develop and implement a nursing care plan to protect Resident 1's physical and psychosocial health and psychotherapy services (referral to psychology service for counseling and possible treatment) were not provided by the facility as ordered by the physician upon discharge from the acute care hospital. As a result of these failures, Resident 1 had not received adequate assessment, care planning and psychotherapeutic services needed to prevent repeated suicide attempts to treat her depression. Resident 1 suffered psychosocial harm from untreated depression as distress was expressed by Resident 1 to facility staff, which led to avoidable hospitalizations and risk of physical and psychological harm from repeated suicide attempts. Findings: Resident 1's clinical record, face sheet (resident profile information) indicated, Resident 1 was admitted to the facility on 7/15/15 with diagnoses that included anxiety disorder (a mental health illness characterized by a feeling of fear and anxiety about current and future events) and schizophrenia (a serious mental disorder characterized by bizarre behavior and an altered perception of reality). Resident 1's Minimum Data Set (MDS) assessment, dated 4/29/16, indicated Resident 1 was free of cognitive deficits, pertaining to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 memory and understanding, and had a Brief Interview of Mental Status (BIMS) score of 15 of 15 (meaning Resident 1 was oriented to time and place and was able to communicate her needs). On 7/28/16 at 10:52 a.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 1 was transferred to the emergency department (ED) for an attempted suicide on 5/11/16 for ingestion of a large number of pills. The ADON stated there was no care plan developed for the 5/11/16 suicide attempt. The ADON stated a care plan for Resident 1 behaviors should have been initiated upon readmission on 5/12/16 by the Licensed Nurse (LN) and a care plan triggered (assessment indicators that require initiation of a care plan) by the MDS assessment should have been initiated by the Director of Nursing (DON) or the ADON. Review of Resident 1's clinical record titled, "Transfer Form" dated 6/10/16, indicated Resident 1 was transferred to the acute hospital emergency department (ED) on 6/10/16 for a suicide attempt by ingesting a large number of pills. Review of Resident 1's Primary Medical Doctor's (PMD) progress notes titled, "Adult Progress Notes," dated 6/7/16 had not indicated any documentation of Resident 1's suicide attempt of 5/11/16 or any orders for psychotherapy follow up after this incident. Review of Resident 1's, "Psychologist Consultation/Follow Up," dated 6/8/16 indicated diagnoses of depression, schizophrenia and anxiety disorder. The note indicated Resident 1's complaints/symptoms were depression, anxiety, aggression, self-destructive thoughts or gestures, excessive sleep, health concerns and attempted history of suicide. The Psychologist's note indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 complained about other residents calling her names, stealing her money and a feeling she had not felt safe. The note indicated the treatment plans/recommendations were a continuation of the current treatment regime (which included medications and behavior monitoring as appropriate). Review of Resident 1's clinical record titled, "Transfer Form" dated 6/10/16, indicated Resident 1 was transferred to the acute hospital emergency department (ED) on 6/10/16 for a suicide attempt by an ingestion of pills. On 6/16/16 at 5 p.m., during a telephone interview, Certified Nursing Assistant (CNA) 1 stated on 6/10/16 at 10:45 p.m., she heard Resident 1 at the nurses' station telling LN 1 she had ingested some pills. CNA 1 stated, "[Resident 1] told [LN 1] she did not know how many pills she took." CNA 1 stated they [CNA 1, LN 1, Resident 1] walked back to Resident 1's room where Resident 1 handed them [LN 1 and CNA 1] an empty bottle of Vitamin C. CNA 1 stated Resident 1 told them [LN 1 and CNA 1] she did not feel well after taking the pills and LN 1 had called the paramedics to transport Resident 1 to the acute care hospital. CNA 1 stated the paramedics transported Resident 1 right after midnight (6/11/16). On 6/22/16 at 3:30 p.m., during a telephone interview, the Director Staff Development (DSD) stated Resident 1 had a history of suicidal ideations. The DSD stated he was not sure if there were written care plans that addressed Resident 1's behaviors resulting from suicidal ideations such as the ingestion of Vitamin C pills, twice. The DSD stated the Social Services Director had not been able to confirm if the pills were obtained from Resident 1's friend. The DSD stated the licensed nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 were responsible for initiating care plans. On 6/22/16 at 4 p.m., during a telephone interview, LN 1 stated Resident 1 had come to the nurses' station on 6/10/16 and stated she wanted to kill herself. LN 1 stated Resident 1 had taken some vitamin C pills. LN 1 stated this was the same situation that happened in May 2016 [suicide attempt by taking vitamin C pills]. LN 1 stated she had not remembered seeing a care plan in the chart for suicide attempts. LN 1 stated she initiated a care plan for suicidal ideations that night (6/10/16) after Resident 1 was transported to the hospital. Resident 1's discharge orders from the acute care hospital dated 6/13/16, indicated, "Discharge Plan: Follow up with... Behavioral Health regarding medication management, psychotherapy, and aftercare support." There was no documented evidence an appointment was made by the facility to the Behavioral Health center after the 6/10/16 through 6/13/16 hospital stay. Resident 1's care plan was initiated on 6/10/16 by LN 1. Resident 1's care plan indicated, "The Resident has a behavior problem as evidenced by having suicidal thoughts related to depression." The goal indicated the Resident would have no behavior problems related to suicidal thoughts. The interventions listed included, "Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes." There was no documented evidence of interventions to follow up with psychotherapy, monitoring of behaviors, or identification of triggers to the suicidal ideations. Review of Social Service Notes dated 6/13/16 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 indicated the Social Services Director (SSD) spoke to Resident 1 upon readmission to the facility from the acute care hospital regarding the facility policy for residents to keep over the counter medications in their rooms. There was no documented evidence a referral was made for psychotherapy services. There was no documentation which indicated the SSD spoke to Resident 1 about her suicidal ideations and triggers or the need to meet with a therapist. The facility policy and procedure undated and titled, "Self Administration of Medication" indicated, "A resident may not be permitted to administer or retain any medication in his or her room." Review of the IDT note dated 7/11/16 indicated the IDT met after Resident 1 was transferred to the acute care hospital to discuss the attempted suicide. The IDT note indicated they had plans to meet upon resident's readmission to the facility. There was no documented evidence the IDT met after Resident 1 was readmitted to the facility to plan care for Resident 1 related to the 7/10/16 attempted suicide. Review of Resident 1's IDT notes dated 6/13/16 indicated the IDT team met regarding the 6/10/16 suicide attempted by Resident 1. The IDT team note indicated the care plans should have been updated to reflect interventions to prevent reoccurrence following the attempted suicide. The IDT recommendations included monitoring the resident every 15 minutes and if appropriate a psychology referral to evaluate Resident 1. The ADON was unable to provide documentation of updated care plans related to the 6/10/16 incident. Review of the care plan titled, "Behavior-suicidal thoughts" dated 6/10/16 and developed by LN 2 did not reflect a revision FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 upon Resident 1's return to the facility to include discharge recommendations from the acute care hospital. Resident 1's discharge orders from the acute care hospital dated 6/13/16, indicated, "Discharge Plan: Follow up with... Behavioral Health regarding medication management, psychotherapy, and aftercare support. Other Resource Instructions: 24 hour Suicide Hotline..." There was no documented evidence of a referral to behavioral health or follow-up as recommended by the acute care hospital. Resident 1's "Transfer Form" dated 7/10/16, indicated Resident 1 was transferred to the ED on 7/10/16 for a suicide attempt. On 7/28/16 at 4:48 p.m., during an interview LN 2 stated she had been passing medications to other residents on 7/10/16 when she was approached by Resident 1. LN 2 stated Resident 1 had made statements to [LN 2] that included Resident 1 not wanting to, "live anymore," and she [Resident 1] was thinking of hanging herself. LN 2 stated she had not called the physician at the time Resident 1 made the statements on 7/10/16 because she was busy passing medications to other residents. LN 2 stated later that morning, around 9 am, she saw Resident 1 in her room with the call light cord wrapped around her neck. LN 2 had observed Resident 1 trying to tighten the call light cord with the cord wrapped around her neck. LN 2 stated she then sent Resident 1 to the acute care hospital and then phoned Resident 1's medical doctor and her conservator. LN 2 stated she did not recall an update to the care plan after the 7/10/16 incident. There was no documented evidence of any care plan revisions following the 7/10/16 attempted suicide incident. On 7/28/16 review of Resident 1's care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 titled, "Behavior-suicidal thoughts" dated 6/10/16 indicated under "Focus, Goals, and Interventions," that no revisions were made following the suicidal attempt of 7/10/16 and subsequent transfer to the acute care hospital. The care plan remained in place without revisions once Resident 1 was readmitted to the facility on 7/25/16. The last revision date on the care plan was on 6/10/16, the same day it was created. On 7/28/16 at 4:15 p.m., during an observation and concurrent interview, Resident 1 stated, "I don't have the right therapy or care here. I need somewhere I can get help. My husband died a year ago, I need help... I can't keep trying to kill myself... I'm still trying to kill myself." Resident 1 stated she saw a psychologist when she was admitted to the acute care hospital. Resident 1 stated the psychologist [psychology evaluation 7/17/16] told her she needed to have therapy when she returned to the facility. Resident 1 stated the SSD at the facility told her they did not have a psychologist available to see residents. Resident 1 stated, each time she asked the SSD for therapy he [SSD] said not to keep asking the same thing over and over about therapy. Resident 1 tearfully referenced the suicide attempt of 7/10/16 and stated LN 2 and CNA 2 found her with the call light cord wrapped around her neck. Resident 1 stated, "I was pulling on it tight, I couldn't breathe... I remember passing out. I was in the hospital for two weeks the last time. You guys need to help me. I am going to end up hurting myself. I just want to transfer to a psychiatric unit and get therapy to get help and stop thinking of ways to kill myself. Recently, I just started sleeping all day. No one comes to talk to me about my problems..." Resident 1 stated the activities staff did not visit her in her room. Resident 1 stated no one came to talk to her about her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 problems after the last suicide attempt on (7/10/16). On 8/1/16 at 5 p.m., during an interview, the Primary Medical Doctor/Medical Director (M.D.) (the physician in charge of caring for the resident) was asked about the care of Resident 1 and concerns regarding the lack of follow-up interventions after each suicidal attempt. A discussion included a lack of revisions to the care plans and a lack of referrals for psychotherapy. The PMD/MD stated he was aware of the need to treat Resident 1 with a psychologist and/or a psychiatrist. The PMD/MD explained that the facility had difficulty finding available psychologists or psychiatrists to treat Resident 1. The PMD/MD stated he was aware the acute care hospital recommended records for Resident 1 included plans and recommendations to treat the ongoing depression and suicide attempts. The PMD/MD was aware the acute care hospital records needed to be reviewed for continuity of care. The PMD/MD was made aware that according to his physician progress notes for Resident 1 there was no documentation of Resident 1's suicide attempts, no referrals to mental health providers such as psychologist or psychiatrist and no directions to the staff on how to deal with Resident 1's ongoing depression and suicidal attempts. The PMD/MD stated he was in charge of the care of Resident 1 and ultimately in charge of the clinical component as the Medical Director for the facility. On 8/3/16 at 3:55 p.m., during an interview, the ADON stated in response to unusual occurrences and MDS triggers the role of the Interdiciplinary Team (IDT) was to initiate plans of care. The ADON stated an attempted suicide was considered an unusual occurrence. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 ADON stated there was no IDT meeting after the 5/11/16 incident upon readmission on 5/12/16 and there was no care plan initiated to address specific interventions following the suicide attempt of Resident 1 to prevent further occurences. On 8/3/16 at 6:40 p.m., during an interview, the Administrator stated when a resident returned from a hospital visit which resulted from an incident that occurred at the facility there should be a plan for a follow-up action to address the incident the next morning at the daily stand up meetings (informal meeting held to share important information among nursing staff). The Administrator stated there should be an IDT meeting following the event of an unusual occurrence, such as occured with Resident 1. The Administrator stated the infomation regarding Resident 1's hospitalization was not passed on to the nursing staff after the 5/11/16 incident. Review of Resident 1's PMD's (Primary Medical Doctor) progress note titled, "Adult Progress Note" dated 7/15/16, indicated no documentation of Resident 1's suicide attempt on 7/10/16 or any orders for psychotherapy follow up care. Resident 1's Transfer form dated 8/1/16 indicated, Resident 1 was transferred to the ED for suicidal ideations (thoughts about committing suicide) on 8/1/16. Resident 1's discharge orders from the acute care hospital dated 8/3/16, indicated, "Follow up with your primary care provider and therapist..." and "Suicide Prevention for Adults: Call 911 if ...is at immediate risk of suicide...Instructions: ...Suicide Hotline..." There was no documented evidence of the discharge instructions being integrated into a plan of care by the IDT or follow up for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 referral to a psychology therapist. On 8/9/16 at 2 p.m., during an interview and concurrent record review, the ADON stated when the MDS was completed and the care area assessments (CAA) triggered "Behaviors," a care plan for Resident 1's behaviors should have been developed and initiated. The ADON reviewed the care plan titled; "Resident Care Plan- Behaviors/Psychotropic Med [medication] Use." The document indicated the Care Plan was initiated on 7/24/15. The ADON stated the care plan appeared to be a care plan for behavior/psychotropic medication use and not for the problem of behaviors. The ADON stated a care plan should have been developed to address the services and interventions needed to prevent the behaviors of suicidal attempts. On 8/17/16 at 10:45 a.m. during a telephone interview the DON stated Resident 1 was again transferred to the ED for an attempted suicide on 8/10/16. Resident 1's MDS assessment dated 1/28/16, Section D0300 (section for depression symptoms) indicated a score of "2" which indicated Resident 1 was feeling bad about herself and depressed. Resident 1's MDS dated 4/29/16, Section D0300 indicated a score of "8" which indicated Resident 1 was feeling increasingly bad about herself and depressed. Section V, titled, "Care Area Assessment" dated 7/28/15 indicated the Care areas were: Psychosocial Well-Being, Behavioral Symptoms and Psychotropic Drug Use. These areas triggered a care plan should be developed. There was no documented evidence the care plans for the Psychosocial Well Being and the Behavioral Symptoms were developed and implemented. Review of Resident 1's care plan titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (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 Care Plan- Behaviors/Psychotropic Med Use" and "Mood" had not included dates or timetables related to the goals care planned for Resident 1's psychological needs. The "By Date" section of the care plan reserved for the projected achievement of the goals was left blank. The facility policy and procedure titled, "Care Plan" undated indicated, "Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs... Care plans are revised as changes in the resident's condition dictate." The facility policy and procedure titled, "Care Planning-Interdisciplinary Team" dated December 2008, indicated, "Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident." The facility policy and procedure titled, "Suicide Threats" dated Revised December 2007, indicated, "Resident suicide threats shall be taken seriously and addressed appropriately ...5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 Facility ID: CA040000025 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: _______________ 555918 (X3) DATE SURVEY COMPLETED 01/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOWLER CARE CENTER 8448 E Adams Ave Fowler, CA 93625 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8IH211 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA040000025 (X5) COMPLETE DATE If continuation sheet 13 of 13