Other·August 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 a RECERTIFICATION survey. Representing the California Department of Public Health by Federal ID: 37529 RN HFEN, 36080 RN HFEN, 37312 RN HFEN and 38641 RN HFEN. Capacity: 46 Census: 46 Sample: 12 Random Residents: 7 Entity Reported Incidents (ERI) investigated during the Recertification survey: ERI CA 00496941: Substantiated, see F 365 ERI CA 00541520: Substantiated with no deficiency identified. ERI CA 00541716: Substantiated with no deficiency identified.

F160 SS=D CONVEYANCE OF PERSONAL FUNDS UPON DEATH CFR(s): 483.10(f)(10)(v)

F160 08/03/2017 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: BIFB11 Facility ID: CA040000025 If continuation sheet 1 of 12 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 07/03/2017 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 (v) Conveyance upon discharge, eviction, or death. Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident’s funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident’s estate, in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on staff interview, clinical record and administrative document review, the facility failed to return resident trust funds after discharge within 30 days for one of 12 sampled resident's (Resident 12). This failure had the potential for Resident 12 and all discharge residents to not have access to monies owed within 30 days of discharge. Finding: On 6/28/17, during a clinical record review, Resident (Res) 12's progress notes dated 4/25/17, at 11:57 p.m., indicated Res 12 was transferred to the acute care hospital and had not returned to the facility after being transferred to the hospital. On 6/28/17 at 10:05 a.m., during a concurrent interview and administrative document review, the facility document, titled, "Resident Statement Landscape" undated, indicated Resident 12 's balance was $36.42 on 11/9/16. At the top of the document, the document indicated the "Date Open" of 7/29/15. "Current Balance: $35.92." The Administrator (ADM) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 2 of 12 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 07/03/2017 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 stated, Res 12 had a balance of $35.92 in the account and should have been released or returned back to Res 12 within 3-7 days after discharge. The ADM stated the Business Office Manager reviewed the trust accounts periodically, and sent a check to the resident or the resident's responsible party (RP) after discharge. The ADM stated, "It was not done, the money is still here." On 06/28/17 at 4:55 p.m., during a concurrent interview and administrative document review with the Business Office Administrative Assistant (BOAA), the BOAA stated, Res 12's account currently had $36.92. The BOAA stated, the money should have been sent to the resident or the RP conservator after discharge. The BOAA stated, it was an "oversight" and the policy was not followed.

F365 SS=G FOOD IN FORM TO MEET INDIVIDUAL NEEDS CFR(s): 483.60(d)(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F365 Event ID: BIFB11 08/03/2017 Facility ID: CA040000025 If continuation sheet 3 of 12 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 07/03/2017 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 (3) Food prepared in a form designed to meet individual needs; This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to prepare and serve a physician ordered mechanical soft diet (foods blended, pureed, ground, or finely chopped to be made easily chewed and swallowed) to meet individual needs for one of seven random sampled residents (Resident [Res] 19), when Res 19 was served chunks of meat too large for Res 19 to swallow. This failure placed all residents on mechanically ordered diets at risk for harm; and resulted in Resident 19's breathing difficulty when Res 19 choked on his food, and required staff to perform the Heimlich Maneuver (placing pressure with the fist in hard, quick thrusts against the resident's abdomen to cause food to be dislodged and ejected from the throat) to clear his throat and restore normal breathing. Res 19 required transportation by ambulance to the acute care hospital for evaluation. Findings: Resident 19's clinical record titled, "Minimum Data Set" (MDS) (a resident assessment tool used to plan resident care) dated 7/8/16, indicated Resident 19 had no teeth or tooth fragments, required a mechanically altered diet (mechanical soft) and required staff supervision during meals. Resident 19's clinical record titled, "Order Summary Report" dated 2/28/17, indicated a physician order for "...MECHANICAL SOFT texture, THIN consistency" diet with start date of 6/25/15. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 4 of 12 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 07/03/2017 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 19's clinical record titled, "Progress Notes [Nursing Notes]" dated 7/26/16, at 12:54 p.m., indicated, "Resident noted with choking episode during lunch unable to cough and difficulty breathing, start hemuleich [Heimlich] maneuver. Advise CNA [certified nursing assistant] to call 911 [emergency response phone number]. resident hemuleich maneuver took over by the DSD [Director of Staff Development] and ADON [Assistant Director of Nursing] present with the patient too. Resident [Resident 19] coughed up and threw up food come out. Applied O 2 [oxygen] 2 liter [flow rate of 2 liters (measure of volume) per minute] via NC [nasal cannula, tubing placed into the nose to deliver oxygen]. No further episode noted of difficulty breathing or respiratory distress...Paramedic arrived at 12:27 p.m...resident awake alert verbally response to care...left in stable condition transfer to [acute care hospital] for further evaluation." The progress note was signed by Licensed Nurse (LN) 1. Resident 19's acute care hospital emergency department (ED) record titled, "Patient Progress" 7/27/16 dated at 6:18 p.m. indicated, "... Clinical Impression: Choking episode, Inappropriate diet." Resident 19's acute care hospital report titled, "Emergency Department Discharge Instructions" dated 7/26/16, indicated, "...diagnosis today is choking episode... maintain a SOFT NO CHEW DIET. You will need an evaluation by a speech therapist for a swallow evaluation." On 8/12/16 at 8:40 a.m., during a concurrent observation and interview in Resident 19's room, the Director of Social Services Designee (SSD) asked Resident 19 if he had teeth. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 5 of 12 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 07/03/2017 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 19 opened his mouth and moved his head side to side. There were no teeth visible in Resident 19's mouth. The SSD stated Resident 19 did not have teeth or dentures to chew his food and that was why Resident 19 was on a mechanical soft diet. On 8/12/16 at 10 a.m., during a telephone interview, the DSD stated on 7/26/16 at 12:30 p.m., other staff members (didn't recall who) in the dining room alerted the DSD Resident 19 was choking on food served during the lunch meal. The DSD stated he performed abdominal thrusts (Heimlich Maneuver) and dislodged a piece of meat "larger than the size of a quarter" from Resident 19's mouth. The DSD stated the dislodged piece of meat was too large to swallow for Resident 19 who had a physician ordered mechanical soft diet. The DSD stated the size of meat expelled from Resident 19 was "not appropriate for a mechanical soft diet...choking was directly related to the size of the chunk of meat." On 8/12/16 at 10:20 a.m., during an interview, the Dietary Services Supervisor (DSS) stated a quarter size piece of meat was not consistent with a mechanical soft diet. The DSS stated the meat should have been chopped or ground up. The DSS stated the cook who prepared Resident 19's meal should have checked the food card (card with resident's diet order and description that accompanies the resident's meal tray) to ensure the food was the right consistency for Resident 19. The DSS stated CNAs and LNs were responsible for checking all the residents' meal trays for physician ordered diets before meals were served to residents. On 3/10/17 at 3:20 p.m., during a telephone interview, LN 1 stated on 7/26/16, she was responsible for verifying Resident 19's lunch FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 6 of 12 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 07/03/2017 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 meal tray was consistent with the meal card and physician ordered mechanical soft diet. LN 1 stated she was aware Resident 19 did not have natural teeth or dentures. LN 1 stated on 7/26/16 she was in the back hallway of the facility and had not verified Resident 19's lunch meal tray matched his diet card. LN 1 stated verifying Resident 19's lunch meal tray would have alerted her the meal was not consistent with Resident 19's diet and could have prevented Resident 19 from choking. LN 1 stated nursing staff were responsible for verifying resident meal trays match their diet cards. LN 1 stated she did not assign another staff member to verify resident meal trays match their diet cards even though facility policy indicated she could have assigned the task to other facility staff. On 3/14/17 at 3:50 p.m., during a telephone interview, CNA 1 stated she had worked at the facility for five years. CNA 1 stated LNs had not checked the meal trays at any time during the time she had worked at the facility. CNA 1 stated it was the practice in the facility for CNAs to check meal trays prior to serving to ensure residents were getting the correct diet. CNA 1 stated she checked meal trays during the lunch meal on 7/26/16 but did not recall if she was the CNA who checked Resident 19's tray to ensure it was consistent with Resident 19's physician ordered mechanical soft diet. CNA 1 stated she knew Resident 19 should have been served ground and chopped foods because he did not have teeth. CNA 1 stated Resident 19 would not have choked if he had been served chopped or ground food. The facility document titled, "Modified Diets" undated, under heading, "Mechanical Soft (Dental Soft) Diet" indicated, "Changes the consistency of the regular diet when there is difficulty with chewing or swallowing... Foods FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 7 of 12 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 07/03/2017 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 are modified in texture by chopping, dicing, and grinding. Menu should be based on ground meats and chopped fruits and vegetables." The facility policy and procedure titled, "Policy and Procedure for Monitoring Dining Room" dated 1/1/08, indicated, "...Charge Nurse will be present during mealtimes at Dining Room and will assist with the following: 1. Verify that resident's trays correspond to their diet cards. 2. Supervise meal intake documentation. 3. Monitor behaviors... 4. P.M. and Weekend Charge Nurse may delegate to a C.N.A her responsibilities at the Dining Room during meal times if there's a medical emergency elsewhere in the building." Review of professional reference, "Edentulous [without teeth] Patient Diet" <https://prezi.com/3tn8holqeiqn/endentulouspatient-diet/>, indicated, "Soft, liquid, blended, chopped or ground foods comprise most of an edentulous diet... Being edentulous poses serious problems in receiving adequate nutrition from the foods you can eat, in addition to concerns centered on decreased chewing efficiency and increased risk of choking."

F458 SS=B BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.90(e)(1)(ii)

F458 07/18/2017 (e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 8 of 12 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 07/03/2017 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 by: This Requirement is not met as evidenced by: *Waiver-Based on observation, the facility failed to have resident rooms that measured at least 80 square feet per resident in 11 of 16 rooms (Rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, & 17). This failure had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort. Finding: On 6/23/17 during the environmental tour, resident rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, & 17 were observed. These rooms did not meet the required square footage requirements; however, the residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms. Room # Residents 1 2 4 5 6 11 12 14 15 16 17 Square Feet 157.20 157.20 271.63 216.02 216.02 214.62 217.09 217.43 157.20 157.20 157.20 FORM CMS-2567(02-99) Previous Versions Obsolete Number of 2 2 4 3 3 3 3 3 2 2 2 Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 9 of 12 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 07/03/2017 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 Recommend waiver continue. ________________________________ Health Facilities Evaluator Nurse Date Request waiver continue. _________________________________ Administrator Signature Date

F465 SS=E SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) 08/03/2017 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and administrative document review the facility failed to maintain a safe and functional building when: 1. A window in the common hallway area bowed over and left the window track when opened. 2. A window in the hallway common area had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 10 of 12 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 07/03/2017 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 incomplete weatherstripping. 3. The handrail in the hallway near room 9 was loose. 4. The exit door in the west hallway did not properly fit into the doorjamb. 5. The drawers in a cabinet in the dining room/activity room were broken. These failures had the potential to place residents at risk for accident hazards. Findings: 1. On 6/23/17 at 2:45 p.m., during a concurrent observation and interview, the large window across from the nurse station was noted to have two sliding windows one on each end of the larger window. The window on the right would leave the track at the top when opened. Multiple attempts were demonstrated to open and close the window and each time the window left the track. The Maintenance Director (MD) stated he was unaware and had not received any work order for the window to be repaired. 2. On 6/23/17 at 2:50 p.m., during a concurrent observation and interview, the large window across from the nurse station was noted to have two sliding windows one on each end of the larger window. The window on the left had incomplete weather stripping and left a gap. The MD stated he was unaware the weather stripping was gone. 3. On 6/23/17 at 3:00 p.m., during a concurrent observation and interview, the handrail outside of room nine moved when touched. The MD stated the handrails should be tight and secure. 4. On 6/23/17 at 3:10 p.m., during a concurrent observation and interview, the exit door at the end of the west hallway was crooked in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 11 of 12 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 07/03/2017 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 door jamb and the outside light was visible from inside the building. The MD stated the door needed to be adjusted. 5. On 6/23/17 at 3:15 p.m., during a concurrent observation and interview, the drawers on the right side cabinets in the dining/activity room did not open or close properly. The MD stated he had not received a work order for repairs. The facility policy and procedure titled, "Maintenance Service" dated 12/09, indicated, "1. The Maintenance Department is responsible for maintaining the buildings... in a safe and operable manner at all times... 2. a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BIFB11 Facility ID: CA040000025 If continuation sheet 12 of 12