Other·May 17, 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: CA00567253 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 CA00567253

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge 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: SKDV11 Facility ID: CA240000018 If continuation sheet 1 of 9 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 02/27/2018 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 resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the physician of a change in condition after a fall for one of three sampled residents (Resident A) when: 1.A change in Resident A's neurological status (the ability of the peripheral and central nervous system to receive, process, and respond to internal and external stimuli) postFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 2 of 9 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 02/27/2018 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 fall was not reported to the physician. 2. A requirement for oxygen for Resident A was not reported to the physician in time. These failures resulted in Resident A not receiving further care related to the change in status and Resident A's condition continuing to deteriorate until she died 10 days later. Findings: An unannounced abbreviated survey was conducted on January 3, 2017, at 10:34 AM, to investigate a complaint on accidents. Resident A was not at the facility during the onsite. 1. During a record review of Resident A's "Face Sheet" (a record that provides the demographic data of the resident) indicated that Resident A was a 85-year-old female who was admitted to the facility on July 11, 2016. Her diagnoses included muscle weakness, and dementia (a wide range of symptoms associated with a decline in memory and other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Resident A's "SBAR/COC Assessment" (Situation Background Assessment Request /Change of Condition-a record that provides the information of a change of condition) dated July 11, 2017 was conducted. Resident was non-verbal and unable to make needs known...noted purplish discoloration on left temporal (the sides of the skull behind the eye) redness on left shoulder and left hip ...Resident is transferred to ER [Emergency Room] for further evaluation". A review of Resident A's general acute care hospital (GACH) radiology (x-ray) reports dated July 11, 2017, was conducted. The report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 3 of 9 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 02/27/2018 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 indicated Resident A had a CT (computerized tomography scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body) scan of the head. In addition, x-rays of her left shoulder, left hip and her head were done. The x-ray report of the left hip, indicated that Resident sustained a subcapital fracture (fracture line extends through the junction of the head and neck of femur) of the left hip. A review of Resident A's CT scan of the head report dated July 11, 2017, indicated Resident A had a "Large scalp hematoma (a solid swelling of clotted blood within the tissues) on the left". A review of Resident A's discharge instructions from the GACH dated July 11, 2017, indicated " ...it is important to observe the patient [resident] for any problems developed from the head trauma ...Please return to the ER immediately if patient develops any change in mentation (thinking or any work of the mind) or for any medical concerns." This document was reviewed with the Director of Nurses (DON) on February 23, 2018 at 9:56 AM. A review of Resident A's "Neurological Flowsheet" (a document which tracks data related to changes in pupil size, blood pressure, pulse, respirations, temperature, speech, level of consciousness and movement in extremities) dated July 11, 2017 at 4 PM through July 14, 2017 at 10 PM, was conducted. The data indicated that Resident A had a change in her bilateral (both) pupil reactions starting on July 13, 2017, at 10 AM (51 hours post-fall). The reaction changed from "brisk" (the normal pupil constricts briskly) reaction to "sluggish" (very slow reaction to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 4 of 9 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 02/27/2018 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 light. A sluggish pupil may be an early focal sign (impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg, or numbness) of an expanding intracranial (within the skull) lesion and increased intracranial pressure). Further review of Residents A's "Neurological Flowsheet" indicated under the "Instructions" "The Licensed Nurse will complete the neurological flow sheet for any un-witnessed fall, or witnessed fall with suspected or known head injury for seventy- two (72) hours following the fall. The Attending Physician will be informed if there is a deviation from the resident's normal status for further instruction." During an interview with DON on February 23, 2018, at 9:56 AM, she confirmed that the facility was unable to provide any documented evidence to show that Resident A's change in neurological condition was reported to the attending physician. During a telephone interview with Licensed Vocational Nurse (LVN 1) on January 17, 2018, at 12:34 PM, she stated that she was required to notify the physician if there was any change in Resident A's neurological status. She further stated that she reviewed Resident A's neurological assessment sheet and that it was a documentation error, however, the Neurological Assessment sheet indicated that other licensed nurses on various shifts had documented (who were not employed at the facility during the investigation) that Residents A's pupils reaction remained sluggish, confirming the change in condition. There was no documented evidence that any of the licensed nurses reported this change of condition to Resident A's physician. A review of Resident A's "ADL Flowsheet" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 5 of 9 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 02/27/2018 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 (ADL-activity of daily living) for the month of July 2017, indicated that Resident A deteriorated in her meal intake to consuming less than 50 % of her meals on average from July 11, 2017 (the day of fall), compared to her pre-fall intake average of 90 %. It further indicated that from July 18 through July 21, 2017(the day of her death) her intake was reduced to one meal with 10% consumption. A record review of the Nursing Progress Notes dated July 18, 2017 (7 days after the reduced oral intake), reflected Resident A's attending physician was notified of the reduced oral intake for which he ordered a swallow evaluation. During an interview with the DON on February 23, 2018, at 1:35 PM, she stated that she reviewed Resident A's clinical record and there is no documented evidence of a swallow evaluation being done on Resident A. During an interview with a Certified Nurse Assistant 1 (CNA 1) on February 6, 2018, at 12:15 PM, she stated that she took care of Resident 1 after the resident returned from the GACH (post-fall). She further stated that Resident 1 was not eating and not responding the way she used to be prior to the fall. CNA 1 stated the she reported Resident A's decline in eating status to the assigned Licensed Vocational Nurse (LVN). There was no nursing documentation between July 21, 2017 at 10:25 PM and July 22, 11:08 AM, when the nursing progress note indicated, "Resident body picked up by [Name of the morgue] Mortuary at approximately 8:35 AM ..." There was no documented evidence of the resident's status or the circumstances under which Resident A was found to have expired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 6 of 9 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 02/27/2018 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 LVN 2 on February 26, 2018, at 8:55 AM, she stated that she took care of Resident A on the night shift (11 PM to 7 AM) when she (Resident A) died (July 22, 2017). LVN 2 further stated that Resident A was dependent for all care and was on supplemental oxygen continuously at the time of her death. LVN 2 stated that Resident A's family was aware that the resident was dying. When inquired about the documentation she stated that she could not recall whether she documented all of this information or not. A review of the nursing progress notes for July11, 2017 through July 22, 2017 was conducted. There was no documented evidence that the family had been informed that Resident A was actively dying. The last documented notification of the family was dated July 21, 2017 at 4:13 PM, when they were notified that Resident A had refused both her breakfast, lunch and was being monitored. A review of the facility policy and procedure titled, "Fall Management Program," undated, indicated that "Post-fall response ...B. The Licensed Nurse will complete the neurological flowsheet ...c. The Attending Physician will be informed if there is a deviation from the resident's normal status for further instruction." A review of the facility policy and procedure titled "Change of Condition Notification" undated, indicated "The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: ... B. A significant change in the resident's physical, mental or psychosocial status ..." This policy was reviewed with DON on February 23, 2018 at 9:56 AM, and she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 7 of 9 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 02/27/2018 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 stated that the staff were required to follow this policy. 2. A review of Resident A's Nursing Progress Notes dated July 20, 2017, at 9:44 PM, indicated that Resident A was provided with 2 liters per minute (liter- a unit of measurement for oxygen administration) oxygen via nasal cannula (a device used to deliver supplemental oxygen). Resident A's clinical notes did not indicate the indication for supplemental oxygen and the condition of Resident A at that time. There was no documented evidence that the physician had been notified of a change in Resident A's respiratory status. (The staff who administered the supplemental oxygen was no longer an employee at the facility during onsite visit) During an interview with the LVN 1, on January 3, 2018, at 1:15 PM, she reviewed the chart and stated that she could not find a physician's order for oxygen administration in Resident A's clinical record. LVN 1 stated that staff were allowed to initiate supplemental oxygen on a resident in an emergency but were required to obtain the physician's order as early as possible. She further stated that obtaining the physician's order on the next day is not an acceptable practice at the facility. A review of Resident A's physician order dated July 21, 2017, indicated that Resident A was to have oxygen administered at 2 liter per minute per nasal cannula to keep her oxygen saturation levels above 92% (normal pulse oximeter readings usually range from 95 to 100 percent). During an interview with a Registered Nurse (RN 1) on January 3, 2018, at 1:30 PM, she stated that during an emergency staff were allowed to administer oxygen to the residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 8 of 9 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 02/27/2018 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 without a physician order but were required to get an order as early as possible. She further stated that obtaining the order on the next day is not an acceptable practice. The facility was unable to provide any documentation to explain the need to administer oxygen to Resident A, or Resident A's response or lack of response to the oxygen administration. A review of the facility policy and procedure titled "Oxygen Therapy" undated indicated that "A. Administer oxygen per physician orders". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SKDV11 Facility ID: CA240000018 If continuation sheet 9 of 9