Other·August 11, 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 an abbreviated survey to investigate a complaint Complaint number CA00541562, linked with CA00540544. Representing the California Department of Public Health were the following surveyors: 37379 35184 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00541562 and 540544 On June 29, 2017 at 6:17 PM, after interviews and record reviews, an Immediate Jeopardy (IJ, a situation that had threatened or is likely to threaten the health and safety of a resident) was called in the presence of the Administrator and Regional Nurse Consultant (RNC) for Tag

F 333. The facility failed to ensure that three out of three sampled residents (Residents 1, 2 and 3) were free from medication errors when the facility failed to have a Registered Nurse (RN) available to administer intravenous (IV) antibiotics for Residents 1, 2 and 3. The corrective action plan provided by the facility included: 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: JYRD11 Facility ID: CA240000018 If continuation sheet 1 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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. Effective June 29, 2017, the facility will provide sufficient RN coverage, and administer IV medications as ordered by the physician, based on physician ordered frequencies. 2. All residents with IV medications will be identified by the RN Consultant in collaboration with the RN staff. Appropriate physician and responsible party will be informed by the licensed nurse for identified missed doses of IV medication/s. 3. Each resident with missed dose/s of IV medication will be placed on 72 hours alert charting for further monitoring. MD and responsible party will be updated for any significant change in condition observed by a licensed nurse. 4. Currently the facility has ensured that ample RN coverage is available to provide the IV administration as ordered by the physician. RN staffing has been scheduled by the DSD/Staffing Coordinator to include one RN per IV administration time. 5. In the event of a call-off resulting in inadequate RN coverage, the contracted registry can be utilized as well as the interim Director of Nurses (DON) to administer the IV administration. 6. In an effort to ensure all licensed nurses are present for their scheduled shift, the interim DON will call the facility at the start of each shift to ensure all scheduled licensed staffs are present. 7. If the facility is unable to obtain RN coverage to administer and manage IV medication, all residents affected will be transferred to a facility that could manage the IV therapy. Consent of transfer will be obtained by a licensed nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 2 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 from the responsible party and attending physician. {Name of the two contracted skilled nursing facilities] have been advised of the potential need for transfer and have confirmed there are ample beds available in the event a transfer is necessary. 8. The facility will temporarily suspend taking orders for IV medication/s until RN coverage is resolved. 9. Facility will continue its effort to hire a DON. For the time being, a full-time interim DON has been identified and will start on June 30, 2017. The corrective action plan was reviewed and accepted on June 30, 2017 at 11:45 AM, in the presence of the Vice President of Operations (VPO), RNC and Interim DON. During interview with Interim DON on June 30, 2017 at 12:45 PM, it was ensured that RNs were available for the future shifts for IV antibiotics currently scheduled for Resident 1, 2 and 3. Schedules for RNs for the month of July 2017 was reviewed to confirm coverage would be available. The IJ was lifted at 12:55 PM on June 30, 2017, in the presence of the Vice President of Operations (VPO), RNC and Interim DON.

F333 RESIDENTS FREE OF SIGNIFICANT MED FORM CMS-2567(02-99) Previous Versions Obsolete

F333 Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 3 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=K ERRORS CFR(s): 483.45(f)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 1, 2 and 3), were free from medication errors when a total of 19 doses of intravenous (given in a vein) antibiotics were not administered as ordered between June 24, 2017 through June 29, 2017, due to the lack of available registered nurses (RNs). This failure resulted in antibiotic therapy not being administered as prescribed by the physician, which placed the residents at risk for their infectious process to progress which could lead to sepsis (bacterial infection in the blood) and possible death. Findings: 1. During a review of the clinical record for Resident 1, the face sheet (a record providing the demographic data of the resident), indicated that Resident 1 was admitted to the facility on June 21, 2017, with diagnoses which included: chronic right lower extremity cellulitis (bacterial infection involving the inner layers of the skin) and osteomyelitis (inflammation in the bone caused by infection). During the review of physician orders for Resident 1, dated June 22, 2017, the orders FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 4 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 that Resident 1 was to receive Vancomycin (medication to treat an infection) 1.5 gram (unit of measurement) intravenously every 12 hours beginning on June 22, 2017 through July 7, 2017. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Resident 1's Intravenous Therapy Medication Record (ITMR) for the month of June 2017, which indicated, Resident 1 did not receive the Vancomycin 1.5 gram intravenously as ordered by physician on following dates: June 24, 2017 at 8 PM, June 25, 2017 at 8 PM, June 27, 2017 at 8 AM, June 28, 2017 at 8 AM, June 28, 2017 at 8 PM and June 29, 2017 at 8 AM. Further review of Resident 1's physician's orders dated June 23, 2017, indicated that Resident 1 was to receive IV Zosyn (a medicine to treat bacterial infection) 3.375 grams every 12 hours through June 28, 2017. An order dated June 29, 2017, indicated that this medication was to continue through July 1, 2017. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Resident 1's ITMR for the month of June 2017, which indicated, Resident 1 did not receive IV Zosyn 3.375 gms. as ordered by the physician for the following dates: June 24, 2017 at 7 PM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 5 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 June 25, 2017 at 7 PM, June 27, 2017 at 7 AM, June 28, 2017 at 7 AM, June 28, 2017 at 7 PM and June 29, 2017 at 7 AM. During an interview with the Administrator (ADM) on June 29, 2017 at 3:47 PM, she stated that she was not aware of the absence of RNs on the shifts in which the IV antibiotics were scheduled for Resident 1. The Administrator stated since there was no Director of Nurses (DON) employed at the facility at present that she was responsible for adequate staffing. 2. During a review of the clinical record for Resident 2, the face sheet (a record provides the demographic data of the resident), indicated that Resident 2 was initially admitted to the facility on September 28, 2014, with a recent readmission from a General Acute Care Hospital (GACH) on June 27, 2017, after an acute hospitalization for pneumonia (infection of the lungs). A review of Resident 2's physician orders dated June 27, 2017, indicated that Resident 2 was to receive Clindamycin (a medicine to treat infection) intravenously (IV, into the vein) 300 mg every eight (8) hours for seven (7) days. A review of Resident 2's ITMR dated June 29, 2017, indicated that Resident 2 received Clindamycin 300 mg IV on June 29, 2017 at 10:20 AM instead of 7 AM, as prescribed. During a concurrent interview with RN 2 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 6 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 June 29, 2017, at 9:58 AM, she stated she worked as a contract nurse and was called in to work at 9 AM on June 29, 2017. 3. During a review of the clinical record for Resident 3, the face sheet (a record provides the demographic data of the resident), indicated that Resident 3 was admitted to the facility initially on April 14, 2017, and was readmitted on June 27, 2017, with diagnoses which included: anemia (lack of red blood cells in the blood), left below knee amputation (removal of natural leg) and pneumonia (infection of the lungs). During a record review of Resident 3's physician admission orders dated June 27, 2017, indicated Resident 3 was to receive Cipro 200 mg (milligrams a unit of measure) intravenously every 12 hours for infection and Zosyn 2.25 gram intravenously every six (6) hours for pneumonia. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Resident 3's ITMR for the month of June 2017, which indicated Resident 3 did not receive the Prescribed antibiotic as follows: Intravenous Cipro on: June 28, 2017 at 9 AM June 29, 2017 at 9 AM Intravenous Zosyn on: June 28, 2017 at 6 AM June 28, 2017 at 12 Noon and June 29, 2017 at 7 AM. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 7 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 RN 1, on June 29, 2017 at 4:03 PM, she stated that there was no RN scheduled for the times that the residents (Residents 1, 2 and 3) were prescribed to receive IV antibiotics. A review of the facility file titled, "Nursing Staffing Assignment and Sign in Sheet", for the month of June 2017, was conducted. The staffing reflected the following date and shifts, no RNs were scheduled to provide prescribed IV antibiotics: June 24, 2017, 3 PM to 11 PM shift and 11 PM to 7 AM shift. June 25, 2017, 3 PM to 11 PM shift and 11 PM to 7 AM shift. June 27, 2017, 7 AM to 3 PM shift. June 28, 2017, 7 AM to 3 PM shift and 11 PM to 7 AM shift. On June 29, 2017, Resident 3 received her scheduled 7 AM IV antibiotic at 10:20 AM. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she stated that omitted medication dosages were considered as medication errors and the nurses should have followed the medication error policy. She further stated neither the attending physician nor she were notified about the omitted doses by the staff. During a review of the facility policy and procedure titled, "Medication Errors", revised on January 2012, indicated "...All errors related to the administration of medications or treatments will be reported to the Director of Nursing Services, the attending physician, and the Administrator immediately ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 8 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 June 29, 2017 at 6:17 PM, after interviews and record reviews, an Immediate Jeopardy (IJ, a situation that had threatened or is likely to threaten the health and safety of a resident) was called in the presence of the Administrator and Regional Nurse Consultant (RNC). The facility failed to ensure that Residents 1, 2 and 3 were free from medication errors, due to the lack of available registered nurses (RNs) to administer their prescribed intravenous (IV) antibiotics. The corrective action plan provided by the facility included: 1. Effective June 29, 2017, the facility will provide sufficient RN coverage, and administer IV medications as ordered by the physician, based on physician ordered frequencies. 2. All residents with IV medications will be identified by the RN Consultant in collaboration with the RN staff. Appropriate physician and responsible party will be informed by the licensed nurse for identified missed doses of IV medication/s. 3. Each resident with missed dose/s of IV medication will be placed on 72 hours alert charting for further monitoring. MD and responsible party will be updated for any significant change in condition observed by a licensed nurse. 4. Currently the facility has ensured that ample RN coverage is available to provide the IV administration as ordered by the physician. RN staffing has been scheduled by the DSD/Staffing Coordinator to include one RN per IV administration time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 9 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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. In the event of a call off resulting in inadequate RN coverage, the contracted registry can be utilized as well as the interim Director of Nurses (DON) to administer the IV administration. 6. In an effort to ensure all licensed nurses are present for their scheduled shift, the interim DON will call the facility at the start of each shift to ensure all scheduled licensed staffs are present. 7. If the facility is unable to obtain RN coverage to administer and manage IV medication, all residents affected will be transferred to a facility that could manage the IV therapy. Consent of transfer will be obtained by a licensed nurse from the responsible party and attending physician. Claremont Healthcare Center and Park Avenue Healthcare Center have been advised of the potential need for transfer and have confirmed there are ample beds available in the event a transfer is necessary. 8. The facility will temporarily suspend taking orders for IV medication/s until RN coverage is resolved. 9. Facility will continue its effort to hire a DON. For the time being, a full time interim DON has been identified and will start on June 30, 2017. The corrective action plan was reviewed and accepted after verifying that the facility had implemented it through observations of IV antibiotic administration, licensed staff interviews, review of the schedule for RN staffing, registry contracts and facility policy revision on June 30, 2017 at 11:45 AM, in the presence of the Vice President of Operations (VPO), RNC and Interim DON. The IJ was lifted at 12:55 PM on June 30, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 10 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 2017, in the presence of the Vice President of Operations (VPO), RNC and Interim DON.

F353 SS=D SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS CFR(s): 483.35(a)(1)-(4)

F353 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] (a) Sufficient Staff. (a)(1) The facility must provide services by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 11 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. (a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure adequate staffing, when: 1. There was no Registered Nurse (RN) available to administer intravenous (IV- into the vein) antibiotics for three out of six residents (Residents 1, 2 and 3), with orders to receive IV antibiotics at prescribed times from June 24, 2017 through June 29, 2017. 2. Two out of six sampled residents (Resident 3 and Resident 6) had delays in receiving care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 12 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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. The facility was below the minimal requirement for the nursing staffing ratio of 3.2 on nine (9) out of 17 randomly picked days (June 10, 11, 13, 16, 17, 18, 21, 24 and 25) in June 2017. This failure resulted in four of six sampled residents (Resident 1,2,3 and 6) not receiving care in a timely manner which placed them at risk for prolonged infection, unnecessary pain, skin breakdown and accidents. Findings: An unannounced abbreviated visit was made to the facility to investigate a complaint regarding short staffing that affected resident care. 1. During the review of clinical record titled, "Intravenous Therapy Medication Record", (ITMR), for Residents 1, 2 and 3, for the month of June 2017, and a concurrent interview with the Administrator on June 29, 2017 at 3:47 PM, the following was found: a. Resident 1 did not receive six (6) doses each of the prescribed IV antibiotics Vancomycin on: June 24, 2017 at 8 PM, June 25, 2017 at 8 PM, June 27, 2017 at 8 AM, June 28, 2017 at 8 AM, June 28, 2017 at 8 PM and June 29, 2017 at 8 AM., and Zosyn on: June 24, 2017 at 7 PM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 13 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 June 25, 2017 at 7 PM, June 27, 2017 at 7 AM, June 28, 2017 at 7 AM, June 28, 2017 at 7 PM and June 29, 2017 at 7 AM. b. Resident 2 received IV Clindamycin on June 29, 2017 at 10:20 AM instead of 7 AM, as prescribed. c. Resident 3 did not receive five (5) doses of the prescribed IV antibiotics Cipro on: June 28, 2017 at 9 AM June 29, 2017 at 9 AM, and IV Zosyn on: June 28, 2017 at 6 AM June 28, 2017 at 12 Noon and June 29, 2017 at 7 AM. and Zosyn. During an interview with RN 1, she reviewed the records on June 29, 2017 at 4:03 PM, and stated that there was no RN scheduled for the times that the residents (Residents 1, 2 and 3) were prescribed to receive IV antibiotics. 2. On June 29, 2017 at 1:23 PM, Resident 3 was observed laying in bed, she was noted to have a below the knee amputation (BKA- leg is absent from below knee). During a concurrent interview with Resident 3 she stated, "I am blind both eyes. It takes long time to answer the call light. Sometimes staff come, turn off the light and say they will return, but they never return." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 14 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 concurrent interview with Resident 3's family member was conducted. The family member, stated that he had to go out multiple times to find the staff to care for his mother, due to call lights not being answered for a long time. During an interview with Resident 6, on June 30, 2017 at 11:01 AM, she stated that staff do not answer the call lights promptly, especially on evening and night shifts and on weekends. She further stated she is worried about the unavailability of staff in a medical emergency. A record review of Resident 6's clinical record titled, "Face Sheet"(a record provides demographic data of resident), indicated that Resident 6 was admitted to the facility on October 25, 2014, and readmitted on December 24, 2015, with diagnoses which included heart failure and muscle weakness. 3. A review of the facility file titled, "Nursing Staffing Assignment and Sign-in-Sheet", for the month of June 2017, reflected that for nine out of 17 randomly picked days (June 10, 11, 13, 16, 17, 18, 21, 24 and 25) in June 2017, the facility was below the minimal requirement for the nursing staffing ratio of 3.2, as follows: June 10, 2017- 2.98 June 11, 2017- 2.84 June 13, 2017- 3.03 June 16, 2017- 2.51 June 17, 2017- 2.61 June 18, 2017- 3.05 June 21, 2017- 3.05 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 15 of 16 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: _______________ 055693 (X3) DATE SURVEY COMPLETED 07/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO GROVE HEALTHCARE & WELLNESS CENTRE, LP 933 E Deodar St Ontario, CA 91764 (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 June 24, 2017- 2.57 June 25, 2017- 2.57 During an interview with the Administrator on June 29, 2017 at 2:20 PM, she stated that "Our payroll person was the one who does the PPD (hours per patient day) ratio. She quit yesterday. Now when I went to grab the ratio, I figured out that she had not done the ratio for the last three months, from April, 2017 through June 2017." During a review of the PPD calculations and concurrent interview with the Administrator on June 29, 2017 at 3:47 PM, she stated she was not aware that the nursing ratio was out of range on some days in June 2017. The Administrator further stated that since there was no DON, she was responsible for adequate staffing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRD11 Facility ID: CA240000018 If continuation sheet 16 of 16