Other·August 16, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of an entity reported incident. Incident Number: CA 00488668 Category: Accidents, Death-General, Nursing Services, Quality of Care/Treatment Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) Number: 22931 The inspection was limited to the specific entity reported incident and does not represent the findings of a full inspection of the facility.

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

F309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide services that were necessary to prevent physical harm to one resident (Resident A). The facility nursing staff had knowledge that Resident A may have ingested hand sanitizer containing ethanol 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: LM5Y11 Facility ID: CA080000015 If continuation sheet 1 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 (alcohol) and did not intervene to obtain medical services until 12 hours later. The facility failed to provide Resident A with necessary care in a timely manner, to attain or maintain the highest practicable physical, mental, psychosocial well-being including but not limited to: 1. Failure to provide comprehensive assessment by the licensed nurse (LN) when Resident A possibly ingested the hand sanitizer. 2. Failure to communicate among the care providers at the time of the incident. In addition, the primary physician and responsible party were not notified timely when the incident occurred as the policy indicated. No incident report completed by the LN as the facility job description of the charge nurse indicated. 3. Failure to call 911 immediately or seek medical consultation when the staff discovered Resident A was unresponsive by the unusual incident. Failure to implement the Physician Orders for Life-Sustaining Treatment (POLST) which included selective treatment for Resident A in timely manner. 4. Failure to provide the transfer information to the receiving hospital. The hospital staff did not know why Resident A was transferred from the nursing facility. As a result, emergency care was delayed more than 5 hours. These failure practices had an affect on Resident A's health and safety, Resident A was transferred on 5/17/16 to the hospital 12 hours after the incident occurred from the facility, and passed away next day on 5/18/16. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 2 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 5/19/16 at 4 P.M., an unannounced visit was conducted to investigate a complaint alleging Resident A ingested hand sanitizer and was transferred to the local acute hospital on 5/17/16, where she died the next day. According the Face Sheet, Resident A was admitted to the facility on 3/11/16 from the hospital. According the physician's "Discharge Summary" from the hospital (sending facility), dated 3/10/16, Resident A was an 82 year old female admitted to the facility on 3/11/16. Her diagnoses included, muscle weakness, severe protein-calorie malnutrition, Cachexia (weakness and wasting of the body due to severe chronic illness), Enterocolitis (inflammation of both the small intestine and the colon) due to Clostridium difficile (an infection of the colon) and severe dementia (brain diseases that cause memory loss). The Initial History and Physical, dated 3/14/16, indicated that "Resident A did not have the capacity to understand and make decision." On 5/19/16, at 4:30 P.M., an interview was conducted with certified nurse assistant (CNA) 1. CNA 1 was the caregiver for Resident A on 5/17/16 during the 3:00 P.M. to 11 P.M. shift of duty. CNA 1 stated that Resident A had a tab alarm on that was used to alert staff if she was making movements that were not safe. Between 8:30 P.M. and 9 P.M. on 5/17/16, she heard the tab alarm going off in Resident A's room. CNA 1 stated that she went into the room and found Resident A sitting at the edge of her bed holding a 16 ounce size bottle of hand sanitizer in her hands. CNA 1 immediately took the sanitizer away from Resident A. CNA 1 observed that the sheets and her blanket were wet. She looked into Resident A's mouth to see if there were any signs of sanitizer or smell of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 3 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 sanitizer but there was not. CNA 1, then went out to the hallway and told her charge nurse (CN) 1 what had happened. Then both CNA 1 and CN 1 went into the room to see Resident A. CN 1 told CNA 1 to go and tell the Nurse Supervisor (NS) 1 who was on the other side of the facility working because CN 1 had never seen anything like this and did not know what to do [CN 1 was a newly hired licensed nurse and had not experienced an incident such as this incident according to CN 1]. CNA 1 stated that she went to the NS 1 and seen that NS 1 was busy, so she pulled her away from the nurse's station and explained what had happened with Resident A. CNA 1 told NS 1 that CN 1 had sent her to inform her of the incident and to find out what it was that she was supposed to do, as she had never experienced this type of situation before. NS 1 asked CNA 1 if the resident was drinking thickening liquids and CNA 1 responded no, I did not see her drink anything. NS 1 told CNA 1, " don't worry, she (Resident A) will be okay, just monitor her". This statement confirmed that CN 1 and LN 1 did not conduct full physical assessment of Resident A at the time the incident occurred. There was no documentation available in Residents A's clinical record or elsewhere for 5/17/16, PM shift (3 PM - 11-PM) regarding this incident on the nurses progress notes by CN 1 or NS 1. There was no evidence of shift report or shift change endorsement conducted by the CN 1 and NS 1 found in the records or their statements. There was no incident report found in the facility's incident log. On 5/19/16 at 6:15 P.M., a joint interview with NS 1 and the Director of Nurses (DON) was conducted. NS 1 stated, "I remember CNA 1 coming to me and telling me that Resident A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 4 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 was drinking a lot. I asked her if Resident A was okay and CNA 1 said yes. I told her to keep an eye on her, thinking it was a drinking problem. After that, I did not hear any more about Resident A, thinking everything was okay". When the NS 1 was asked if she had checked on Resident A anytime during the working shift, since it would have been her responsibility to directly observe Resident A in order to validate the information collected by CNA 1, she replied, she did not because she thought everything was okay. NS 1 stated she did not hear CNA 1 tell her anything about hand sanitizer. SN 1 further stated that she knew nothing of the incident until she was called at home by the night shift nurse at about 5:45 A.M. on 5/18/16. This statement confirmed that SN 1 did not directly assess and document Resident A at the time the incident occurred. During this same interview, the DON acknowledged that no documentation regarding the incident involving Resident A was available as no input was put into Resident A's clinical record or elsewhere. On 5/19/16 at 6:20 P.M., CN 1 on the PM shift was asked if she had documented anything about the incident in Resident A's medical record. The CN 1 stated that staff had been instructed by the DON to not document anything until something went "wrong or bad". A review of the report of Suspected Dependent Adult/Elder Abuse which documented by the DON, dated 5/18/16 at 3:21 P.M., indicated "LN did not report or document the allegation of Resident A drinking hand sanitizer to the medical doctor, son or Administrator. Resident was assessed by registered nurse (RN) but information was not recorded. Medical Doctor and family were not notified in a timely manner. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 5 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 Registered Nurse did not follow up with the licensed vocational nurse (LVN) for additional info such as assessment, treatment and notifying Medical Doctor, etc." A concurrent record review and joint interview with the DON on 5/19/16, at 6:27 P.M., was conducted. The facility's job description for LN indicated "rounds were to be performed to review physical, medical and emotional status and to implement required nursing interventions...investigation of accidents and unusual occurrences were to be written and reported to the Director of Nurses. In addition, notification to the physician and resident's responsible party of any resident accidents/incidents. Fill out and complete Incident report forms on all such occurrences and chart such information in the residents' medical records as outlined in the facility's established policies and procedures (P&P). Give nursing reports upon reporting in and ending shift duty hours." The personal file for CN 1 was reviewed and indicated that CN1 had been employed elsewhere prior to coming to this facility as a licensed vocational nurse (LVN) since 6/1999. The experience documented that CN 1's experience included, evaluating patient care needs and prioritizing needed treatments. In addition, assessed patients, documenting their medical histories and daily changes. There was no job description for Nurse Supervisor. The DON stated that in her absence the charge nurses were to function as supervising nurses. An RN was always available for consultation by the RN if necessary. The job description for the Director of Nurses was reviewed during this time. The job FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 6 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 description indicated, "written and oral reports/recommendations to the Administrator, that concerned the operation of the nursing service department was to be done. Completing medical forms, reports, evaluations, studies, charting as necessary. Ensure that direct nursing care be provided by a licensed nurse. Review nurse's notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care and that such care is provided in accordance with the resident's wishes. Monitor nursing personal to ensure that they are following established safety regulations in the use of equipment and supplies. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Ensure that the facility's policy and procedures governing advance directives are reviewed with the resident and/or representative." The DON acknowledged that NS 1 and CN 1 did not follow their job description. On 5/19/16 at 4:30 P.M., Resident A's clinical record review with the DON was conducted. A care plan for Resident A, dated 3/11/16 indicated that Resident A had a cognitive deficit, communication deficit, limited mobility, and a lack of awareness which placed her at risk for injury. The approaches to address the issues included, remove hazards from the environment, answer call light promptly, and check the resident every 2 hours. The DON was asked how Resident A was able to access the hand sanitizer; the DON stated that she did not know how Resident A was able to obtain it. The DON acknowledged that the action performance of 2 hour rounds was not effective and unable to prevent hazards from happening. A documentation of the 2 hour rounds was requested but no documentation was available. The care plan was not followed as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 7 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 documented. The Physician Orders for Life-Sustaining Treatment (POLST) for Resident A, dated 3/14/16, indicated "Do not attempt resuscitation/DNR, Allow Natural Death. Selective Treatment: goal of treating medical conditions while avoiding burdensome measures. In addition to treatment in ComfortFocused Treatment, use of medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate...Transfer to hospital only if comfort needs cannot be met in current location." The DON acknowledged that Resident A was involved in an unusual incident and the facility should have notified the attending physician and obtained direction from the physician in a timely manner. The DON acknowledged that Resident A's condition was not related to a natural cause. A review of the ER Physician Assistant statement dated 5/18/16 at 9:28 A.M., indicated that Resident A was transported to the emergency room by emergency medical service (EMS) with no information other than there was low blood pressure and Resident A was non- responsive. The emergency room physician contacted Resident A's primary physician and was told that comfort measures were the only measures to be implemented. At 1:40 P.M., 5 hours 30 minutes later, the emergency room staff received a call from the DON at the SNF informing them that they [SNF Staff] had just discovered that there was a possibility that Resident A could have ingested an unknown amount of hand sanitizer. The ER physician ordered a blood test to find out if there was alcohol in Resident A's blood. Results came back with an alcohol level of approximately 7%, which is more than seven times the legal limit for operating a motor vehicle..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 8 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 A review of the laboratory report, dated 5/18/16. Collection Time of specimen was at 12:30 P.M. Results obtained at 1:33 P.M. Result of 738 Ethanol (alcohol). Normal parameters (0 -10) milligrams per deciliter The ED physician did not feel comfortable limiting Resident A to comfort measures in light of the severe ethanol toxicity nor would it be right to call the incident a natural death. Initiation of maxillary aggressive resuscitation short of cardiopulmonary resuscitation (CPR) and intubation was then provided. However, Resident A expired on 5/19/16 at 8:30 A.M., pronounced by the ED physician.

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.75(l)(1)

F514 The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide any verbal or documented information to the receiving hospital emergency room (ER) about the condition of Resident A. The facility did not complete a transfer information document of Resident A's condition prior to the transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 9 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 facility failed to ensure that sufficient information was transferred with the resident at the time of transfer. As a result the hospital emergency department did not know why Resident A was transferred to the hospital ER at the time of admission. This failure practice contributed to a delay in necessary medical intervention producing a decline in Resident A's physical well-being. As a result, Resident A did not receive the required medical care and expired on 5/18/16 at the hospital. Findings: On 5/19/16 at 4 P.M., an unannounced visit was conducted to investigate a complaint alleging Resident A ingested hand sanitizer and was transferred to the local acute hospital on 5/17/16, where she died the next day. According the Face Sheet, Resident A was admitted to the facility on 3/11/16 from the hospital. According the physician's "Discharge Summary" from the hospital (sending facility), dated 3/10/16, Resident A was an 82 year old female admitted to the facility on 3/11/16. Her diagnoses included, muscle weakness, severe protein-calorie malnutrition, Cachexia (weakness and wasting of the body due to severe chronic illness), Enterocolitis (inflammation of both the small intestine and the colon) due to Clostridium difficile (an infection of the colon) and severe dementia (brain diseases that cause memory loss). The Initial History and Physical, dated 3/14/16, indicated that "Resident A did not have the capacity to understand and make decision. On 5/19/16 at 4:30 P.M., Resident A's clinical record was reviewed with the director of nursing (DON). A care plan for Resident A, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 10 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 dated 3/11/16 indicated that Resident A had a cognitive deficit, communication deficit, limited mobility, and a lack of awareness which placed her at risk for injury. The approaches to address the issues included, remove hazards from the environment, answer call light promptly, and check the resident every 2 hours. The DON was asked how Resident A was able to access the hand sanitizer, the DON stated that she did not know how Resident A was able to obtain it. The DON acknowledged that the action performance of 2 hour rounds was not effective and unable to prevent hazards from happening. A documentation of the 2 hour rounds was requested but no documentation was available. The care plan was not followed as documented. The Physician Orders for Life-Sustaining Treatment (POLST) for Resident A, dated 3/14/16, indicated "Do not attempt resuscitation/DNR, Allow Natural Death. Selective Treatment: goal of treating medical conditions while avoiding burdensome measures. In addition to treatment in ComfortFocused Treatment, use of medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate...Transfer to hospital only if comfort needs cannot be met in current location.," The DON acknowledged that Resident A was involved in an unusual incident and the facility should have notified the attending physician and obtained direction from the the physician in a timely manner. The DON acknowledged that Resident A's condition was not related to a natural cause. A review of the ER Physician Assistant statement, dated 5/18/16 at 9:28 A.M., indicated that Resident A was transported to the emergency room by emergency medical service (EMS) with no information other than there was low blood pressure and Resident A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 11 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 was non-responsive. The emergency room physician contacted Resident A's primary physician and was told that comfort measures were the only measures to be implemented. At 1:40 P.M., 5 hours and 30 minutes later, the emergency room staff received a call from the DON at the SNF that they [SNF Staff] had just discovered that there was a possibility that Resident A could have ingested an unknown amount of hand sanitizer. The ER physician ordered a blood test to find out if there was alcohol in Resident A's blood. Results came back with an alcohol level of approximately. 7% which is more than seven times the legal limit for operating a motor vehicle..." A review of the laboratory report, dated 5/18/16 showed Collection Time of specimen was at 12:30 P.M. and results obtained at 1:33 P.M. Result of 738 Ethanol (alcohol) Normal parameters (0 -10) milligrams per deciliter. The ED physician did not feel comfortable limiting Resident A to comfort measures in light of the severe ethanol toxicity nor would it be right to call the incident a natural death. Initiation of maxillary aggressive resuscitation short of CPR and intubation was then provided. However, Resident A expired on 5/19/16 at 8:30 A.M., pronounced by the ED physician. According to the hospital medical record for Resident A, on 5/18/16 at 3:21 P.M. the facility DON faxed notification of Resident A's transfer to the hospital, documenting that a hand sanitizer may have been ingested on 5/17/16 between 8:30 P.M. and 9:00 P.M. and that no assessment was performed and there was no documentation relating to the incident of Resident A. In addition, no report of the incident had been given to the oncoming night shift staff. This documentation confirmed that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 12 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 there was no transfer sheet available in the closed record of Resident A. On 5/19/16 at 5:45 P.M., the charge nurse (CN) 1 on the PM shift was asked if she had documented anything about the incident in Resident A's medical record. The CN 1 stated that staff had been instructed by the DON to not document anything until something went "wrong or bad". On 5/19/16 at 6:10 P.M., review of the facility's undated job description for Charge Nurse was conducted. The job description indicated that investigation of accidents and unusual occurrences were to be written and reported to the Director of Nurses. In addition, notify physician and resident's responsible party of any resident accidents/incidents. Fill out and complete Incident report forms on all such occurrences and chart such information in the residents's medical records as outlined in the facility's established polices and procedures (P&P). The facility's P&P for emergency transfer/discharge summary was not available when requested as there was no policy and procedure in place per the DON. A review of Title 22, 72519 Patient Transfer, indicated "(a)The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide continuity of care shall be transferred with the patient at the time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date,time, condition of the patient and a written statement of the reason FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 13 of 14 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: _______________ 555557 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (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 for the transfer. (2) Informed written or telephone acknowledgement of the patient, patients's guardian or authorized representative except in an emergency." On 5/19/16 at 6:25 P.M., the DON and administrator were interviewed and acknowledged that the facility failed to provide the necessary information regarding Resident A's condition when transferring her to the receiving the hospital to ensure that continuity of care would be provided. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LM5Y11 Facility ID: CA080000015 If continuation sheet 14 of 14