Other·March 29, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED to reflect exit date of 5/3/19, validation of Immediate Jeapordy (IJ) removal plan and IJ removal, deletion of Complaint CA 00617860 with findings under F-tag 880 and Complaint CA 00624355. The following reflects the findings of the California Department of Public HealthLicensing and Certification during a RECERTIFICATION REVISIT SURVEY. Representing the California Department of Public health by Federal ID: 35286 RN/ HFES II, 35737 RN/ HFES II, 29470 RN/HFEN, 41187 RN/HFEN, 39589 RN/HFEN Capacity: 46 Census: 38 Sample: 41 Deficient practices were identified during the RECERTIFICATION REVISIT SURVEY. Facility was not back in substantial compliance with the federal regulations. During the REVISIT Survey, the following deficiencies were issued: F 584, 600, 609, 610, 658, 660, 835, 837, 841, 880, 921. During the Revisit Survey, the following Facility Reported Incidents (FRI) were investigated: FRI CA 00627324: Substantiated with deficiency refer to F 658 FRI CA 00619352: Substantiated with no deficiency. FRI CA 00621830: Substantiated with no deficiency. FRI CA 00620904: Substantiated with no deficiency. 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: EM2Q13 Facility ID: CA040000025 If continuation sheet 1 of 62 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 05/03/2019 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 RECERTIFICATION second revisit survey resulted in findings of Substantial NonCompliance for CFR 483.10, F-tag 584, and CFR 483.12, F-tag 600, F-tag 609 and F-tag 610. An Immediate Jeopardy for CFR 483.21, F-tag 660 was called on 3/8/19 at 3:38 p.m. with the facility administrator, Director of Nursing, Governing Body Member and the Vice President of Clinical Operations. The facility submitted an acceptable IJ removal plan on 4/23/19 at 4:56 p.m. The IJ removal plan was validated and implemented to address and outline steps to follow when addressing safe discharges from the facility. The IJ situation was removed on 5/3/19 at 4:40 p.m., with the administrator.

F584 SS=F Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 07/08/2019 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 2 of 62 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 05/03/2019 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 use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain a clean and homelike environment when: 1. Resident bed linens had holes,stains and tears that were not replaced. These failures had the potential to violate the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 3 of 62 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 05/03/2019 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 residents' rights to have a clean, sanitary and comfortable homelike environment. Findings: 1. During a concurrent interview and record review with the Director of Nursing (DON), on 3/8/19, at 11 a.m., the DON stated she had been observing resident linens since August [2018]. The DON reviewed administrative documents and was unable to find documented evidence of completion of random weekly observations to check resident bed linens. The DON stated the Plan OfCcorrection (POC) accepted [on 3/6/19] indicated linens with holes, stains and tears would be thrown away or repaired. The DON stated a sewing machine was purchased for the laundry staff to sew the holes and tears in the linens instead of throwing them away and replaced with new ones. The DON stated, during the quality assurance and performance improvement (QAPI) meeting the linen condition was discussed with the administrator. During a concurrent interview and record review with the laundry supervisor (LS), on 3/8/19, at 11:20 a.m., LS stated she did not have a personal check-off list to record her random weekly linen inspections. The LS stated she completed her observations by looking at the linen inspection log and not the linen. The LS stated the log was completed by the person folding the laundry. The LS reviewed the facility's linen inspection tracking log dated from 2/16/19 through 2/28/19 and 3/2/19 through 3/6/19 which indicated linens were identified with holes, tears, and stains. The log indicated the facility had not replaced or repaired the linen after the staff identified linens and resident gowns with holes, tears and stains. The Licensed Nurse (LN) stated the damaged linens and resident gowns were not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 4 of 62 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 05/03/2019 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 discarded and replaced because the facility did not have linens to replace the damaged linens. The LN stated she informed the administrator of the linen situation. The LN stated she had not presented these findings to the QAPI committee. The LN stated the QAPI meeting presentation consisted of the Administrator reading the violated regulation and nothing else. During an interview with the Administrator on 3/8/19, at 2:37 p.m., he stated the facility did not have sufficient linens to discard linens with holes, tears and stains in February and the first week of March. The Administrator stated he approved a March linen supply order. The Administrator stated the QAPI meeting presentation consisted of reading the violated regulation to the members of the QAPI committee. The Administrator was asked how the QAPI committee monitor the implemented systemic change for sustainability. The Administer was unable to answer the question. The Administrator reviewed his administrative documents and was unable to find documented evidence the QAPI committee had monitored the systemic change for implementation and sustainability. The facility policy and procedure titled, "Quality of Life - Homelike Environment" dated 05/17, indicated, "...the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: e. Clean bed and bath linens that are in good condition ..."

F600 SS=F Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 07/08/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 5 of 62 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 05/03/2019 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 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 interview and record review the facility failed to implement a system to ensure monitoring process components of the abuse prevention protocol were followed when the facility did not implement effective interventions to protect and keep residents of the facility free from potential abuse. This failure had the potential to place residents at risk for abuse and mistreatment and negatively impact residents emotional and psychological health. Findings: During a concurrent interview and record review with the Director of Nursing (DON), on 3/8/19, at 8:30 a.m., the DON stated she had been conducting daily rounds to observe for signs of resident abuse. The DON stated she would log the observations from her daily rounds and provide a copy to the administrator monthly. The DON reviewed administrative documents and was unable to find documented evidence of completion of an abuse prevention tracking log. The DON stated the Plan Of Correction (POC) indicated she and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 6 of 62 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 05/03/2019 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 Administrator had to present a report to the Quality Assurance Performance Improvement (QAPI) committee with timely abuse reporting data. The DON stated, "I don't have that." The DON stated the POC indicated the QAPI Project Improvement Plan (PIP) team would review interventions in place for the incident and update in the resident care plan or protocol. The DON reviewed her administrative documents and was unable to find documented evidence of the QAPI PIP team care plan reviews. The DON stated, "We don't have that." The DON stated during the QAPI meeting the administrator would read the violated deficiency to the QAPI team. She stated the QAPI team did not evaluate for the effectiveness of the POC system implementation. During an interview with the Administrator, on 3/8/19, at 9:15 a.m., the Administrator stated the QAPI meeting presentation consisted of reading the violated regulation to the members of the QAPI committee. The Administrator was asked on the QAPI committee process regarding conduction of the monitoring for the implementation of the abuse prevention systemic change for sustainability. The Administer was unable to answer the question. The Administrator reviewed his administrative documents and was unable to find documented evidence the QAPI committee had monitored the systemic change for implementation and sustainability. During a concurrent interview and record review with the Medical Records (MR) staff, on 3/8/19 at 11 a.m., MR staff reviewed the "Medical Records QA (Quality Assurance) reporting -POC compliance" logs dated 12/2018, 1/2019 and 2/2019, which indicated, "Tag: F600, Issue: Review all outside provider appointments to ensure all documentation had been obtained. Monitoring frequency as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 7 of 62 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 05/03/2019 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 needed." The MR staff stated she was assigned by the administrator to monitor the compliance of F600. The MR staff reviewed the POC F600 accepted date 3/6/19 and stated she had been monitoring the wrong information. She stated F 600 was a regulation that required residents to be free from abuse and neglect and had nothing to do with medical appointments. The MR staff stated the monitoring log was created by the Administrator and given to her to complete and submit to the Administrator for QAPI. The MR staff stated the Administrator may not be aware the monitoring log contained the wrong information. The MR staff stated during the QAPI meeting the administrator would read the violated deficiency to the QAPI team. She stated the QAPI team had not discussed the effectiveness of the POC system implementation or sustainability. During an interview with the Administrator, on 3/8/19, at 2 p.m., the Administrator reviewed the "Medical Records QA (Quality Assurance) reporting -POC compliance" logs dated 12/2018, 1/2019 and 2/2019, which indicated, "Tag: F600, Issue: Review all outside provider appointments to ensure all documentation had been obtained. Monitoring frequency as needed." The Administrator, stated, "I didn't notice its wrong." During an interview with the Governing Body Member (GBM) on 3/8/19, at 1:42 p.m., the GBM Administrator reviewed the "Medical Records QA (Quality Assurance) reporting POC compliance" logs dated 12/2018, 1/2019 and 2/2019, which indicated, "Tag: F600, Issue: Review all outside provider appointments to ensure all documentation had been obtained. Monitoring frequency as needed." The GBM stated the monitoring log was monitoring the wrong information for F600. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 8 of 62 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 05/03/2019 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 GBM stated, "I have not looked at those."

F609 SS=F Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 07/08/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 9 of 62 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 05/03/2019 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: Based on interview and record review the facility failed to implement monitoring process components of the abuse prevention protocol to ensure abuse reporting procedures were followed by the facility staff when the Administrator and Director of Nursing (DON) did not ensure the abuse reporting allegation system was effectively implemented, monitored and evaluated for sustainability and to ensure deficient practice did not reoccur. This failure had the potential for possible abuse to go uninvestigated and unreported and negatively impact residents emotional and psychological health. Findings: During a concurrent interview and record review with the Social Services Director (SSD), the SSD reviewed Resident 23's social service notes and InterDisciplinaryTeam (IDT-a team of professionals in the facility who review resident status) notes. The SSD stated the altercations dated 12/24/19, 12/31/19 and 1/9/19 had no evidence there was follow up for three days for the 72 hour period of monitoring for psychosocial wellbeing, and the IDT did not meet after the altercation dated 12/24/19 as in accordance with the plan of correction (POC). During a concurrent interview and record review with the DON, on 3/8/19, at 8:30 a.m., the DON stated she had been conducting daily rounds to observe for signs of resident abuse. The DON stated she would log her daily rounds and provide a copy of the rounds to the administrator monthly. The DON reviewed her administrative documents and was unable to find documented evidence an abuse reporting report was created and presented to the QAPI committee. The DON stated the POC indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 10 of 62 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 05/03/2019 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 she and the SSD would present abuse trends to the QAPI committee. The DON stated she did not have a trending log, but she would present the number of altercations and a faxed document that would represent the reporting. The DON stated the POC indicated she and the Administrator had to present a report to QAPI on timely abuse reporting to all required agencies. The DON stated, "I don't have that." The DON stated the POC indicated the QAPI Project Improvement Plan (PIP) team would review care plan interventions in place for the abuse incident and update in the resident care plan or protocol as part of the abuse investigation action to attempt to prevent abuse. The DON reviewed her administrative documents and was unable to find documented evidence of the QAPI PIP team care plan intervention updates and reviews. The DON stated, "We don't have that." The DON stated during the QAPI meeting the administrator would read the violated deficiency to the QAPI team. She stated the QAPI team did not evaluate for the effectiveness of the POC system implementation. During an interview with the Administrator on 3/8/19, at 9:15 a.m., the Administrator stated the QAPI meeting presentation consisted of reading the violated regulation to the members of the QAPI committee. The Administrator was asked regarding the QAPI committee process and the monitor process for the implementation of the abuse reporting process for sustainability. The Administer was unable to answer the question. The Administrator reviewed his administrative documents and was unable to find documented evidence the QAPI committee had monitored the systemic change for implementation and sustainability. During a concurrent interview and record review with the Medical Records (MR) staff, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 11 of 62 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 05/03/2019 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 3/8/19 at 11 a.m., the MR staff stated during the QAPI meeting the administrator would read the violated deficiency to the QAPI team. She stated the QAPI team had not discussed the effectiveness of the POC system implementation or sustainability. During an interview with the Governing Body Member (GBM) on 3/8/19, at 1:42 p.m., the GBM stated the administrator received POC implementation direction and no other monitoring was conducted to ensure the POC was effectively implemented and monitored for sustainability. During an interview with the Administrator, on 3/8/19, at 2 p.m., the Administrator reviewed his administrative documents and was unable to find documentation of a department monitoring report for timely abuse reporting in accordance with the POC. The Administrator stated, "I didn't have that." The Administrator stated he only read the plan of deficiencies to the QAPI committee.

F610 SS=F Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 07/08/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 12 of 62 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 05/03/2019 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 §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure a system was implemented to ensure all allegations of abuse were thoroughly investigated. This failure had the potential for abuse allegations to continue in the facility for all residents. Findings: During a concurrent interview and record review with the Social Services Director (SSD), on 3/7/18, at 3:42 p.m., the SSD stated during the Quality Assurance Performance Improvement (QAPI) meeting he and the Director of Nursing (DON) informed the QAPI committee of the number of altercations residents were involved in for the month. The SSD stated the nurse informed him of the abuses and he and the DON completed the abuse investigations. The SSD stated he did not know who completed the abuse allegation investigation review. The SSD stated he was a member of the IDT and according to the Plan of Correction (POC) accepted on 3/6/19 the IDT should be reviewing all abuse investigations. The SSD reviewed the POC and stated he did not know the IDT had to review the abuse allegation investigations. During a concurrent interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 13 of 62 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 05/03/2019 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 review with the Activity Director (AD), on 3/7/19 at 4:44 p.m., the AD stated she was a member of the IDT. The AD stated the POC indicated the IDT members would review the abuse incident investigation to ensure the investigation was completely investigated. The AD stated she was not asked to review the abuse allegation investigation. The AD stated during the QAPI meeting the administrator would read the violated deficiency to the QAPI team. She stated the QAPI team did not discuss abuse investigations or the effectiveness of the POC system implantation or sustainability. During a concurrent interview and record review with the DON, on 3/8/19, at 8:30 a.m., the DON stated she had conducted daily rounds to observe for signs of resident abuse. The DON stated she logged her observations done during daily rounds and provide a copy to the administrator monthly. The DON stated the POC indicated all reportable incidents would be reviewed by the IDT team on the next business day of any altercation reported to ensure a thorough investigation was conducted. The DON stated she did not have documentation the IDT conducted reviews of the incident investigation. The DON stated during the QAPI meeting the administrator would read the violated deficiency to the QAPI team. She stated the QAPI team did not evaluate for the effectiveness of the POC system implementation. During an interview with the Administrator, on 3/8/19, at 9:15 a.m., the Administrator stated the QAPI meeting presentation consisted of him reading the violated regulation to the members of the QAPI committee. The Administrator was asked on the QAPI committee monitoring process for the implementation of the abuse investigation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 14 of 62 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 05/03/2019 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 process for sustainability. The Administrator reviewed his administrative documents and was unable to find documented evidence the QAPI committee was monitoring the systemic change for implementation and sustainability. The Administrator stated, "I don't have that." During an interview with the Governing Body Member (GBM) on 3/8/19, at 1:42 p.m., the GBM stated the administrator received POC implementation direction and no other monitoring was conducted to ensure the POC was effectively implemented and monitored for sustainability. During an interview with the Administrator, on 3/8/19, at 2 p.m., the Administrator reviewed his administrative documents and was unable to find documentation of department of the POC implementation and sustainability progress in accordance with the POC. The Administrator stated, "I didn't have that." The Administrator stated he only read the plan of deficiencies to the QAPI committee and did not conduct additional reviews or monitoring.

F658 SS=G Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 07/08/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure treatment was provided in accordance with professional standards of practice for 1 of 4 sampled residents (Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 15 of 62 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 05/03/2019 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 5) when Licensed Nurses did not follow physician orders for Resident 5. As a result of this failure, Resident 5 did not receive Revlimid (medication used to treat blood disorder and helps production of red blood cells) from 11/8/18 through 3/5/19 which required hospitalization for blood transfusions on four separate occasions from 11/8/18 through 3/5/19 and a missed weekly blood test to evaluate blood cell count for one week. Findings: During a review of the clinical record for Resident 1, titled, "Progress Notes" dated 1/31/19 at 5:29 p.m., indicated, "RESIDENT RETURNED FROM CHEMOTHERAPY [cancer treatment] APPOINTMENT WITH NEW LAB ORDERS." During a review of the clinical record for Resident 5, titled, "Order Listing Report" dated 3/13/19 at 3:40 p.m., indicated Resident 1 had an order for a "CBC [complete blood count], and CMP [comprehensive metabolic panel] every Tuesday... order date 1/31/19." During a review of the clinical record for Resident 5, titled, .... laboratory results indicated, Resident 5's CBC and CMP were drawn on 2/5/19, 2/12/19, and missed on 2/26/19. During an interview with the Director Of Nursing (DON), on 3/12/19, at 3:44 p.m., she reviewed the clinical record and was unable to find documentation of the lab result for the CBC and the CMP blood test ordered for 2/26/19. The DON stated the CBC and CMP for 2/26/19 were not done as ordered. During an interview with the Lab Assistant (LA), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 16 of 62 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 05/03/2019 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 3/14/19, at 12:40 p.m., she stated on 2/26/19 the lab drawn was not a CBC and CMP. During a review of the clinical record for Resident 5, titled, "Laboratory request log" dated 2/26/19, did not reflect a request for a CBC and CMP to be drawn. During a review of the clinical record for Resident 5, titled, "Admission Record" (document containing resident personal information) indicated Resident 5 was admitted to the skilled nursing facility (SNF) on 3/25/15 and readmitted on 9/28/18 with diagnoses that included Myelodysplastic Syndrome (when bone marrow does not produce enough mature blood cells). During an interview with the DON, on 3/13/19 at 5:22 p.m, she reviewed the clinical record and stated Resident 5 returned to the facility on 9/28/18 from the acute care hospital with a referral for oncology (cancer specialist) and hematology (blood disorder specialist). During a concurrent interview and record review with the DON, on 3/13/19 at 5:45 p.m., she reviewed the clinical record and stated Resident 1 had an oncology appointment on 11/8/18 at 10 a.m. The DON stated Resident 5 returned from his oncology appointment on 11/8/18 at 1 p.m. with an order for Revlimid 10 mg daily. During an interview with the DON, on 3/13/19 at 5:55 p.m. she reviewed the clinical record for Resident 5, the "[medical clinic name] Oncology Clinic," dated 11/8/18, at 10:25 a.m., indicated, "Likely Etiology (cause) for anemia and thrombocytopenia (low platelet count) is underlying Myelodysplastic syndrome based on bone marrow results. Plan: -Keep Hgb FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 17 of 62 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 05/03/2019 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 (Hemoglobin)( Hemoglobin is a protein in your red blood cells that carries oxygen to your body's organs and tissues and transports carbon dioxide from your organs and tissues back to your lungs. If a hemoglobin test reveals that your hemoglobin level is lower than normal, it means you have a low red blood cell count-anemia).> (over) 8 and plt (plateletscomponent of blood whose function is to stop bleeding by clumping and clotting blood vessel injuries) >20 -will start revlimid 10 mg daily. Patient unable to make his decisions and lacks understanding. Treatment outweighs risk. repeat CBC, CMP and type and screen -will start fluconazole [antifungal medicine], acyclovir [Acyclovir is used to treat infections caused by certain types of viruses], and ciprofloxacin [medication is used to treat a variety of bacterial infections] for prophylaxis (prevention) - f/u [follow up] in 4 weeks and 2 weeks with... for lab checks." The DON stated Ciprofloxacin, Acyclovir, and Fluconazole medications were put in the orders but not Revlimid. During a review of the clinical record for Resident 1, titled, "Progress Notes" dated 11/8/2018, at 1:57 p.m, indicated, "Resident returned from appointment at 1300 (1 p.m.). New orders for fluconazole, acyclovir, and ciprofloxacin. Resident in stable condition." During an interview with the DON, on 3/13/19 at 6 p.m., she stated Resident 1 had an appointment on 11/20/18 at 9:15 a.m. for education with the Nurse Practitioner (NP) regarding Revlimid and returned on 11/20/18 at 11:15 a.m., with instructions on how to take Revlimid. The DON reviewed the clinical record and was unable to find documentation of the physician order and was unable to find documentation on an order being faxed to pharmacy and determined Resident 1 had not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 18 of 62 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 05/03/2019 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 taken Revlimid. The DON stated Resident 5 did not have the medication. The DON stated this was a medication she would have to approve and she did not approve it because she was unaware of the document. During a review of the clinical record for Resident 1, titled, "Progress Notes," dated 11/20/18, indicated, " ... Patient comes in today for new medication education ... 1. Education: Patient has been provided with verbal and printed education regarding following medications: revlimid ... 3. Patient continues to resident in skilled nursing facility, accompanied by CNA today. Both are asked to make sure to let office know start date for Revlimid, and have lab results faxed over ... " During an interview with the DON, on 3/13/18, at 6:20 p.m., she reviewed the clinical record and stated on 12/6/18 she received a call from the doctor's office who notified her Resident 5 was sent to the emergency room to obtain lab work and a blood transfusion due to a critical lab value of Hgb 5.3. The DON stated Resident 1 would be on a new medication to increase his blood count. The DON stated she dis not know what medication and did not ask what medication was ordered. During a review of the clinical record for Resident 1, titled, "Progress Notes" dated 12/20/18, at 12:53 p.m., indicated, "Oncology office called, asked if resident was currently taking revlimid, this nurse looked at orders both previous and current with none found for revlimid. Doctors office is going to attempt to get prior authorization for revlimid and send via mail due to the medication not being able to be filled through local pharmacy." During an interview with the Pharmacy Technician (PT) from [name of] Pharmacy, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 19 of 62 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 05/03/2019 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 3/14/19, at 9:22 a.m., she stated Resident 1's record had not indicated an order was faxedto the pharmacy for Revlimid for 11/2018, 12/2018 or 1/2019. The PT stated it was a medication they could not get and if the facility faxed over the order and the pharmacy was unable to provide the medication they would have notified the facility it would need to be provided from an outside pharmacy. The PT stated they never received an order for Revlimid. The "Lippincott Manual of Nursing Practice" 10th Edition dated 2014, page 16-17 indicated, " Standards of practice General Principles... 1 b. These standards provide patients with a means of measuring the quality of care they receive. Common Departures from the Standards of Nursing Care... failure to follow physicians orders..."

F660 SS=J Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 07/08/2019 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 20 of 62 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 05/03/2019 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. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 21 of 62 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 05/03/2019 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 extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one of three sampled residents (Resident 23) when Resident 23 was discharged to a room and board facility (provided lodging and food in an independent living setting) without the benefit of determining whether or not Resident 23 had the capacity and/or capability to self-administer his medications which included insulin and blood pressure medications. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 23's needs and required services prior to discharge and did not conduct training and education related to Resident 23's capability to care and administer medications for himself without staff assistance. As a result of these failures, Resident 23 was admitted to the Acute Care Hospital (ACH) Telemetry unit (medical care unit dedicated to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 22 of 62 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 05/03/2019 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 continuous care and monitoring of patient's heart rate, blood pressure, breathing and other vital signs) within 24 hours of transfer to the Room and Board with high blood pressure of 202/117 millimeters of mercury (mm Hg), (MAYO clinic dated 1/9/19 indicated an adult male's normal blood pressure is below 120/80.) Resident 23 remained in the hospital until 2/26/19 (24 days). Because of these failures and the identified serious harm sustained by Resident 23 and potential serious harm to all residents of the facility, an Immediate Jeopardy (IJ) situation was called on 3/8/19 at 3:38 p.m. with the facility administrator, Director of Nursing, Governing Body Member and the Vice President of Clinical Operations. The facility was instructed to submit an IJ removal plan that addressed the IJ situation. The facility submitted an acceptable IJ removal plan on 4/23/19 at 4:56 p.m. The IJ removal plan was validated and implemented to address and outline steps to follow when addressing safe discharges from the facility. The IJ situation was removed on 5/3/19 at 4:40 p.m., with the administrator. Findings: During a review of the clinical record for Resident 23, titled, "Face sheet" (document with resident demographic information) undated, indicated Resident 23 was a 54-yearold male admitted to the facility on 2/7/05 with diagnosis which included Diabetes Mellitus, Type 2 (a disorder resulting from the body's inability to make enough, or to properly use, insulin [a hormone which regulates the amount of sugar in the blood), Hypertension (high blood pressure), Dysphagia (difficulty swallowing) intracranial (brain) injury, disorder of white FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 23 of 62 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 05/03/2019 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 blood cells (a low number of cells that fight infections of fungi and bacteria), schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior) and bipolar disorder (a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior). During a concurrent interview and record review with the Director of Nursing (DON), Administrator (Adm) and Governing Body Member (GBM), on 3/7/19 at 9:06 a.m., the DON reviewed the facility's resident abuse monitoring log dated 12/2018 to 1/2019 which indicated Resident 23 had resident to resident altercations on 1/9/19, 1/22/19, and 1/28/19. The DON stated Resident 23 was "safely" discharged from the facility on 2/1/19 to a board and care facility (a licensed 24-hour care property). The DON stated Resident 23's level of care had not improved or changed which would have required a discharge from the facility to a lower level of care. The DON stated on 1/28/19 Resident 23 inappropriately sexually touched a female residents bottom and was placed on close monitoring with one staff member assigned specifically to his care. The DON stated, "Then we discharged him." The Adm stated, "He [Resident 23] asked to be discharged to [name of a skilled nursing facility] ... [nursing facility] did not have open beds so we sent him to a board and care." Review of Resident 23's clinical record, titled, "Minimum Data Set (MDS) quarterly assessment" (a standardized, comprehensive assessment tool), dated 12/10/18, Brief Interview for Mental Status (BIMS - evaluates cognition, the ability to remember and think clearly) scored 14 points (0 -15 possible points) indicated Resident 23 was cognitively intact. The MDS assessment, section G indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 24 of 62 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 05/03/2019 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 23 required daily limited to extensive one staff person assistance with his bathing, dressing, toileting, personal hygiene and bathing needs. The MDS assessment, section H indicated Resident 23 was "Always incontinent" of bowel and bladder. The MDS assessment, section K indicated, the resident had a swallowing disorder of holding food in his mouth/cheeks, coughing or choking during meals. The MDS assessment indicated Resident 23 required a mechanically altered and therapeutic diet (pureed-blended or mashed). Review of Resident 23's clinical record, titled, "Weekly nursing summary" (weekly nursing assessment) dated 1/26/19, indicated, "Cognition short term and long term memory loss." Weekly summary dated 1/19/19, indicated, "Cognition long term memory loss." Resident 23 required extensive assistance with his bed mobility, transfers, eating, dressing and bathing. Weekly summary dated 1/13/19, indicated, "Cognition: short term and long term memory loss." During a concurrent interview and record review with the DON, on 3/7/19, at 9:27 a.m., the DON reviewed Resident 23's physician orders dated 2/2019 and stated Resident 23 required a pureed diet (mashed or blended food) because he was a risk for choking. The DON stated Resident 23 required licensed nurses to perform routine checks of his blood sugars, administer insulin injections for the treatment of his diabetes and give medication tablets crushed because of his risk for choking. The DON stated she did not know if Resident 23 would be able to perform all of his care independently because the staff did not provide assessments to evaluate if he was able to understanding discharge teaching regarding his care and medication needs. The DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 25 of 62 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 05/03/2019 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 owner of the board and care came to the facility to evaluate Resident 23 for admission on 2/1/19 and stated she could take Resident 23 with her at that time. The DON stated the facility called Resident 23's doctor, obtained a discharge order and discharged Resident 23 on 2/1/19 with the owner of the room and board. The DON stated there was no discharge planning process and the discharge of Resident 23 was decided on 2/1/19 without consideration for discharge planning preparation. The DON stated the facility did not provide Resident 23 discharge medication administration training to prepare him for the discharge to the room and board (lower level of care). The DON stated Resident 23 was incontinent of bowel and bladder and needed assistance from staff to perform his hygiene needs and did not know if Resident 23 would be able to perform his own hygiene needs on his own. The DON stated Resident 23's care needs were not assessed prior to his discharge to the Room and Board. During a concurrent interview and record review with the DON, on 3/7/19, at 9:45 a.m., the DON reviewed the clinical record for Resident 23 and was unable to find a medical indication or documentation where Resident 23's level of care needs had improved to a level that required discharge to a room and board (facility providing independent living). The DON stated the Social Service Director (SSD) began the search to locate a facility in order to discharge Resident 23 on 1/30/19. The DON stated she did not know the list of services the board and care provided or if the facility was licensed to provide the level of care Resident 23 required. The DON stated, "[Name of person from the Room and Board] came to our facility and she said that she would accept him at her board and care with a diagnosis of diabetes and we believed her. We didn't check FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 26 of 62 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 05/03/2019 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 anything. We safely discharged [Resident 23]. It wasn't our responsibility to check other facility's for the services they provide. That would be the responsibility of that facility to know, not us. She [board and care individual] said she could accept him and we discharged him. The rest was her responsibility. I know it looks like we let a stranger take him. But we safely discharged him." The DON reviewed the "Social Service Discharge Summary" dated 1/31/19 which indicated, "Resident [23] requested discharge to Room and Board placement." DON stated she did not know the facility Resident 23 was discharged to was a room and board rather than a Board and Care. She stated, "I did not know that." The DON stated the facility had not performed assessments or evaluation of Resident 23's care needs prior to his discharge. The DON stated, "We did not do any of that." During a concurrent interview and record review with the DON and the Adm, on 3/7/19, at 10:16 a.m., DON and Adm reviewed Resident 23's clinical record and were unable to find documentation of IDT meeting to plan, evaluate and assess for Resident 23's capacity and/or capability to self administer his own medication, monitor his blood pressure and blood sugars on his own without staff help. The Adm stated, "I don't think we did anything wrong. We discharged him safely, plus he wanted to go." During a concurrent interview and record review with the DON, on 3/7/19, at 10:30 a.m., The DON reviewed Resident 23's clinical record and was unable to find documentation of an effective discharge process. The DON stated, "I guess we don't have a process for discharging because all we did was tell [SSD] to find a place, then we get an order and we discharge the resident." The DON was unable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 27 of 62 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 05/03/2019 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 find documented evidence the facility performed an effective discharge process for Resident 23. During a concurrent interview and record review with the SSD, on 3/7/19, at 10:36 a.m. he stated, "[Resident 23] told me that he wanted to leave." The SSD stated he made the arrangements on 1/31/19 for the owner of the board and care to come out to the facility on 2/1/19 to evaluate resident and take him that same day because. The SSD stated he made the arrangements for Resident 23 to go to a room and board because Resident 23 had asked to leave the facility. The SSD stated he was aware the facility was not a board and care but a room and board and was aware that Resident 23 would need to be able to take care of all of his needs on his own without staff help. The SSD stated he informed the room and board owner Resident 23 was a diabetic on 1/31/19 and the owner accepted him. The SSD stated Resident 23 does not have family or friends for support. The SSD stated resident had been at the facility since 2005. The SSD stated he had performed the BIMS assessment dated 12/10/18 and stated Resident 23 was able to make his own decisions. The SSD stated he was part of the IDT and the IDT did not meet to plan or ensure assessment were performed prior to Resident 23's discharge. The SSD reviewed Resident 23's clinical record and was unable to find documentation of assessments or evaluations of Resident 23's discharge needs prior to discharge. The SSD stated, "We didn't do any of that." A policy and procedure for the IDT responsibilities during the discharge process was requested from the SSD and DON on 3/7/19 and 3/8/19 and one was not provided. During an interview with Certified Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 28 of 62 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 05/03/2019 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 Assistant (CNA) 20, on 3/7/19 at 2:26 p.m., she stated Resident 23 had confusion and she had never heard him request to leave the facility. She stated, "I don't know why they moved him." During an interview with CNA 21, on 3/7/19, at 2:34 p.m., she stated Resident 23 had confusion and was on a pureed diet for the risk of choking. During an interview with Medical Records (MR) staff, on 3/7/19 at 3 p.m., MR staff stated she helped pack Resident 23's belongings for the discharge and saw Licensed Vocational Nurse (LVN 2) give the Room and Board owner a bag with medications and a list of the medication. She stated, "I don't know if [Resident 23] knew that he was moving out. Maybe he thought it was an outing." During an interview with Medical Doctor (MD 2), on 3/7/19 at 4 p.m., MD 2 stated on 1/31/19 a staff member who she did not remember spoke with her informing her the facility had found a board and care facility that would be able to care for Resident 23's medical and care needs 24/7 and Resident 23 would have less restrictions. MD 2 stated on 2/1/19 LVN 2 phoned her asking for the discharge order. MD 2 stated she did not ask questions and no one informed her that Resident 23 was being discharged to a room and board. MD 2 stated she did not write discharge prescriptions for diabetic supplies. MD 2 stated, "He was not discharged with insulin supplies ...plus he wouldn't be able to manage his diabetes ... the risk of his pureed diet was pretty significant. This was not a safe discharge. The way it was done was not safe ..." MD 2 stated she was not accurately informed of Resident 23's discharge. During an interview with the Acting Dietary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 29 of 62 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 05/03/2019 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 Supervisor (ADS), on 3/7/19 at 4:44 p.m., the ADS stated Resident 23 had behaviors of taking food from other residents which was not pureed, during supervised meal times, and he was unable to tolerate the food because he was unable to swallow and would start coughing. The ADS stated Resident 23 was a high risk for choking and required the skilled nursing services with 24-hour care and supervision because he had confusion. During an interview with the Room and Board Owner (RBO), on 3/7/19 at 5 p.m., she stated the facility had requested placement in her room and board on 1/31/19 for a male resident with diabetes. The RBO stated she informed them she would be able to pick him up on 2/1/19 and the facility agreed. The RBO stated the facility was not truthful with her. The facility had informed her that Resident 23 was able to perform his care and hygiene needs. The RBO stated she was at the facility on 2/1/19 and saw resident walking without the use of a walker or wheelchair. The RBO stated the facility staff began packing his belongings and gave her a bag of medication. The RBO stated she took Resident 23 and on the way he became incontinent of his bowels and was not able to perform his own hygiene care needs. The RBO stated by day two Resident 23 developed shortness of breath and appeared to have swelling on his face and stomach. The RBO stated The staff member in the home called 911 and he was taken to the emergency room. The RBO stated the home provided regular textured meals to Resident 23 because the facility had not informed her he required a pureed diet. The RBO stated, "I did not know that, we gave regular food. Maybe he was choking and that is why he was having shortness of breath. The RBO stated the people in her home need to be self-sufficient as the facility was a Room and Board and staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 30 of 62 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 05/03/2019 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 not able to do much for them. The RBO stated she took Resident 23's medications and belongings to the ER and did not accept Resident 23 back in her Room and Board because he was not at their level of care. The RBO stated, "He was not stable." During an interview on 3/8/19, at 8:35 a.m., LVN 2 stated she was the nurse that discharged Resident 23 on 2/1/19. LVN 2 stated she did not know the reason Resident 23 was discharged. She stated the DON asked her to call MD 2 and obtain a discharge order for Resident 23 to a board and care facility. LVN 2 stated she informed MD 2 that Resident 23 was going to a board and care facility and MD 2 gave the discharge order. LVN 2 stated Resident 23 required 24/7 skilled nursing services because he was unable to selfadminister insulin, perform blood sugar testing and/or administer his own medication. LVN 2 stated he required staff to care for his needs. LVN 2 stated she did not give the RBO insulin syringes for Resident 23's insulin administration and the RBO had informed her the home did not have diabetic supplies. LVN 2 stated she was not aware Resident 23 was discharged to a room and board. LVN 2 stated "He needs a place like this (Nursing facility with 24-hour nursing care). He cannot change his brief. He needs nurses to manage his medications. He cannot do things." Review of Resident 23's "Care Plan" revised date 3/30/18, indicated, "Resident's overall condition requires long-term care at this time due to: ... Family unable to provide 24 hour, 7 day a week care ... Resident requires assistance with Activities of Daily Living (ADL)... Resident unable to provide self-care ..." Review of Resident 23's "Care Plan" revised FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 31 of 62 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 05/03/2019 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 date 3/30/18, indicated, "Chronic/Progressive decline in intellectual functioning characterized by: Deficit in memory, judgment, decision making and thought process related to: ...Brain injury..." Review of Resident 23's "Discharge Care plan" dated 1/31/19, indicated, "Discharge Planning, initiated 1/31/19, created on 2/11/19 ...Goal: per discussion on 1/31/19 Resident [23] requested safe discharge to alternative placement when possible ...Resident discharged from [facility name on 2/1/19]." Review of Resident 23's "Physician orders" dated 2/1/19, indicated, "Resident has limited cognitive ability to make healthcare decisions." Resident 23's prescriptions included, a puree diet, finger sticks blood glucose twice a day for diabetes monitoring, crush all meds and place in applesauce, Insulin Lispro injections 4 units three times a day, Insulin Lispro injections following scale after blood sugar testing, Insulin Lantus 12 units one time per day, Metformin 1000 milligrams (mg -diabetes medication) twice a day, Enalapril (blood pressure [B/P] medication) 20 mg twice a day, Metoprolol (medication used for high blood pressure) 100 milligrams (mg-dosage) two times a day, and Norvac (used for treatment of high blood pressure) 10 mg once a day. During an interview on 3/8/19, at 3 p.m., LVN 4 stated nursing staff were told by the SSD on 1/31/19 to make sure Resident 23's belongings were packed because he would be leaving the next day. LVN 4 stated she was told Resident 23 was to be ready to leave when the room and board staff member came to the facility to get him. LVN 4 stated she questioned SSD about who had arranged Resident 23's discharge to go to a lower level of care and asked if the room and board understand the acuity (level of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 32 of 62 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 05/03/2019 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 care needed) of care Resident 23 needed. LVN 4 stated in her opinion and based on her experience caring for Resident 23, she did not think he was capable of understanding discharge medication and care teaching. LVN 4 stated she informed SSD regarding her opinion of Resident 23's required level of care. LVN 4 stated Resident 23 was unable to administer his own medications or administer his own insulin injections. LVN 4 stated, "I don't think he could read." LVN 4 stated Resident 23 required assistance with all of his care and required 24-hour skilled nursing care. Review of the hospital clinical record for Resident 23, the hospital "Discharge summary" dated 2/2/19 to 2/26/19, indicated, "Admission diagnosis Hypertensive emergency [on 2/2/19] ...blood pressure was elevated (202/117). He was given medications but blood pressure still high. He was started on Nicardipine (blood pressure medication given in the veins to lower the blood pressure) gtt [drip] in the ER ... Admitted to step down telemetry. 2/3/19 Continues with Nicardipine gtt ... Nicardipine gtt was tapering [reducing] off on 2/4/19. Adjust medications for uncontrolled blood pressure. 2/9/19, Neurology consult ... 2/10/19 confirmed that the [patient] does not have capacity [to make decisions] ... 2/11/19 BP medications adjusted more today. 2/12/19 BP medications adjusted more today. 2/13/19 developmentally delayed pt [patient] BP improving, but still needs adjusting medications ... Blood sugar 214 (on 2/2/19) ... HgA1C (a blood test used to monitor diabetes control) 7.0 % (according to the American Diabetic Association normal blood sugar level are between 70 -120 and a normal HgA1C is less than 5.7%)... Discharge date 2/26/19." The facility policy and procedure titled, "Discharging the Resident" dated 12/16, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 33 of 62 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 05/03/2019 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 purpose of this procedure is to provide guidelines for the discharge process. Preparation ... d. Who will be providing the resident's care (i.e. nurses, assistants, therapist, ext.) Why the discharge is necessary ... if the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions ...Assess and document [teaching and discharge instructions] ...All assessment data obtained during the procedure ..."

F835 SS=F Administration CFR(s): 483.70

F835 07/08/2019 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility administrative staff failed to effectively utilize facility resources to ensure residents could attain and or maintain their highest practicable physical, mental and psychosocial well-being for one of three sampled residents (Resident 23) and 37 sampled residents in a census of 38 residents when: 1. Resident 23 was discharged to a room and board facility (provides lodging and food in an independent living setting) without the benefit of determining whether or not Resident 23 had the capacity and/or capability to self-administer his medications which included insulin and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 34 of 62 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 05/03/2019 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 blood pressure medications. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 23's needs and required services prior to discharge and did not conduct training and education related to Resident 23's capability to care and administer medications for himself without staff assistance. As a result of these failure, Resident 23 was admitted to the Acute Care Hospital (ACH) Telemetry unit (medical care unit dedicated to continuous care and monitoring of patient's heart rate, blood pressure, breathing and other vital signs) within 24 hours of transfer to the Room and Board with high blood pressure of 202/117 millimeters of mercury (mm Hg), (MAYO clinic dated 1/9/19 indicated an adult male's normal blood pressure is below 120/80.) Resident 23 remained in the hospital until 2/26/19 (24 days). 2. The facility failed to provide water pitchers for 38 of 38 residents, when the facility did not have water pitchers at the resident's bedside for residents to access. The water was kept behind the secured nurses station in a water igloo and not accessible to residents when residents expressed thirst. This failure had the potential for residents to become dehydrated. 3. The facility failed to implement systemic changes from their annual recertification survey plan of correction (POC) for F-tag 584, 600, 609, 610, 834, 837, and 841. These failures resulted in the potential for residents to be subjected to abuse and for needs to go unmet. Findings: 1. During a review of the clinical record for Resident 23, titled, "Face sheet" (document FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 35 of 62 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 05/03/2019 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 with resident demographic information) undated, indicated Resident 23 was a 54-yearold male admitted to the facility on 2/7/05 with diagnosis which included Diabetes, Type 2 (a disorder resulting from the body's inability to make enough, or to properly use, insulin [a hormone which regulates the amount of sugar in the blood), Hypertension (high blood pressure), Dysphagia (difficulty swallowing) intracranial (brain) injury, disorder of white blood cells (a low number of cells that fight infections of fungi and bacteria), schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior) and bipolar disorder (a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior)." During a concurrent interview and record review with the Director of Nurses (DON), Administrator (Adm) and Governing Body Member (GBM), on 3/7/19 at 9:06 a.m., the DON reviewed the facility's resident abuse monitoring log dated 12/2018 to 1/2019 which indicated Resident 23 had resident to resident altercations on 1/9/19, 1/22/19, and 1/28/19. The DON stated Resident 23 was "safely" discharged from the facility on 2/1/19 to a board and care facility (a licensed 24-hour care property). The DON stated Resident 23's level of care had not improved or changed required a discharge from the facility to a lower level of care. The DON stated on 1/28/19 Resident 23 inappropriately sexually touched a female residents bottom and was placed on close monitoring with one staff member assigned specifically to his care. The DON stated, "Then we discharged him." The Adm stated, "He [Resident 23] asked to be discharged to [name of a skilled nursing facility] ... [nursing facility] did not have open beds so we sent him to a board and care." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 36 of 62 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 05/03/2019 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 Review of Resident 23's Minimum Data Set (MDS) quarterly assessment (a standardized, comprehensive assessment tool), dated 12/10/18, Brief Interview for Mental Status (BIMS - evaluates cognition, the ability to remember and think clearly) scored 14 points (0 -15 possible points) indicated Resident 23 was cognitively intact. The MDS assessment, section G, indicated Resident 23 required daily limited to extensive one staff person assistance with his bathing, dressing, toileting, personal hygiene and bathing needs. The MDS assessment, section H, indicated Resident 23 was "Always incontinent" of bowel and bladder. The MDS assessment, section K, indicated, the resident had a swallowing disorder of holding food in his mouth/cheeks, coughing or choking during meals. The MDS assessment indicated Resident 23 required a mechanically altered and therapeutic diet (pureed-blended or mashed). Review of Resident 23's "Weekly nursing summary" (weekly nursing assessment) dated 1/26/19, indicated, "Cognition short term and long term memory loss." Weekly summary dated 1/19/19, indicated, "Cognition long term memory loss." Resident 23 required extensive assistance with his bed mobility, transfers, eating, dressing and bathing. Weekly summary dated 1/13/19, indicated, "Cognition: short term and long term memory loss." During a concurrent interview and record review with the DON, on 3/7/19, at 9:27 a.m., the DON reviewed Resident 23's physician orders dated 2/2019 and stated Resident 23 required a pureed diet (mash food) because he was a risk for choking. The DON stated resident required licensed nurses to perform routine checks of his blood sugars, administer insulin injections for the treatment of his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 37 of 62 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 05/03/2019 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 diabetes and give medication tablets crushed because of his risk for chocking. The DON stated she did not know if Resident 23 would be able to perform all of his care independently because the staff did not provide assessments to evaluate if he was able to understanding discharge teaching regarding his care and medication needs. The DON stated the owner of the board and care came to the facility to evaluate Resident 23 for admission on 2/1/19 and stated she could take Resident 23 with her at that time. The DON stated the facility called Resident 23's doctor, obtain a discharge order and discharged Resident 23 on 2/1/19 with the owner of the room and board. The DON stated there was no discharge planning process and the discharge of Resident 23 was decided on 2/1/19 without consideration for discharge planning preparation. The DON stated the facility did not provide Resident 23 discharge medication administration training to prepare him for the discharge to the room and board (lower level of care). The DON stated Resident 23 was incontinent of bowel and bladder and needed assistance from staff to perform his hygiene needs and did not know if Resident 23 would be able to perform his own hygiene needs on his own. The DON stated Resident 23's care needs were not assessed prior to his discharge to the Room and Board. During a concurrent interview and record review with the DON, on 3/7/19, at 9:45 a.m., the DON reviewed the clinical record for Resident 23 and was unable to find a medical indication or documentation where Resident 23's level of care needs had improved to a level that required discharge to a room and board (facility providing independent living). The DON stated the Social Service Director (SSD) began the search to locate a facility in order to discharge Resident 23 on 1/30/19. The DON stated she did not know the list of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 38 of 62 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 05/03/2019 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 the board and care provided or if the facility was licensed to provide the level of care Resident 23 required. The DON stated, "[Name of person] came to our facility and she said that she would accept him at her board and care with diabetes and we believed her. We didn't check anything. We safely discharged [Resident 23]. It wasn't our responsibility to check other facility's for the services they provide. That would be the responsibility of that facility to know, not us. She [board and care individual] said she could accept him and we discharged him. The rest was her responsibility. I know it looks like we let a stranger take him. But we safely discharged him." The DON reviewed the "Social Service Discharge Summary" dated 1/31/19 which indicated, "Resident [23] requested discharge to Room and Board placement." DON stated she did not know the facility Resident 23 was discharged to was a room and board rather than a Board and Care. She stated, "I did not know that." The DON stated the facility had not performed assessments or evaluation of Resident 23's care needs prior to his discharge. The DON stated, "We did not do any of that." During a concurrent interview and record review with the DON and the Adm, on 3/7/19, at 10:16 a.m., DON and Adm reviewed Resident 23's clinical record and were unable to find documentation of IDT meeting to plan, evaluate and assess for Resident 23's capacity and/or capability to self-administer his own medication, monitor his blood pressure and blood sugars on his own without staff help. The Adm stated, "I don't think we did anything wrong. We discharged him safely, plus he wanted to go." During a concurrent interview and record review with the DON, on 3/7/19, at 10:30 a.m., The DON reviewed Resident 23's clinical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 39 of 62 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 05/03/2019 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 record ad was unable to find documentation of an effective discharge process she stated, "I guess we don't have a process for discharging because all we did was tell [SSD] to find a place, then we get an order and we discharge the resident." The DON was unable to find documented evidence the facility performed an effective discharge process for Resident 23. During a concurrent interview and record review with the SSD, on 3/7/19, at 10:36 a.m. he stated, "[Resident 23] told me that he wanted to leave." The SSD stated he made the arrangements on 1/31/19 for the owner of the board and care to come out to the facility on 2/1/19 to evaluate resident and take him that same day because. The SSD stated he made the arrangements for Resident 23 to go to a room and board because Resident 23 had asked to leave the facility. The SSD stated he was aware the facility was not a board and care but a room and board and was aware that Resident 23 would need to be able to take care of all of his needs on his own without staff' help. The SSD stated he informed the room and board owner Resident 23 was a diabetic on 1/31/19 and the owner accepted him. The SSD stated Resident 23 does not have family or friends for support. The SSD stated resident had been at the facility since 2005. The SSD stated he had performed the BIMS assessment dated 12/10/18 and stated Resident 23 was able to make his own decisions. The SSD stated he was part of the IDT and the IDT did not meet to plan or ensure assessment were performed prior to Resident 23's discharge. The SSD reviewed Resident 23's clinical record and was unable to find documentation of assessments or evaluations of Resident 23's discharge needs prior to discharge. The SSD stated, "We didn't do any of that." A policy and procedure for the IDT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 40 of 62 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 05/03/2019 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 responsibilities during the discharge process was requested from the SSD and DON on 3/7/19 and 3/8/19 and one was not provided. During an interview with Certified Nursing Assistant (CNA) 20, on 3/7/19 at 2:26 p.m., she stated Resident 23 had confusion and she had never heard him request to leave the facility. She stated, "I don't know why they moved him." During an interview with CNA 21, on 3/7/19, at 2:34 p.m., she stated Resident 23 had confusion and was on a pureed diet for the risk of choking. During an interview with Medical Records (MR) staff, on 3/7/19 at 3 p.m., MR staff stated she helped pack Resident 23's belongings for the discharge and saw Licensed Vocational Nurse (LVN 2) give the Room and Board owner a bag with medications and a list of the medication. She stated, "I don't know if [Resident 23] knew that he was moving out. Maybe he thought it was an outing." During an interview with Medical Doctor (MD 2), on 3/7/19 at 4 p.m., MD 2 stated on 1/31/19 a staff member who she did not remember spoke with her informing her the facility had found a board and care facility that would be able to care for Resident 23's medical and care needs 24/7 and Resident 23 would have less restrictions. MD 2 stated on 2/1/19 LVN 2 phoned her asking for the discharge order. MD 2 stated she did not ask questions and no one informed her that Resident 23 was being discharged to a room and board. MD 2 stated she did not write discharge prescriptions for diabetic supplies. MD 2 stated, "He was not discharged with insulin supplies ...plus he wouldn't be able to manage his diabetes ... the risk of his pureed diet was pretty significant. This was not a safe discharge. The way it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 41 of 62 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 05/03/2019 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 done was not safe ..." MD 2 stated she was not accurately informed of Resident 23's discharge. During an interview with the Acting Dietary Supervisor (ADS), on 3/7/19 at 4:44 p.m., ADS stated Resident 23 had behaviors of taking food from other residents that was not pureed during supervised meal times and he was unable to tolerate the food because he was unable to swallow and would start coughing. The ADS stated Resident 23 was a high risk for choking and required the skilled nursing services with 24-hour care and supervision because he had confusion. During an interview with the Room and Board Owner (RBO), on 3/7/19 at 5 p.m., she stated the facility had requested placement in her room and board on 1/31/19 for a male resident with diabetes. The RBO stated she informed them she would be able to pick him up on 2/1/19 and the facility agreed. The RBO stated the facility was not truthful with her. The facility had informed her that Resident 23 was able to perform his care and hygiene needs. The RBO stated she was at the facility on 2/1/19 and saw resident walking without the use of a walker or wheelchair. The RBO stated the facility staff began packing his belongings and gave her a bag of medication. The RBO stated she took Resident 23 and on the way he became incontinent of his bowels and was not able to perform his own hygiene care needs. The RBO stated by day two Resident 23 developed shortness of breath and appeared to have swelling on his face and stomach. The RBO stated The staff member in the home called 911 and he was taken to the emergency room. The RBO stated the home provided regular texture meals to Resident 23 because the facility did not inform her he required a pureed diet. The RBO stated, "I did not know that, we FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 42 of 62 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 05/03/2019 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 gave regular food. Maybe he was choking and that is why he was having shortness of breath. The RBO stated the people in her home need to be self-sufficient as the facility was a Room and Board and staff were not able to do much for them. The RBO stated she took Resident 23's medications and belongings to the ER and did not accept Resident 23 back in her Room and Board because he was not at their level of care. The RBO stated, "He was not stable." During an interview on 3/8/19, at 8:35 a.m., Licensed Vocational Nurse (LVN) 2 stated she was the nurse that discharged Resident 23 on 2/1/19. LVN 2 stated she did not know the reason Resident 23 was discharged. She stated the DON asked her to call MD 2 and obtain a discharge order for Resident 23 to a board and care facility. LVN 2 stated she informed MD 2 that Resident 23 was going to a board and care facility and MD 2 gave the discharge order. LVN 2 stated Resident 23 required 24/7 skilled nursing services because he was unable to self-administer insulin, perform blood sugar testing and/or administer his own medication. LVN 2 stated he required staff to care for his needs. LVN 2 stated she did not give the RBO insulin syringes for Resident 23's insulin administration and the RBO had informed her the home did not have diabetic supplies. LVN 2 stated she was not aware Resident 23 was discharged to a room and board. LVN 2 stated "He needs a place like this (Nursing facility with 24-hour nursing care). He cannot change his brief. He needs nurses to manage his medications. He cannot do things." Review of Resident 23's "Care Plan" revised date 3/30/18, indicated, "Resident's overall condition requires long-term care at this time due to: ... Family unable to provide 24 hour, 7 day a week care ... Resident requires assistance with Activities of Daily Living FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 43 of 62 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 05/03/2019 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 (ADL)... Resident unable to provide self-care ..." Review of Resident 23's "Care Plan" revised date 3/30/18, indicated, "Chronic/Progressive decline in intellectual functioning characterized by: Deficit in memory, judgment, decision making and thought process related to: ...Brain injury..." Review of Resident 23's "Discharge Care plan" dated 1/31/19, indicated, "Discharge Planning, initiated 1/31/19, created on 2/11/19 ...Goal: per discussion on 1/31/19 Resident [23] requested safe discharge to alternative placement when possible ...Resident discharged from [facility name on 2/1/19]." Review of Resident 23's "Physician orders" dated 2/1/19, indicated, "Resident has limited cognitive ability to make healthcare decisions." Resident 23's prescriptions included, a puree diet, finger sticks blood glucose twice a day for diabetes monitoring, crush all meds and place in applesauce, Insulin Lispro injections 4 units three times a day, Insulin Lispro injections following scale after blood sugar testing, Insulin Lantus 12 units one time per day, Metformin 1000 milligrams (mg -diabetes medication) twice a day, Enalapril (blood pressure [B/P] medication) 20 mg twice a day, Metoprolol (medication used for high blood pressure) 100 milligrams (mg-dosage) two times a day, and Norvac (used for treatment of high blood pressure) 10 mg once a day. During an interview on 3/8/19, at 3 p.m., LVN 4 stated nursing staff were told by the SSD on 1/31/19 to make sure Resident 23's belongings were packed because he would be leaving the next day. LVN 4 stated she was told Resident 23 was to be ready to leave when the room and board staff member came to the facility to get FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 44 of 62 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 05/03/2019 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 him. LVN 4 stated she questioned SSD about who had arranged Resident 23's discharge to go to a lower level of care and asked if the room and board understand the acuity (level of care needed) of care Resident 23 needed. LVN 4 stated in her opinion and based on her experience caring for Resident 23, she did not think he was capable of understanding discharge medication and care teaching. LVN 4 stated she informed SSD regarding her opinion of Resident 23's required level of care. LVN 4 stated Resident 23 was unable to administer his own medications or administer his own insulin injections. LVN 4 stated, "I don't think he could read." LVN 4 stated Resident 23 required assistance with all of his care and required 24-hour skilled nursing care. Review of the hospital clinical record for Resident 23, the hospital "Discharge summary" dated 2/2/19 to 2/26/19, indicated, "Admission diagnosis Hypertensive emergency [on 2/2/19] ...blood pressure was elevated (202/117). He was given medications but blood pressure still high. He was started on Nicardipine (blood pressure medication given in the veins to lower the blood pressure) gtt [drip] in the ER ... Admitted to step down telemetry. 2/3/19 Continues with Nicardipine gtt ... Nicardipine gtt was tapering [reducing] off on 2/4/19. Adjust medications for uncontrolled blood pressure. 2/9/19, Neurology consult ... 2/10/19 confirmed that the [patient] does not have capacity [to make decisions] ... 2/11/19 BP medications adjusted more today. 2/12/19 BP medications adjusted more today. 2/13/19 developmentally delayed pt [patient] BP improving, but still needs adjusting medications ... Blood sugar 214 (on 2/2/19) ... HgA1C (a blood test used to monitor diabetes control) 7.0 % (according to the American Diabetic Association normal blood sugar level are between 70 -120 and a normal HgA1C is less than 5.7%) ... Discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 45 of 62 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 05/03/2019 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 date 2/26/19." The facility policy and procedure titled, "Discharging the Resident" dated 12/16, indicated, " ...The purpose of this procedure is to provide guidelines for the discharge process. Preparation ... d. Who will be providing the resident's care (i.e. nurses, assistants, therapist, ext.) Why the discharge is necessary ... if the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions ...Assess and document [teaching and discharge instructions] ...All assessment data obtained during the procedure ..." 2. During an observation on 3/8/19 at 8:20 a.m., at the nurse's station, in the secure nurses station an orange igloo water jug was on a cart with disposable white drinking cups. Resident 6 walked up to the nurses and stated, "I'm thirsty, I'm thirsty. Can I have some water." Housekeeper (HK) 1 stated I can't give you water. I am going to look for someone to give you water because I cannot do that." Resident 47 walked up to the nurses and stated, "I'm thirsty too, can I have some water." Resident 46 propelled her wheelchair to the nurse's station and stated she would like a drink of water. HK 1 stated "I can't give you eater. I am going to look for someone to give you water because I cannot do that." Residents waited for a drink of water for 12 minutes. Certified Nursing Assistant (CNA 21) arrived at the secure nurses' station and unlocked the half door to the nurse's station where the water igloo 5-gallon container was kept and gave the three residents water to drink. During an interview with HK 1, on 3/8/19 at 8:32 a.m., HK 1 stated she had been employed with at the facility for three years. HK 1 stated non-nursing staff were not allowed to give FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 46 of 62 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 05/03/2019 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 water to residents. During a concurrent interview and observation with CNA 21, on 3/8/19 at 8:33 a.m., CNA 21 walker around and stated that none of the resident room had water pitcher. CNA 21 stated she was informed that Resident were not provided water pitchers because they could drink from someone else's water pitchers and they had behaviors. CNA 21 stated the facility does not have water pictures available for the residents. During an interview with LVN 2, on 3/8/19, at 8:33 a.m., she stated, the facility did not have water pitchers available because residents had behaviors and water pitchers were not available. LVN 2 stated the risk of residents not having free access to water could result in dehydration. LVN 2 stated if residents were unable to ask for water there would be no way for staff to know they were thirsty. During an interview with the DON, on 3/8/19, at 8:38 a.m., the DON stated the facility does not provide water pitcher to the residents because the facility has residents with behaviors. The DON stated the risk of having water pitchers was the resident could potentially drink from another resident's water pitcher, urinate in the water pitcher or spill the water which would be a fall risk. The DON stated she had been employed at the facility ten years prior and the facility had never had water pitchers. The DON stated staff offered water three times a day and offered water with the three meals. The DON stated resident not having access to water could potential be a risk for dehydration. The DON stated the facility did not have a policy and procedure on their water offering process. The DON did not provide a policy and procedure for hydration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 47 of 62 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 05/03/2019 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 During an interview with the Administrator, on 3/8/19 at 10:10 a.m., the Administrator stated the facility does not provide water pitchers to the resident because they have behaviors. No additional information was provided. During a concurrent observation and interview with Resident 6, on 3/8/19, at 4:16 p.m., Resident 6 was sitting outdoors wearing two heavy jackets, a long sleeve shirt, pants, a beanie cap and a hat over the cap. Resident 6's face was observed with perspiration. Resident 6 stated, "I'm warm, It's getting hot but I like staying out here." Resident 6 stated he had to ask for water if he was thirsty. Resident 6 stated he would like to have access to water without having to ask for a drink from the staff. During an interview with LVN 4, on 3/12/19 at 4:32 p.m., LVN 4 stated she purchased plastic water bottles for three resident (Resident 6, 40 and 32) and Resident 22's daughter bought him his water bottle because residents were always thirst. LVN 4 stated, "I wanted them to have water." 3. Cross reference F584, F600, F609, F610,

F837, and F841

F837 SS=F Governing Body CFR(s): 483.70(d)(1)(2)

F837 07/08/2019 §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 48 of 62 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 05/03/2019 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 §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the Governing Body provided oversight to the facility Administrator, management staff and implemented effective policies and procedures for care of the residents to ensure necessary resources and care were met to attain or maintain residents highest practical, physical, mental and psychosocial well-being. The Governing body failed to provide oversight and monitor the facilities annual recertification implementation of the plan of correct (POC) when: 1. The Governing Body failed to provide oversight to the facility Administrator and management staff when: residents were subjected to continued use of bed linens with holes, stains and tears since 8/23/18. The facility provided an acceptable Plan of Correction (POC) for bed linens not being in good repair on 3/6/19 and the POC was not implemented at the time of the second revisit survey at the facility. These failures had the potential to place residents at risk for injuries and violated resident rights to have a clean, sanitary and comfortable homelike environment. Cross reference F584 2. The Governing Body failed to provide oversight to the facility Administrator and management staff when the quality assurance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 49 of 62 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 05/03/2019 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 and performance improvement (QAPI) committee failed to implement monitoring processes for abuse prevention POC system change for sustainability. The facility provided an acceptable POC for the prevention of resident abuse on 3/6/19 and the POC was not implemented at the time of the second revisit survey at the facility. These failures had the potential to place residents at risk for abuse and mistreatment and negatively impact residents emotionally and psychological health. Cross reference F600 3. The Governing Body failed to provide oversight to the facility Administrator and management staff when the QAPI committee failed to implemented and evaluated the abuse reporting POC monitoring process for sustainability. The facility provided an acceptable POC for the prevention of resident abuse on 3/6/19 and the POC was not implemented at the time of the second revisit survey was conducted at the facility. This failure had the potential for possible abuse to go uninvestigated and unreported and negatively impact residents emotionally and psychological health. Cross reference F609. 4. The Governing Body failed to provide oversight to the facility Administrator and management staff when the abuse investigation POC monitoring process was not implemented by the QAPI committee to ensure the abuse investigation system was effectively implemented, monitored and evaluated for sustainability and to ensure deficient practice does not recur. Cross reference F610 5. The Governing Body failed to provide oversight to the facility Administrator and management staff and as a result the facility failed to develop and implement effective discharge planning processes for one of three FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 50 of 62 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 05/03/2019 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 sampled residents (Resident 23) when Resident 23 was discharged to a room and board facility (provides lodging and food in an independent living setting) without the benefit of determining whether or not Resident 23 had the capacity and/or capability to self-administer his medications which included insulin and blood pressure medications. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 23's needs and required services prior to discharge and did not conduct training and education related to Resident 23's capability to care and administer medications for himself without staff assistance. As a result of these failure, Resident 23 was admitted to the Acute Care Hospital (ACH) Telemetry unit (medical care unit dedicated to continuous care and monitoring of patient's heart rate, blood pressure, breathing and other vital signs) within 24 hours of transfer to the Room and Board with high blood pressure of 202/117 millimeters of mercury (mm Hg), (MAYO clinic dated 1/9/19 indicated an adult male's normal blood pressure is below 120/80.) Resident 23 remained in the hospital until 2/26/19 (24 days). Cross reference F660 Findings: During an interview with the Governing Body Member (GBM) on 3/12/19, at 7:32 p.m., the GBM stated the administrator and administrative staff were given guidance during the implementation of the POC and after the development and acceptance of the POC the administrator and administrative staff were expected to fully implement, monitor and evaluate the POC systemic change to ensure the all residents were provided safe care and a safe environment. The GBM stated he did not review the implementation and monitoring of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 51 of 62 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 05/03/2019 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 POC and was not always involved with daily operations of the facility. The GBM stated he did not review documentation of the POC monitoring or evaluation of the effectiveness of the POC. The GBM was actively involved during the revisit survey and stated he recognized the Administrative staff needed additional guidance. The GBM stated the administrative staff did not fully implement past none-compliance systemic changes in accordance with the POC.

F841 SS=F Responsibilities of Medical Director CFR(s): 483.70(h)(1)(2)

F841 07/08/2019 §483.70(h) Medical director. §483.70(h)(1) The facility must designate a physician to serve as medical director. §483.70(h)(2) The medical director is responsible for(i) Implementation of resident care policies; and (ii) The coordination of medical care in the facility. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the Medical Director provided effective oversight to ensure policies and procedures were in place for 38 of 38 residents when the facility's policies and procedures dated 1990 to 1999 were not current with standards of practice and minimum regulatory requirements. This failure had the potential for resident care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 52 of 62 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 05/03/2019 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 needs to go unmet. Findings: During an interview with Licensed Vocational Nurse (LVN 4) on 3/12/19 at 5 p.m., LVN 4 stated she was used to referring to resident care policies and procedures when situations occurred like abuse or resident discharges. LVN 4 looked for resident care policies and procedures and stated she was unable to find policies. LVN 4 stated the facility did not have resident care policy and procedures available for the staff to review since 6/2018. During an interview with the Director of Nursing (DON) on 3/12/19 at 5:30 p.m., the DON stated, "Yes, we have policies and procedures at the nurse's station. They're a little old but they're still good." The DON found a thin white binder with flower prints with policies and procedures dating from 1990 to 1999. The DON stated, "See here they are. The Policy is dated 1990 a little old but still good." During an interview with the Governing Body Member (GBM) on 3/12/19, at 7 p.m., the GBM reviewed the facility nurses station and staff areas looking for resident care policies and procedures and was unable to find facility policies and procedures. The GBM stated the corporation had provided the Administrator a flash drive (dated storage device that connect to computers and other device) with all of the corporations' resident care policies and procedures. The GBM stated the Administrator was directed to install the policies and procedures in all staff computers to ensure staff had access to resident care policies and procedures. The GBM stated the Administrator had not provided the staff access to the policies and procedures. The GBM stated he was not aware the facility did not have access to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 53 of 62 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 05/03/2019 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 policies and procedures since 6/2018. The DON provided a small binder with policies and procedures dated 1990 through 1999. The GBM stated, "Those policies belong to the previous owners and are too old." The GBM was asked regarding the POC indicating the GBM would meet with the Medical Director during the quarterly Quality Assurance and project improvement (QAPI) committee meeting to discuss resident care policies implementation, changes and reviews. The GBM would discuss clinical operations trends and psychotropic consent process updates with the Medical Director and devise strategic planning along with administrator to address said trends. The GBM stated the facility did not have current standard of practice resident care policies available for the facility staff. The GBM stated the only person who had access to the resident care policies was the administrator. The GBM stated the facility did not fully implement past none-compliance systemic changes in accordance with the Plan of Correction (POC) accepted 3/6/19. The GBM stated he had not conducted the review that was indicated in accordance with the POC.

F880 SS=F Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 07/08/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 54 of 62 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 05/03/2019 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 §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 55 of 62 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 05/03/2019 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 corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to prevent cross contamination (the transfer of germs from one surface to another) when: 1. Housekeeping/Laundry staff (H/L 5) distributed clean laundry to all of the facility residents with double gloved hands and without performing appropriate hand hygiene during the delivery of clean laundry. 2. Housekeeping/Laundry staff (H/L 3) failed to remove personal protective equipment (PPE) and perform hand hygiene after completing the disinfection of a resident room. These failures resulted in the potential to spread infection to residents and staff. Findings: 1. During a concurrent observation and interview with H/L 5, on 3/10/19, at 12 p.m., in the facility hallway, H/L 5 pushed a laundry cart and distributed clean laundry while wearing two pairs of gloves. H/L 5 began to distribute resident laundry to female residents of the facility and ended with the male residents. H/L FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 56 of 62 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 05/03/2019 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 5 stated she wore two pairs of gloves for the distribution of clean laundry and would not remove the double gloves until she completed the distribution of laundry to all the residents of the facility. H/L 5 touched doors and resident furniture each time she entered rooms to distribute laundry. H/L 5 exited the rooms and applied hand sanitizer from the facility wall dispenser and rubbed her gloved hands with the hand sanitizer. H/L 5 completed the laundry distribution performing the same practice. H/L 5 never removed her double gloves during the distribution and never performed appropriate hand hygiene. During an interview with H/L 5 and the Laundry/Housekeeping supervisor (LS), on 3/10/19, at 12:24 p.m., H/L 5 stated she worked in the facility laundry department for the past three years. H/L 5 stated she did not know she was required to wash her hands after touching the residents environment. H/L 5stated she wore double gloved hands because she did not want to catch anything going around in the facility. H/L 5 stated she was not familiar with the facility handwashing policy and procedure. H/L 5 stated she wore the gloves and applied hand sanitizer to her gloved hands thinking it was ok to do so. H/L 5 stated, "I have done it like this for three years and no one has ever said anything to me." LS stated H/L 5 was required to wash her hands after touching a resident and or providing a service. LS and H/L 5 could not remember the last hand washing inservice given to them. LS stated it was not appropriate to utilize double gloves and apply hand sanitizer on gloved hands. During an interview with the DON, on 3/10/19, at 12:40 p.m., she stated the laundry staff was responsible to perform hand hygiene either by using soap and water or by using the hand sanitizer available in the wall dispenser. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 57 of 62 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 05/03/2019 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 DON stated hand hygiene was required before and after resident care or after touching a residents environment and after the removal of gloves. The DON stated she was not aware laundry staff was distributing laundry while wearing double gloves and without performing hand hygiene. 2. During an observation on 3/10/19 at 11:15 a.m., H/L 3 was observed outside of the facility wearing an isolation gown and gloved hands. H/L 3 went to the outside facility storage shed to access a large box. H/L 3 enterred the facility wearing PPE while carrying a large box, she opened the housekeeping closet and began to organize the multiple boxes of gloves. During an interview with HKP 1, on 3/10/19 at 11:30 a.m., she stated she was still wearing the PPE and had not removed it in order to protect her from getting sick. H/L 3 stated she did not know she had to remove the PPE after cleaning the environment. H/L 3 stated she began wearing PPE after the facility scabies outbreak. H/L 3 stated she finished moping a resident room and did not perform hand hygiene or remove her PPE after she finished the task. During an interview with the Administrator (ADM) on 3/10/19 at 12:50 p.m., he stated the facility currently did not have a Staff Developer to perform the Inservice for hand hygiene. The facility policy and procedure titled, "Handwashing/Hand Hygiene dated 8/15, indicated, "This facility considers hand hygiene the primary means to prevent the spread of infections...2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors...8. Hand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 58 of 62 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 05/03/2019 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 hygiene is the final step after removing and disposing of personal protective equipment use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 10. single use disposable gloves shoul be used...c. When in contact with a resident, or equipment or environment of a resident..."

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 07/08/2019 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for a resident census of 38, staff and visitors when: 1. One of two hallway restrooms used by residents had uneven cracked flooring and a leaking toilet after a restroom demolition and renovation project was completed. 2. Previous water damage and repair of dry wall and baseboards in the male hallway were cracked, uneven and peeling away from the wall. 3. The top aspect of the exterior window for room 14 was being held with duct tape, a large sheet of broken Plexiglas was leaning against a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 59 of 62 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 05/03/2019 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 wall outside of the building and within reach of residents, the exterior cemented pathway adjacent to a shed was uneven with a lift of 2.5 inches in height, there were fallen tree branches on the dirt terrain adjacent to the cemented walkway which created trip hazards for ambulatory residents. 4. Resident 7's bed frame had two protruding metal sharp slots. These failures placed 38 residents, staff and visitors at risk for infection and injury from the lack of a sanitary and unsafe environment. Findings: 1. During an observation on 3/10/19 at 10:15 a.m., of the hallway restroom located on the corner of the male resident hallway. The flooring had uneven and cracked portions and a water leak from the base of the toilet. During a concurrent observation and interview with the Administrator (ADM), on 3/10/19, at 10:20 a.m., he stated the hallway restroom was recently repaired [1/2019] and had not seen the cracked flooring or leaks coming from the base of the toilet. The ADM stated the maintenance man was not in the facility and did not know if the maintenance man was aware of the condition of the hallway restroom. 2. During a concurrent observation and interview with the ADM, on 3/10/19, at 10:25 a.m., in the hallway of the facility. There were cracked, uneven and peeling portions to the walls next to the laundry room and activity office. Several baseboards were lifted and peeling away from the wall. The ADM stated the areas were previously repaired by the maintenance man. 3. During an observation on 3/10/19 at 11 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 60 of 62 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 05/03/2019 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 in the outside facility walkway. An exterior bedroom window for room 14 had a long piece of duct tape throughout the top aspect of the window. During a concurrent observation and interview, with Certified Nursing Assistant (CNA 20), on 3/10/19 at 11:05 a.m., in the outside facility walkway. She stated the exterior of the window for room 14 was being held up with duct tape. CNA 20 stated the window broke or fell out but could not remember when. During a concurrent observation and interview with the Director of Nursing (DON), on 3/10/19 at 11:30 a.m., in the outside facility walkway. She stated the exterior of the window for room 14 was being held up with duct tape. The DON stated she did not know why duct tape was used on the exterior portion of the window and was not an appropriate repair. During a concurrent observation and interview with the ADM, on 3/10/19 at 11:34 a.m., in the outside facility walkway. He stated the grounds of the facility were safe and free of hazards. The ADM identified the duct tape located on the exterior portion of the window for room 14 and stated he did not know why the tape was there. The ADM stated he would have to speak with the maintenance man and figure out why duct tape was used. A sheet of broken Plexiglas was placed against an exterior wall of the facility which was accessible to all residents who walked passed the broken Plexiglas. The ADM stated he did not know why the Plexiglas was there and stated it should not have been placed there. Further observations of the exterior facility walkways were noted with cemented walkways being lifted by adjacent trees. The walkway had a lift of 2.5 inches with the surrounding dirt terrain filled with broken fallen tree branches. The ADM remained silent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 61 of 62 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 05/03/2019 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 when asked if he considered the exterior of the facility a safe environment for the residents of the facility. 4. During a concurrent observation and interview with CNA 17, on 3/10/19 at 10:25 a.m., in Resident 7's room. Resident 7's bedframe had two metal protrusions designed to insert bedrails. The metal protrusions were sharp and created a potential hazard for Resident 7 and staff performing bedside care. CNA 17 the metal protrusions were sharp and her pants would frequently get caught during bed side care. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 1), on 3/10/19 at 11:46 a.m., in Resident 7's room. She stated the two metal protrusions were sharp and created a hazard for the resident and staff. LVN 1 stated, "I did not pay attention to the metal protrusions prior to today." During an interview with the DON, on 3/10/19 at 1 p.m., she was unable to produce a policy and procedure on how the facility provided a safe environment for the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EM2Q13 Facility ID: CA040000025 If continuation sheet 62 of 62