Other·July 10, 2018

F600 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/12/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 slapped Resident 1 on the back of the head. This failure placed Resident 1 at risk for increased anxiety, fear, and mental anguish due to a physical assault by a facility caregiver. Findings : Resident 1's clinical record titled, "Admission Record" (a document containing resident's personal information) indicated Resident 1 was admitted to the skilled nursing facility (SNF) on 4/10/14 with diagnoses that included schizophrenia (a severe mental disorder resulting in altered perception of reality), psychosis (severe mental disorder exhibited by 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: GL1Q11 Facility ID: CA040000025 If continuation sheet 1 of 5 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 06/12/2018 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 loss of contact with reality) and anxiety (disorder causing feelings of uneasiness and worry). Resident 1's Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) Assessment dated 1/31/18, indicated Resident 1 had severe cognitive (pertaining to memory, reasoning and judgement) impairment. On 3/7/18 at 2:46 p.m., during an observation and concurrent interview with the Director of Nursing (DON) and Resident 1 in the dining room, Resident 1 was sitting calmly in a chair. When asked if Resident 1 was able to answer some questions Resident 1 waved both arms in the air and yelled, "NO! NO!" The DON stated Resident 1 liked to sit in the dining room and to walk around the facility using his walker. The DON stated on Monday 3/5/18 at 1:45 p.m. the facility cook reported she witnessed CNA 1 slap Resident 1 on the back of the head with a hard slap. The DON stated the cook reported the incident between CNA 1 and Resident 1 occurred on 3/5/18 at 5:20 a.m. when Resident 1 refused to leave the dinning room. The DON stated the facility recorded video showed CNA 1 hitting Resident 1 on the back of the head. On 3/7/18 at 2:48 p.m., during an observation in the DON's office, the DON played the facility recorded video which indicated a date stamp of 3/5/18. During the video CNA 1 was standing in the doorway of the dining room waiting for Resident 1. Resident 1 was seen entering the dining room. CNA 1 put her arm behind Resident 1's back and attempted to guide him toward a chair. Resident 1 resisted CNA 1's assistance to the chair. CNA 1 then grabbed Resident 1's arm and Resident 1 pushed CNA 1 away. CNA 1 pushed Resident 1 down into the chair. Both Resident 1 and CNA 1 were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GL1Q11 Facility ID: CA040000025 If continuation sheet 2 of 5 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 06/12/2018 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 observed to wave their hands in front of one another's face as if to strike the other person or to protect themselves. The cook then entered the dining room. CNA 1 then struck Resident 1 hard on the back of the head with her hand. Resident 1 got up and walked out of the dining room. On 3/7/18 at 3:30 p.m., during an interview with the facility Administrator (Adm) in the DON's office, the Adm stated, "It is what it is. The video tells it all. She [CNA 1] did it. She [CNA 1] slapped [Resident 1] on the back of the head." On 4/9/18 at 3:30 p.m., during a phone interview, the facility cook stated she heard voices and loud noises in the dining room (on 3/5/18) around 5 am. The cook stated it was unusual to hear noise in the dining room that early because staff and residents are not usually in the dining room at that time. The cook stated she went into the dining room and saw CNA 1 holding Resident 1 by the arm trying to get him to sit in a chair. The cook stated Resident 1 pulled away from CNA 1 and then CNA 1 slapped Resident 1 on the back of the head. The cook stated Resident 1 then left the dining room. On 5/22/18 at 4:15 p.m., during a telephone interview, CNA 1 stated on the morning of the incident (3/5/18) she attempted to re-direct Resident 1 out of the dining room and into the hallway. CNA 1 stated Resident 1 was a high risk for falls. CNA 1 stated Resident 1 did not follow her directions to leave the dining room. CNA 1 stated, "We both got frustrated and I got angry. I got ahold of his arm. [Resident 1] became agitated and pushed me back. That's when I slapped him on the back of the head hard. I am so very sorry. I know I should not have done that." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GL1Q11 Facility ID: CA040000025 If continuation sheet 3 of 5 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 06/12/2018 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 1's clinical record titled, "Progress Notes" dated 3/5/18 at 3:06 p.m., indicated "...No injury related to incident this morning. No indication of pain. Resident activity per usual..." The Progress Note was signed by Licensed Nurse (LN) 1. On 6/7/18 at 12:10 p.m., during an interview, the Director of Staff Development (DSD) stated she was the charge nurse on 3/5/18 at the time of the incident between CNA 1 and Resident 1. The DSD stated the cook did not inform her of the incident and she was not aware the incident occurred until she received a phone call from the administrator later that same day. The DSD stated all facility staff, including cooks, were mandated reporters and should report abuse immediately to the charge nurse. The DSD stated failure to report abuse immediately placed the resident at risk for continued abuse. On 6/7/18 at 1:36 p.m., during an interview, the Assistant Administrator (AA) stated the cook reported the incident between Resident 1 and CNA 1 to him on 3/5/18 at 1:45 p.m. The AA stated Resident 1 was assessed by the day charge nurse and no injury was noted. Facility Policy and Procedure titled, "Abuse Prevention Program" dated revised December 2016, indicated, "Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse...Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GL1Q11 Facility ID: CA040000025 If continuation sheet 4 of 5 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 06/12/2018 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 ID PREFIX TAG Event ID: GL1Q11 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 5 of 5