Other·January 8, 2018

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 abbreviated survey Complaint Intake Number: CA00559231 Representing the California Department of Public Health: Surveyor ID: 37379 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint intake number CA00559231

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

F323 (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 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: FRUE11 Facility ID: CA240000018 If continuation sheet 1 of 8 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 01/04/2018 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 facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (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 implement safeguards to prevent accidents for one of three sampled residents (Resident A), when: 1. A Certified Nurse Assistant (CNA 1) who was not familiar with Resident A's inability to assist during repositioning, turned her to the side. This resulted in Resident A falling off of the bed onto the floor requiring an acute care hospitalization and surgical intervention for a fracture of the right hip and femur (thigh). 2. Two Physical Therapists (PT 1 and PT 2) providing bedside physical therapy, assisted Resident A to a sitting position at the edge of the bed, but failed to ensure the bed was locked. This resulted in Resident A sliding off of the bed onto the floor and sustaining a skin tear and hematoma (a solid swelling of clotted blood within the tissues) of the left leg stump (the pedicle remaining after removal of part of the limb). Findings: During the onsite visit Resident A was not at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FRUE11 Facility ID: CA240000018 If continuation sheet 2 of 8 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 01/04/2018 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 the facility. 1. A review of Resident A's face sheet (a record that provides the demographic data of the resident), indicated she was admitted to the facility on October 4, 2017, with diagnoses that included hypertension (high blood pressure) and a left below knee amputation (BKAacquired absence of an extremity) and readmitted on October 20, 2017, with an additional diagnosis of fracture of hip with surgical intervention. A review of the facility's incident log indicated that Resident A had a fall with a fracture on October 15, 2017, and a second fall with an injury on October 31, 2017. A review of Resident A's "SBAR/COC Assessment" (Situation, Background, Assessment and Request/Change of Condition) sheet dated October 15, 2017, indicated " ...9:35 PM. Resident being changed by staff. While turned towards the ® (right) side resident rolled off bed onto floor. 9:45 PM Loud noise heard. Staff/charge nurse ran to room with resident laying on floor in supine (face up) position. At this time assess patient with ® leg turned towards the right lower leg, blood at site of old wound ..." Resident A was transferred to the general acute care hospital (GACH 1) for further care and evaluation. A review of Resident A's SBAR/COC dated October 15, 2017, indicated under the section titled "Things that make the condition or symptom worse are: Assisted x 1, SR (side rails) not up x 2." On the same form under the section titled "Things that make the condition or symptom better are : x 2 assistance (two person assistance)." A review of Resident A's MDS (an assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FRUE11 Facility ID: CA240000018 If continuation sheet 3 of 8 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 01/04/2018 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 tool) dated October 10, 2017, reflected under section G (functional status) that she scored a "3/2" (extensive assistance/one person assist) for bed mobility, which indicated she was unable to turn over independently. Under the section G 0400 (functional limitation in range of motion), was listed a score of "1" for the lower extremity hip, knee, ankle, foot) which indicated impairment on one side. A review of Resident A's Interdisciplinary Team (IDT- clinical department heads meeting to discuss the incident) notes dated October 17, 2017, indicated "...CNA (CNA 1) stated she explained procedure to resident and when CNA (CNA 1) was ready to reposition resident facing towards the window, resident also swung right leg over towards window quickly, causing resident to roll off bed and fall to the floor. CNA (CNA 1) immediately called for assistance. Charge nurse responded by doing quick assessment due to staff noting bleeding from resident's right lower extremity with exposed bone..." A review of the history and physical reports from the general acute care hospital (GACH 1), dated October 15, 2017, indicated that Resident A had an x-ray of the right hip done, and it revealed a comminuted (a break in the bone into more than two fragments) intertrochanteric (upper thigh near hip) fracture of the right hip. A review of Resident A's GACH 1 reports titled "Consultation Notes" dated October 18, 2017, indicated that Resident A underwent an open reduction and internal fixation of right femur (a surgical procedure to the upper thigh) and post operatively Resident A suffered with complications which included hypotension (low blood pressure), she required a blood transfusion and had an acute kidney injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FRUE11 Facility ID: CA240000018 If continuation sheet 4 of 8 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 01/04/2018 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 a telephone interview with CNA 1, on December 5, 2017, at 1:15 PM, she stated while she was changing the Resident A's linens alone, Resident A turned to the left side very fast and fell over the two one quarter side rails. During an interview with CNA 2 on November 2, 2017, at 12:38 PM, she stated that Resident A was not able to help the staff with turning during daily care and always needed two staff to do the position change. An interview with the Director of Nurses (DON) and Administrator was conducted on November 2, 2017 at 12:58 PM. The Administrator stated that a new Certified Nurse Assistant (CNA 1) was changing Resident A's position alone, during Resident A's fall. She further stated that the bed side rails were not up during that time. During an interview with a Licensed Vocational Nurse (LVN 1) on November 2, 2017, at 1:55 PM, she stated that Resident A was heavy in stature (188 pounds) and was not able to help with daily care and position change by grabbing and holding on to the side rails. During an interview with Resident A's family member on November 2, 2017, at 3:02 PM, she stated her mother's (Resident A) one leg was a BKA and the other leg had no strength for her to use to turn by herself. A record of Resident A's fall risk assessment dated October 11, 2017 (four days prior to first fall), indicated Resident A's level mobility was 'immobile" and Resident A was identified as "low risk" for falls. A record review of Resident A's post fall risk assessment (after the first fall) dated October 17, 2017, indicated next to "Did the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FRUE11 Facility ID: CA240000018 If continuation sheet 5 of 8 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 01/04/2018 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 present to facility with fall, or has he/she fallen since admission (recent history of fall)" was documented as 'No" (even though Resident A had a fall two days prior). It further indicated that Resident A was at "low risk" for falls even though she had a prior fall. 2. A review of Resident A's SBAR/COC assessment report dated, October 31, 2017, under section "Nursing Notes" indicated "Resident was assisted by two therapists in sitting at the edge of the bed for the treatment. Resident (A) started to slide down from the edge of the bed and both therapists adjusted her position and lay her in supine position on the floor...Resident (A) presented with an injury at anterior (nearer the front) left stump 0.5 x 1.7 centimeter (cm-a unit of measurement) with scant bleeding and lateral left stump hematoma 4.4 x 4.2 cm". Resident A was transferred out to the GACH 1 for further evaluation. A review of Resident A's physician orders (during the readmission after the surgery following the first fall), dated October 22, 2017, indicated Resident A had an order for Physical Therapy/Occupational Therapy (PT/OT) evaluation and treatment daily, five times a week for four weeks to include therex (therapeutic exercises), theract (therapeutic activity), neuromuscular re-education (exercises to regain the skeleton-muscular strength), wheelchair management and training. During a review of Resident A's MDS (a resident assessment tool) Section G 0400 (a section that demonstrated the functional limitation in range of motion) dated October 27, 2017, indicated that Resident A had decreased her function and was scored as a "2" which indicated she had impairment of both lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FRUE11 Facility ID: CA240000018 If continuation sheet 6 of 8 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 01/04/2018 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 PT 1, on November 2, 2017, at 1:38 PM, he stated that he along with PT 2 assisted Resident A to sit at the edge of the bed. The PT 1 stated, Resident A had no gait belt (a device used by caregivers to transfer care receivers with mobility issues, from one position to another, from one location to another, or while assisting ambulating patients, who have problems with balance) on her during fall, which made them unable to hold the Resident properly while she was sliding down from bed. During a telephone interview with PT 2 on December 11, 2017, at 2:48 PM, her statement was in contradiction to PT 1's account of the incident. PT 2 stated, Resident A's fall was an unexpected fall and she was able to hold the resident by her gait belt. She further stated that she saw blood on Resident A's leg, but she did not know how it happened. During an interview with PT 2 on December 28, 2017, at 10:41 AM, she stated the bed was not in the locked position at the time of Resident A's fall. When inquired about the brakes on the bed being checked to ensure they were in the locked position prior to starting the therapy she stated, "I checked it. It wasn't moving without lock". A review of the Interdisciplinary Team Conference Notes dated November 1, 2017, indicated, "Resident sent to the hospital for further evaluation as safety precaution. Interventions upon return will be max assist x 2 (two persons) at all times, no edge of bed activity for therapy. Therapy to be in bed or wheelchair only. ID (identify) brakes are in lock [ed] position with color code to be done by [name of maintenance staff member]. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FRUE11 Facility ID: CA240000018 If continuation sheet 7 of 8 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 01/04/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: FRUE11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000018 (X5) COMPLETE DATE If continuation sheet 8 of 8