Other·May 30, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during an abbreviated survey for complaint CA 00508510. Representing the California Department of Public Health: 31651, HFEN. The abbreviated survey was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint CA 00508510.

F204 SS=G PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG CFR(s): 483.12(a)(7)

F204 05/31/2017 A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency the State LTC ombudsman, residents of the facility, and the legal representatives of the residents or other responsible parties, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.75(r). 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: IHLJ11 Facility ID: CA040000025 If continuation sheet 1 of 15 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 05/09/2017 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to plan and provide a safe discharge, for one of two sampled residents (Resident 1) when Resident 1 was discharged on 9/22/16 to the home of his elderly Responsible Party (RP) who indicated to facility staff she was incapable of caring for Resident 1. Resident 1 was diagnosed with psychiatric/mental health illnesses and exhibited frequent episodes of aggression and violent behavior. Resident 1 was discharged without the necessary medications for his mental health illnesses, without adequate notice to the RP and without medical justification of a discharge to a lower level of care. These failures resulted in Resident 1's unsafe discharge to his RP's home where he did not receive the medically prescribed services, became progressively agitated and left the home within a day of discharge and wandered the streets. Resident 1 exhibited aggressive behavior while wandering the streets and was taken to a mental health treatment center by the local police and from there was transported to the acute care hospital under a Welfare and Institutions Code 5150 (involuntary psychiatric hold for suspected danger to self or others). Findings: The clinical record titled, "Admission Record" (document containing resident profile information) indicated Resident 1 was a 64 year old male admitted on 6/10/16 with diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life), schizophrenia (a disorder marked by severely impaired thinking, emotions, and behaviors), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 2 of 15 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 05/09/2017 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 kidney failure and Parkinson's disease ( a progressive neurological disease characterized by weakness, tremor (uncontrollable shaking of extremities) and rigidity (stiffness of body movements). Resident 1 was discharged on 9/22/16. Resident 1's Physician Orders dated 9/1/16, indicated Resident 1's medications included: Abilify (a medication to treat schizophrenia) 10 milligrams (mg) (a unit of measurement) once daily, Aricept (medication to treat dementia) 10 mg daily at bedtime, Depakote (anti-seizure medication also used as a mood stabilizer) 500 mg two tablets daily at bedtime, Seroquel (medication to treat schizophrenia) 300 mg daily and Trazadone (medication to treat depression) 300 mg daily at bedtime. Resident 1's clinical record titled, "Minimum Data Set (MDS) ( a resident assessment tool used to plan care)" dated 6/13/16, indicated Resident 1 had moderate cognitive (pertaining to memory, reasoning and judgement) impairment. On 10/27/16 at 1:35 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 had a history of verbal and physical altercations with staff and with other residents while in the facility. The DON stated Resident 1 had been discharged from the facility (on 9/22/16) and his RP and his Family Member (FM) 1were upset Resident 1 had been discharged. On 10/27/16 at 2 p.m., during an interview, the Social Service Director (SSD) stated Resident 1 had behavior problems prior to discharge from the facility. The SSD stated Resident 1 had aggressive behavior, hit a staff member and displayed threatening behavior to staff. The SSD stated the Interdisciplinary Team FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 3 of 15 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 05/09/2017 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 (IDT, team of facility staff that includes nursing, dietary, social services, activities staff and other healthcare providers that meet to review resident needs and plan individualized care) met 9/19/16 after Resident 1 struck a staff member. According to the SSD the IDT decided to discharge Resident 1 because of his aggressive behavior and frequent refusal of medication. The SSD stated she called Resident 1's RP on Monday 9/19/16 and told her Resident 1 would be discharged from the facility and for the RP to start looking for placement for Resident 1. The SSD stated she called the RP on Tuesday 9/20/16 and Wednesday 9/21/16 and the RP stated she did not have any transportation to pick up Resident 1. On 9/22/16 the SSD stated she accompanied the Assistant Administrator (AA) and dropped Resident 1 off at the RP's home. The SSD stated the AA returned to the facility to get Resident 1's medication and then brought those to the RP's home. The SSD stated she did not know if the RP was provided any discharge instructions. The SSD stated Resident 1's discharge (on 9/22/16) was not a safe discharge because Resident 1's RP was elderly (84 years old) and Resident 1 had a history of aggressive behavior and violent outbursts. On 10/28/16 at 9:50 a.m., during an interview, the SSD stated she was newly hired by the facility when Resident 1 was discharged on 9/22/16. The SSD stated she did not know how to go about the discharge process and had asked a SSD at another facility what she should do to discharge Resident 1. The SSD stated she did not determine Resident 1's needs at discharge and did not plan any care for Resident 1's discharge home. On 10/28/16 at 1:30 p.m., during an interview, Licensed Nurse (LN) 1 stated she was the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 4 of 15 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 05/09/2017 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 nurse on duty when Resident 1 was discharged (on 9/22/16). LN 1 stated she did not know the reason for Resident 1's discharge. LN 1 stated Resident 1's Primary Care Physician (PCP) wrote the order for discharge and she (LN1) followed the order. LN 1 stated the physician did not include a reason for Resident 1's discharge in the order. On 10/28/16 at 2:20 p.m., during a telephone interview, Resident 1's RP stated she was unable to provide care for Resident 1 at her home. The RP stated Resident 1 had a history of violent outbursts and she was too old to take care of him. When asked if she had agreed to take Resident 1 home upon discharge from the facility on 9/22/16, the RP stated she was 84 years old and had difficulty understanding what was going on or what documents the facility wanted her to sign. The RP repeated she could not take care of Resident 1. The RP stated she was worried about what would happen to Resident 1. The RP stated he (Resident 1) had been in and out of her home since discharge from the facility on 9/22/16. On 11/1/16 at 2:50 p.m., during a telephone interview, Resident 1's RP stated after Resident 1 was discharged to her home (on 9/22/16) he had become agitated. The RP stated Resident 1 left the home about 5 a.m. the next morning. The RP stated Resident 1 left the home for two or three days at a time and then would return briefly only to leave again. The RP stated she had reported Resident 1 missing to the local police department. The RP stated Resident 1 had been taken to the Acute Care Hospital (ACH) sometime during the previous weeks but had left the hospital. The RP stated on 10/31/16 Resident 1 came home and told her he needed to go back to the hospital. The RP stated she called an ambulance and Resident 1 was taken FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 5 of 15 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 05/09/2017 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 to the ACH. On 11/2/16 at 2:23 p.m., during a telephone interview, FM 1 stated Resident 1's RP was unable to care for Resident 1. FM 1 stated the RP was elderly and required assistance from family members for her own activities of daily living (ADLs) and provision of meals. FM 1 stated the RP did not have a bed available for Resident 1 nor could she provide food and meals for him. FM 1 stated the family received no warning from the facility Resident 1 was being discharged. FM 1 stated a phone call on 9/21/16 was made to the RP to pick him [Resident 1] up from the facility. FM 1 stated the RP had told the SSD she [RP] could not provide care for Resident 1 and had no transportation to pick him up from the facility. FM 1 stated the facility made no attempts to place Resident 1 in another setting other than the RP's home. FM 1 stated Resident 1 was dropped off by facility staff on 9/22/16 without any notice, consent or discharge instructions. FM 1 stated Resident 1 did not have important medications with him at discharge. FM 1 stated Resident 1 needed Seroquel (medication to control symptoms of schizophrenia) and did not have that medication upon discharge. FM 1 stated the only paperwork given to the RP on 9/22/16 was an inventory list to sign to indicate she (the RP) had received Resident 1's personal belongings from the facility. FM 1 stated, "At [RP's] age, she didn't understand [what was happening]." FM 1 stated she phoned the SSD and told her the facility failed to give the RP and FM 1 the opportunity to find placement for Resident 1. FM 1 stated, "We would have looked for another place." FM 1 stated Resident 1 had been roaming the streets "dirty and hungry" since discharge. FM 1 stated another family member had seen Resident 1 on the street the previous week and took him home. FM 1 stated Resident 1 became violent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 6 of 15 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 05/09/2017 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 at home and she [FM 1] called police. FM 1 stated the RP never requested for Resident 1 to come home. FM 1 stated, "We (the family) take care of her (RP)." On 11/3/16 at 10:32 a.m., during an interview, Resident 1's RP stated she was not given a thirty day notice letting her know Resident 1 was going to be discharged. The RP stated she received a phone call on 9/19/16 from the SSD asking her to pick up Resident 1. The RP stated she told the SSD she was unable to pick up Resident 1. The RP stated a man (Assistant Administrator) and a woman (SSD) came to her home on 9/22/16 and dropped off Resident 1. The RP stated, "They didn't bring any medicine, so I called them [the facility] and they dropped it off. A man dropped it [the medicine] off with no instructions but he did make me sign for them. On the slip of paper there was a medicine named Seroquel, but it was missing. That's the one I remember because he has taken that for years. If he [Resident 1] doesn't take it [Seroquel] he doesn't sleep. He gets irritable. Others [medications] were missing but I can't remember ... I told them I couldn't care for him. They didn't ask me if I could care for him. No instructions were given to me on anything." The RP stated "[Resident 1] gets really bad without his medication [Seroquel] because he has been mentally ill for 42 years and now he has dementia along with the schizophrenia." The RP was asked if she had agreed to take Resident 1 home and the RP stated she told the facility she was not able to take care of Resident 1. On 11/4/16 at 3:30 p.m., during an interview, the AA stated he and the SSD discharged Resident 1 to the RP's apartment on 9/22/16. The AA stated he dropped Resident 1 off at the RP's home and made a second trip to drop off Resident 1's medications. When asked about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 7 of 15 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 05/09/2017 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 whether or not discharge instructions were provided, the AA stated he went over how to match the medications to the doctor's order with the RP. The AA stated it was not in his job description as an assistant administrator to provide medication instruction but he did review the medications with the RP "as a favor." When asked if the AA was a nurse, he stated "no." The AA stated "In small facilities you have to be ready to all pitch in" On 11/4/16 at 3:45 p.m., during an interview, the facility Administrator (Adm) stated if there had been a nurse available to review Resident 1's medications with the RP (at discharge on 9/22/16) they would have done that. The Adm stated there was not a nurse available and the AA reviewed the medications. The request was made to the facility to provide any discharge instruction documents and none were provided. On 11/4/16 at 4 p.m., during an interview, Resident 1's PCP stated he was informed there was an attempt to discharge Resident 1 to home on 9/19/16 but on that day Resident 1 was transferred to the acute care hospital (ACH) for an evaluation for altered mental status [change in cognitive status]. The PCP stated he understood the family wanted to take Resident 1 home with them and that was the reason for discharge on 9/22/16. The PCP stated he did not know if Resident 1's condition had improved or if he no longer required skilled nursing care. The PCP stated in retrospect, he should have spoken to the family himself. The PCP stated he was not sure if the IDT met to plan Resident 1's discharge. The PCP stated the discharge on 9/22/16 was ultimately his responsibility because he wrote the discharge order and he did not have all of the information regarding Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 8 of 15 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 05/09/2017 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 On 11/4/16 at 4:30 p.m., during an interview, the Adm stated she was not certain if an IDT meeting was held to plan for Resident 1's discharge. The Adm stated nursing and the SSD discussed Resident 1's discharge. The Adm stated the reason for Resident 1's discharge was Resident 1 wanted to go home with the RP and the RP wanted to care for Resident 1 in her home. When asked whether the Adm spoke directly to the RP about taking Resident 1 home the Adm stated she thought the RP told the SSD she wanted to take Resident 1 home. On 3/22/17 at 2:40 p.m., during a telephone interview, the DON stated Resident 1 was discharged to home with the RP on Thursday, 9/22/16. The DON stated Resident 1 was readmitted to the facility from the ACH on 11/2/16. Resident 1 was not an admitted resident of the facility from 9/23/16 to 11/2/16. Resident 1's "Social Services New Admit Assessment" dated 6/21/16 indicated, "Discharge Plan: Because of the assistance on ADL's no discharge is planning for this resident [Resident 1]. Prior living arrangements: Convalescent facility. Family's expectations and feelings regarding discharge and availability for support: Family will be available for support... Plan: long term care anticipated." Review of Resident 1's clinical record did not indicate evidence of any documentation related to an IDT meeting to develop or discuss Resident 1's discharge plan. The DON was unable to produce an IDT note related to discharge planning for Resident 1 by the end of the abbreviated survey. Resident 1's "Notice of Transfer/Discharge" signed by the Adm and dated 9/19/16 indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 9 of 15 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 05/09/2017 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 the discharge was to become effective 9/22/16. The notice indicated Resident 1 was being discharged to the RP's residence. The notice indicated the decision to discharge Resident 1 was made by the IDT. There was no evidence documented of an IDT meeting or discussion of the decision to discharge. The Notice of Transfer/Discharge indicated the reason for the discharge was "Responsible Party wishes to take him home with her." Resident 1's clinical record titled "Resident Transfer Form" dated 9/19/16 indicated Resident 1 was transferred to the ACH Emergency Department (ED) on 9/19/16 at 9:25 p.m. for evaluation of "altered mental status." The Resident Transfer Form indicated "Diagnoses: unspecified dementia without behavioral disturbances, mental disorders due to known condition, Reason for Transfer: Altered Mental Status-striking staff." The Resident Transfer form indicated, "Behavior ...disruptive, belligerent, combative, suspicious ..." Resident 1's clinical record from the ACH ED dated 9/19/16, titled, "History of Present Illness (HPI)" indicated " ...male presents on psychiatric hold for alleged aggressive behavior. He reports that he ate his meal and then got mad at the SNF when they wouldn't let him go outside and smoke. Does have a history of dementia and schizophrenia, lives at a SNF and has baseline GCS [Glasgow Coma score tool to evaluate level of consciousness measured between 0-15, with zero being coma and 15 being normal) 14. Per EMS [emergency medical services] form, apparently he allegedly got angry and hit another SNF resident yesterday as well. Currently he has no complaints, and is denying SI/HI (Suicidal Ideation/Homicidal Ideation), AH/VH (Auditory Hallucinations/Visual Hallucinations). Appears FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 10 of 15 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 05/09/2017 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 well ... Impression: Well adult examination; alleged aggressive behavior; medical clearance for psychiatric care ... Plan of Care: ...would like patient returned to [SNF] in the morning ..." Resident 1's "Weekly Summary" dated 9/22/16, indicated "Resident have increased altered mental status, resident very aggressive." Resident 1's Progress Notes [Nurse's Note] dated 9/22/16 and signed by LN 1 indicated, "Telephone order from [MD] stating it is appropriate for resident to be discharged with RP." Resident 1's unsigned "Transfer/Discharge Report dated 9/22/16, indicated "Discharge to home and with responsible party." Resident 1's "Physician's Summary" indicated, "Discharge date: 9/22/16, Rehabilitation Potential: limited -Schizophrenia, unspecified dementia without behavioral disturbance, Prognosis: home with family." The Physician's Summary was signed and dated 10/1/16 by the PCP. There was no medical justification documented for Resident 1's discharge home. Resident 1's "Progress Notes" [Nurse's Note] documented by the DON, dated 9/22/16, indicated "Resident was discharged home to [RP] today... Resident was taken to [RP's] residence with all belongings (inventory list reviewed and signed by RP); he was accompanied by SSD and Assistant Administrator." Resident 1's ACH clinical record titled, "Physician's Discharge Summary" dated 10/28/16, indicated Resident 1 was admitted to the ACH on 10/24/16. The Discharge Summary indicated "[Resident 1]... presents with altered mental status... He was sent here from [a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 11 of 15 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 05/09/2017 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 Psychiatric Health Facility (PHF)] at which point 5150 (involuntary psychiatric hold) was initiated. ... He was apparently found verbally harassing people at a local business facility. He was subsequently taken to the PHF from which he came here for further neurological evaluation... When I spoke to the patient he was alert only to person but not to time and place. He did not know why he was here ...Placement was pending at which time patient eloped [left without the knowledge or permission of the ACH staff]. Discharge date: 10/28/16. Discharge diagnoses: eloped." Review of Resident 1's care plan indicated, "Focus: Resident to be discharged to home with his Responsible Party to her residence... Date initiated 9/22/16, Date created 10/28/16. Goal: Resident to have a safe discharge to RP's residence. Interventions: Complete Nursing Assessment... Obtain Physician's Order... Provide current medications to RP... Provide MD orders... Provide Transportation... " There was no documented evidence the care plan addressed Resident 1's mental disorder or behaviors to ensure a safe discharge to the RP's home. The care plan was created 37 days after the discharge of 9/22/16. The facility's policy and procedure titled, "Documentation of Transfers/Discharges" dated 4/7/98, indicated "1. When the facility anticipates a resident's discharge to a private residence... a post -discharge plan will be developed which will assist the resident to adjust to his or her new living environment... 2. The post discharge plan will be developed by the care plan team with the assistance of the resident and his/her family... 4. As a minimum the post-discharge plan will include: d. the identity of specific resident needs after discharge... i.e., medications... Appropriate referrals, when necessary are made by Social FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 12 of 15 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 05/09/2017 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 Services... 5. Social services will review the plan with the resident and the family before the discharge is to take place." There was no documented evidence of a post - discharge plan being developed or provided to the RP. The facility's policy and procedure titled, "Documentation of Transfers/Discharges" dated 4/7/98, indicated "When a resident is transferred or discharged, his or her medical records shall be documented as to the reasons why such action was taken. 2. Should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's attending physician: b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. 4. Documentation from the care planning team concerning all transfers or discharges must include, as a minimum and as they may apply: The reasons for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or representative; c. ... d. The date and time of the transfer or discharge; f. The mode of transportation; g. A summary of the resident's overall medical, physical and mental condition; i. Disposition of medications." The facility's policy and procedure titled, "Notice of Transfers and/or Discharge" dated 4/7/98, indicated "Our facility shall provide a resident and/or the resident's representative with a thirty day notice written notice of an impending transfer or discharge. 2. The resident, and/or representative will be provided with the following information. a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. the location to which resident is being transferred or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 13 of 15 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 05/09/2017 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 discharged; the name, address, and telephone number of the state long-term care ombudsman; e. The name, address and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill ... f. The name address and telephone number or the state health department agency that has been designated to handle appeals of transfers and discharge notices." The facility's policy and procedure titled, "Preparing a Resident for Transfer or Discharge" dated 4/7/98, indicated "Our facility shall prepare a resident for a transfer or discharge. 2. e. Nursing services will be responsible for Preparing the discharge summary; f. Preparing medications as permitted by law." The facility's policy and procedure titled, "Discharge Summary" dated 4/7/98, indicated "A discharge summary shall be prepared for each resident discharged from our facility. 2. As a minimum the discharge summary will contain a summary of the resident's status to include a description of the resident's: a. medically defined condition ...g. Mental and psychosocial status (the resident's ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); m. Drug therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). 4. A copy of the discharge summary will be filed in the resident's medical record." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IHLJ11 Facility ID: CA040000025 If continuation sheet 14 of 15 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 05/09/2017 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: IHLJ11 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 15 of 15