Other·January 27, 2017

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 an abbreviated standard survey to investigate two complaints. Complaint Numbers: CA00512311 and CA00516154 Representing the California Department of Public Health: 33786 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for the complaint numbers CA00512311 and CA00516154.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 12/10/2016 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. 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: I99611 Facility ID: CA240000013 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555521 12/29/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MESA CARE CENTER 9333 La Mesa Dr Rancho Cucamonga, CA 91701 (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 (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the hoyer lift sling (a supportive device that is used with a mechanical lift) is safe to use to transfer the residents from bed to and from wheelchair for one of two sampled residents (Resident A). This failure resulted in Resident A falling from the hoyer lift sling onto the floor, sustaining hip and pelvis fractures and requiring hospitalization. Finding: An unannounced visit was made to the facility on December 6, 2016 at 3:15 PM to investigate a complaint regarding quality of care. A review of Resident A's clinical record, reflected Resident A was admitted to the facility on April 19, 2016 with diagnoses which included hypertension (high blood pressure), diabetes (high blood sugar), and hemiplegia (unable to move one side of the body). A review of the history and physical, completed by the physician on April 22, 2016, indicated Resident A does not have the capacity to understand and make her own decision. A review of the Resident Assessment Instrument (RAI-a facility comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I99611 Facility ID: CA240000013 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555521 12/29/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MESA CARE CENTER 9333 La Mesa Dr Rancho Cucamonga, CA 91701 (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 assessment tool) functional status (the measure of a person's ability to perform activities of Daily Living (ADL's) dated November 1, 2016, indicated Resident A required staff assistance with all her ADLs. Resident A was non ambulatory. A review of the licensed nurse's progress notes, dated November 24, 2016 at 10:15 PM, reflected Resident A was noted to be grimacing and crying after the fall. "Resident [A] was being transferred from the wheelchair to the bed via hoyer lift...both CNA (Certified Nursing Assistant) state that the sling broke from one support loop supporting the lower extremities. Resident [A] ascended down on both legs and rested onto the left side..Nurse contacted 911 immediately...Resident [A] transported to hospital." Resident A was not in the facility during the investigation. During an interview with the Licensed Vocational Nurse (LVN 1) on December 6, 2016 at 4:45 PM, he stated after the incident on November 24, 2016 every hoyer lift sling in the facility were checked and found 4 (Four) slings were torn after tugging the straps and the support loops. They were all removed from the floor. During an interview with CNA 2 on December 6, 2016 at 5:30 PM, she stated on November 24, 2016 she assisted CNA 1 to transfer Resident A from the wheelchair to the bed using the hoyer lift. CNA 2 stated during the transfer she heard a tear from the hoyer sling. She had noticed the hoyer lift sling was torn. Resident A fell hard on the left side landing on the metal support base of the hoyer lift. During an interview with the Administrator on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I99611 Facility ID: CA240000013 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555521 12/29/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MESA CARE CENTER 9333 La Mesa Dr Rancho Cucamonga, CA 91701 (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 December 6, 2016 at 6 PM, she stated prior to the incident the facility did not have any policy in place on how to ensure the hoyer lift slings are safe to use to transfer the residents using the hoyer lift. During an interview with the Certified Nursing Assistant (CNA 1) on December 7, 2016 at 6:30 PM, she stated on November 24, 2016, she was assigned to take care of Resident A. She stated at approximately 7 PM, Resident A was up in the wheelchair with a hoyer lift sling underneath her. Resident A was put on the wheelchair by CNA 3. CNA 1 stated she asked CNA 2 to help transfer Resident A from the wheelchair to the bed with the hoyer lift. CNA 1 stated while she was lifting Resident A from the wheelchair to the bed using a hoyer lift, she heard a tear from the hoyer lift sling. CNA 1 stated she noticed the hoyer lift sling tore from the strap loops from the hoyer lift. Resident A fell out of the sling onto the floor. CNA 1 was asked if she had checked the straps and the strap loops prior to transfer the resident, she responded "No. The sling was worn out, it looks old. We kept using it over and over again. I assumed the sling was safe." CNA 1 stated she should have checked the sling straps and strap loops prior to transfer the resident. CNA 1 stated prior to the incident she had not been inserviced on how to inspect the hoyerlift sling that included checking the straps and the support loops. CNA 1 stated Resident A required a hoyer lift transfer. CNA 3 was not available to be interviewed during the investigation. During an interview with the Director of Nursing (DON) on December 7, 2016 at 6:50 PM, she stated there was no system in place on how to check the hoyer lift sling strap and strap loops to ensure the hoyer lift slings are safe to use to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I99611 Facility ID: CA240000013 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555521 12/29/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MESA CARE CENTER 9333 La Mesa Dr Rancho Cucamonga, CA 91701 (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 transfer the residents using the hoyer lift prior to the incident on November 24, 2016. During a review of the inservice record on December 7, 2016 at 7 PM, at the Director of Staff Development's office, showed there was no record of inservice had been provided to the staff on how to inspect the hoyer lift sling prior to the incident. The DON verified the finding at the time of document review. A review of the hoyer lift sling manufacture "Instruction Manual" indicated "Carefully inspect the sling before each use for wear and damage to seams, fabric, straps and strap loops...Use only slings that are in good condition. Discard and destroy old...slings" During an interview with the complainant on December 8, 2016 at 3:45 PM, the complainant stated Resident A had fallen from the hoyer lift sling at the facility on November 24, 2016 at approximately 7:30 PM. Resident A was sent to the acute hospital where Resident A was found to have hip and pelvis fractures. A review of the x-ray result from the acute hospital, dated November 24, 2016, indicated Resident A sustained left hip and pelvis fractures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I99611 Facility ID: CA240000013 If continuation sheet 5 of 5