Other·August 1, 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 an abbreviated standard survey to investigate a facility reported incident. FRI number: CA00585877 Linked with complaint number: CA00586460 Representing the California Department of Public Health: Surveyor: 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 the intake number CA00585877 and one deficiency was issued for intake number CA00586460.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 07/12/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve 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: CRN411 Facility ID: CA240000029 If continuation sheet 1 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure the necessary hygienic care and report an alleged allegation of neglect to the State Survey Agency on one of three sampled residents (Resident 1). This failure had the potential to jeopardize the protection, health and safety of Resident 1. An unannounced onsite visit was conducted on May 11, 2018 to investigate a complaint on resident abuse. Resident 1 was not at the facility during the visit. Findings: During an interview with Director of Nurses (DON) on May 11, 2018, at 8:45 AM, when asked about any alleged incident with Resident 1 about "on a cold day, left him on a bed, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 2 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 naked, soiled diaper on". DON stated she heard about that incident. She further stated that Resident 1's wife reported it to Director of Staff Development (DSD), and the she took care of it. During an interview with DSD on May 14, 2018, at 3:19 PM, she stated Resident 1's wife came to her and reported that her husband (Resident 1) was found eating directly on top of the bed with no sheets. Resident 1 was sitting in bed with a soiled diaper and with no clothing on April 30, 2018, at 8:15 AM. The DSD stated that she investigated the allegation and the Certified Nurse Assistant 1 (CNA 1) assigned to care for Resident 1 was sent home early pending results of the investigations. DSD discussed the incident with CNA1, and asked to sign the statement of allegation however, CNA 1 refused to sign. DSD stated the allegation of neglect was never reported to the State Agency (SA). During an interview with the DON, on May 14, 2018, at 3:30 PM, she stated that the facility had a discussion with Resident 1's wife, regarding the incident. The DON stated that CNA 1 stated that Resident 1 refused to change his sheets. Upon request for documented evidence of refusal, she stated she did not have any. During a telephone interview with CNA 1 on May 14, 2018, at 4:32 PM, he stated that he went to Resident 1's room around 8:50 AM on April 30, 2018, and saw Resident 1's wife was taking pictures of him. He further stated Resident 1 was eating breakfast in bed with no sheets, no clothes on and was wearing only a diaper. CNA 1 stated that he did not get report at the beginning of the shift and did not know who was taking care of him prior to his arrival. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 3 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 Licensed Vocational Nurse 3 (LVN 3) on May 14, 2018, at 3:44 PM, she stated that Resident 1 was under her assignment on the alleged event day and she was not aware of the event. She further reviewed Resident 1's care plan for refusal of care, but could not find any. Attempted to call Resident 1's wife multiple times on June 13, 2018 and was not able to contact her. During an interview with DSD and Administrator on June 12, 2018, at 1:42 PM, DSD stated the facility follows the following guidelines for reporting incidents: "State and Federal Mandated Reporting Guidelines in Long-Term Care Facilities", indicated as follows: " ...Neglect ...2. The failure to assist in personal hygiene, or in the provision of food, clothing or shelter ..." "Elder Justice Act (EJA) (Skilled Nursing Facilities- Federal Law" indicated as follows: " ...The EJA establishes two time-limits for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event. Event that result in serious bodily injury shall be reported immediately, but not later than 2 (two) hours after forming the suspicion, and all other reports within 24 hours ..."

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 07/12/2018 Facility ID: CA240000029 If continuation sheet 4 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure adequate monitoring for one of three sampled residents (Resident 1), when Resident 1 was found unconscious under direct sunlight, with abnormal vital signs and multiple blisters on his body. This failure resulted in Resident 1 requiring an acute care hospitalization for second-degree burns due to heat exposure. An unannounced onsite visit was conducted on May 8, 2018, at 1:06 PM, to investigate a facility reported incident on resident abuse and neglect. Resident 1 was hospitalized at the acute care hospital (GACH 2) during the onsite visit for second- degree skin burns (also called as partial thickness burn that may include blistering, indicating damage has been done to the underlying layers of skin). Findings: A record review of Resident 1's "face sheet" (a record that provides the demographic data of the resident) indicated, an elderly resident who was admitted to the facility on May 6, 2014, with diagnoses that included dementia (a general term for loss of memory and other mental abilities severe enough to interfere with activities of daily life) and hypertension (high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 5 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 blood pressure). A review of Resident 1's "Transfer to Hospital Note" dated May 5, 2018, indicated, "Resident was found outside at 3:50 PM, during change of shift. CNA reported to charge nurse resident was unconscious with labored breathing. VS [Vital Signs] 178/128 [Blood Pressure], 30, 28 ,102.0 O2 sat 51%. Oxygen administered, brought the O2 up to 62% pt. [Resident 1] still unconscious but breathing. Paramedics called. Sent to GACH 1[Name of the hospital]..." During an interview with Licensed Vocational Nurse 1 (LVN 1) on May 8, 2018, at 3:28 PM, she stated the assigned CNA 1 (CNA 1) for Resident 1 left his shift early without notifying her. She stated that she did not notify the Chain of Command (COC) when she realized that CNA 1 left the facility prior to the end of the shift. She stated that she assigned the run to another CNA 2 (CNA 2) to cover for CNA 1's residents, however she did not give any specific instructions or care needs of the patients whom she has to give care for. During a telephone interview with CNA 1, on May 14, 2018, at 4:32 PM, he stated that he had an emergency on May 5, 2018, that required for him to leave the shift early. He stated that he notified the Director of Staff Development (DSD) via text and the DSD did not approve the request. He stated he further notified his chain of command (LVN 1) about the refusal from DSD and his need to leave early. He stated he left around 1:30 PM on May 5, 2018. During an interview with CNA 2 on May 8, 2018, at 3:17 PM, she stated that she was busy with other residents' linen change and by the time she was done caring for them it was already change of shift. She further stated that, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 6 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 LVN 1 did not tell her what were the care needs of the residents for whom she had to care for. During an interview with the CNA 3 on May 9, 2018, at 3:30 PM, she stated that she was looking for her residents after her change of shift around 3:45 PM. CNA 3 said she accidentally found Resident 1 sitting on a chair, leaning to right side in direct sun light, at the back patio. She further stated that she found him unresponsive to call or shake, drooling and he was very hot. After she notified LVN 2, with the help of another staff member, she transported Resident 1 to the front nursing station in a wheel chair. During an interview with LVN 2, on May 8, 2018, at 3:45 PM, she stated after the change of shift around 3:45 PM, CNA 3 found Resident 1 sitting on a chair, at the back patio, unresponsive. When CNA 3 brought Resident 1 in, he was unresponsive, drooling, had labored breathing, with a 102 degree Fahrenheit body temperature, his skin was red and was very hot to touch. She stated she called 911 (emergency medical service) to transport the resident to the nearest hospital. Through multiple interviews with the staff members working on the alleged event day and time, it indicated that the last time Resident was observed was around 1:30 PM on May 16, 2018. A review of Resident 1's Emergency Department (ED) records from the General Acute Care Hospital 1 (GACH 1), indicated that Resident 1 was transported at GACH 1 on May 5, 2018, at 5:05 PM with altered level of consciousness, acute heat stroke and multiple areas of second degree burns. Further review of the ED records, indicated that after providing the emergency medical interventions, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 7 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 1 was transferred to GACH 2 on May 5, 2018, at 6:16 PM in "serious" condition to seek for further medical interventions. A review of ED records from GACH 2, indicated that Resident 1 was admitted to GACH 2 on May 5, 2018 (did not indicate time), with " ...core temperature of 104 F, second degree burns over abdomen and arms and <5% of surface area and blisters on his head ..." At GACH 2, Resident 1 was diagnosed with "heat stroke, leukocytosis (increased amount of white blood cells in the blood that is frequently a sign of an inflammatory response, most commonly the result of infection) and AKI (acute kidney injury) /Rhabdomyolysis (is a serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal (kidney) failure) " and was treated extensively with IV fluids, supportive care and wound care. A review of Resident 1's wound care consult record at GACH 2, dated May 6, 2018, indicated skin/ wound condition as follows: I. Top of head has large Bullae (a fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin and also called blister), 8x7 cm, II. Lt. Parietal area (upper central scalp) with large bullae 3x3x2 cm, III. Central frontal area has 2 open areas with epidermal (top layer of the skin) loss and pink/red tissue exposed. The area is 2.5x5 cm. Area is weeping serous fluid. There is also periwound blistering still 6x6 cm, IV. Lt. eye lid has a denuded (swollen) area 2x2 cm. Both eyelid and face are edematous, (swollen) V. Lt. Lateral neck has a small intact blister 1x1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 8 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 cm in skin fold area, VI. Lt. hand has large bullae already partially broke and open. Bullae extends on the dorsal (back) hand from metacarpal (bones of the hands and fingers) area to above the wrist, 17x10 cm, VII. Abdomen has multiple bullae and some open partial thickness areas. Total area is 23x20 cm, VIII. Left dorsal foot has two open blisters each 2x2 cm dry, IX. Rt. Shin has intact blisters 17cm x 6 cm, X. Rt. Dorsal foot: bullae with partial thickness opening, pink/red tissue. Area 3.5x6.8cm. A review of Resident 1's "Brief Interview for Mental Status" (BIMS- an assessment tool for mental status and cognitive level) dated February 17, 2018, under section 'C 1000.Cognitive skills for Daily Decision Making" indicated that his score was "3" (severely impaired- never or rarely made decisions). A review of Resident 1's "Care Plan" initiated on March 28, 2016 and revised on September 23, 2016, indicated that Resident 1 " ...is a wander risk r/t impaired safety awareness, disoriented to place." During an interview, and record review with the DON on May 11, 2018 at 8:45 AM, she stated that Resident 1 was admitted to the facility prior to her employment with the facility. She further stated she was unable to find documented evidence that the risk of wandering assessment was done on Resident 1, during his stay at the facility. During an interview with the DSD on May 9, 2018, at 2:54 PM, she stated the LVN had the responsibility to notify the COC when a CNA leaves prior to the end of shift without permission. She further stated LVN 1 did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 9 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 notify her when CNA 1 left early. During an interview with the DON on May 9, 2018, at 3:00 PM, she stated, " if the CNA 1 [CNA 1] had not left the shift early, this incident would not have been happened ." A review of the facility policy and procedure titled, "Wandering, Unsafe Resident", revised on November 2010, indicated " ...6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior ..." On May 9, 2018, at 4:09 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 Director of Nurses (DON) and Regional Nurse Consultant (RNC) for inadequate monitoring and supervision. The DON and the RNC were verbally notified of the IJ situation identified based on the facility's failure to ensure adequate monitoring for Resident 1, who has a history of wandering. On May 5, 2018, around 3:45 PM, Resident 1 was found at the back patio, under direct sunlight, unconscious, with unstable vital signs and required an acute care hospitalization. The acute care hospital identified him with multiple second-degree burns due to exposure to the sunlight. The facility was notified that this failure had a potential to endanger a universe of 58 resident's health and safety. The corrective action plan provided by the facility indicated as: "PLAN OF CORRECTION 1. HOW CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 10 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE The Resident was found to be unresponsive and immediately taken to the closest Emergency Room via Ambulance. CDPH, Ombudsman, and the San Bernardino County Sheriff's office was contacted to notify of the incident as soon as Mill Creek Manor was aware of the severity of the incident. The staff (CNA and LVN) that was assigned to this resident were placed on suspension pending investigation and if found to have deficient practices that resulted in the resident's injuries will be terminated from employment with Mill Creek Manor. 2. HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN. Each resident will be identified on admission and quarterly for an elopement risk score with an assessment. The score will assist in determining the level of care to be provided to the resident for wandering and elopement risk. All residents will be placed on hourly monitoring and the CNA staff will keep a log of the monitoring that is being used. At the end of each shift the LVN assigned will ensure the monitoring is complete and placed in the log binder at the nurse's station. The log will address for each CNA the resident's location, It is the CNAs responsibility to alert the LVN or Charge Nurse on duty if the resident is noted to be changed from the resident's baseline status. A manager on duty program will be implemented to ensure that resident safety is maintained on weekends. The Manager on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 11 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 duty every weekend will assist the DSD and DON to maintain proper staffing and safety for all residents by performing safety checks every 2 hours and will be part of MOD duties. A huddle will be called by the Charge Nurse at the beginning of each shift to verify resident assignments, resident concerns being addressed, and CNA shift duties are assigned. When a change in staffing occurs for any reason scheduled or unscheduled change the Charge Nurse will call a huddle immediately and redistribute the resident load. The CNA and LVN staffing will be maintained by the staffing ladder to ensure the facility meets PPD Each Day in accordance with Title 22. If CNA staffing is short for any reason the facility will utilize overtime coverage with current staff members, a Per Diem/ On call CNA pool, staff from facilities under the same corporation, and registries. The Charge Nurse LVN will be instructed per Policy and Procedure to redistribute the assignment with the staff available in the building of Certified CNAs. The certified CNAs can be utilized from the RNA and activities programs to ensure resident safety during a shift if an unscheduled down staffing occurs. The Charge Nurse will be required to notify the DSD (or Manager on Duty if the DSD is unavailable) at any time a CNA leaves a shift without prior approval from the DSD, DON, or Administrator. The Charge Nurse is not to determine if a CNA can leave early from shift without permission from the DSD (or designated Manager on Duty). The DSD (or designated Manager on Duty) will determine ability of an approved down staffing prior to approval being given to the CNA by the Charge Nurse. The CNA staff are to receive assignments for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 12 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 shift and start the rounding procedure to account for all assigned residents. Any time a change of assignment occurs the CNA will be given the assignment and complete a walking round to account for all residents. The LVN staff on shift will be responsible to do a walking round for change of shift hand off to account for all residents and receive a report from the nurse leaving shift. If at any time a resident is found not accounted for and is not found by staff during rounds. A huddle will be called and on Duty Manager will be notified of the missing resident. In the huddle a staff member will be assigned to each area of the building for a safety search until the resident is accounted for. All clinical staff and management staff will be in serviced on the policy and procedures for: Hourly Rounding, Staff Assignments for start of shift and down staffing, Start of shift hand off and walking rounds report. 3. WHAT MEASURES WILL BE PUT INTO PLACE OR WHAT SYSTEMIC CHANGES THE FACILITY WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR The policy and procedure for down staffing or the change in assignments will be provided to all staff members. All hourly rounding logs will be verified with the DON and DSD. The Charge Nurses will be held accountable for ensuring the safety of each resident is monitored for their shift. The charge nurse will notify the DSD/DON for assistance when needed with the assignment. All staff will receive an in-service on the policy and procedures being implemented on and the Inservices will start on 05/9/2018 and complete on 05/11/2018 by end of day. An in-service FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 13 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 has been provided to all clinical staff on Tuesday May 8, 2018 in regard to Plan of Correction for Hot weather and Dehydration Evaluation. At start of first shift scheduled with the staff members on LOA or unavailable for inservice on the dates originally provided all POC in services will include dehydration evaluations, hydration measures, hot weather procedures, Hourly Rounding, Staff Assignments for start of shift and down staffing, Start of shift hand off and walking rounds report. All staff members are contacted during the in-service time frame of 05/09/2018 to 05/11/2018 to be made aware of the in-service compliance requirements prior to start of next scheduled shift or at start of next scheduled shift. The in-services will be provided annually to all staff and as part of the initial policy and procedure education upon hire. 4. HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED. THE FACILITY MUST DEVELOP A PLAN FOR ENSURING THAT CORRECTION IS ACHIEVED AND SUSTAINED, THIS PLAN MUST BE IMPLEMENTED, AND THE CORRECTIVE ACTION EVALUATED FOR ITS EFFECTIVENESS. THEN POC MUST BE INTEGRATED INTO THE QUALITY ASSURANCE SYSTEM This process will be discussed in the QA and QAPI meeting monthly. The QA will meet and ensure 100% completion of the logs for compliance with safety checks through 90 days from start of implementation. Every shift will be monitored for compliance with the facility daily audit process. After the 90 day compliance is met the QA team will monitor to ensure compliance is maintained every month. Each 24 hours will ensure that the PPD was met daily and assignments maintained. The PPD and staffing assignment will be discussed by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 14 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 DON/DSD in each morning meeting throughout the week." The corrective action plan was reviewed and accepted on May 11, 2018, at 4:20 PM. But based on observation, interview, and record review, the facility was found to be in noncompliance with the corrective action plan to remove the potential for harm. The following were conducted: 1. During an observation and review of the facility hourly monitoring check log was done on May 11, 2018, at 9:46 AM, it was observed that CNA 4, was doing hourly monitoring rounds. A concurrent record review was done on hourly rounding log with CNA 4. The review indicated that the hourly checking log was not filled out from May 11, 2018, at 7:00 AM. A concurrent interview with CNA 1 stated that the hourly monitoring check list was handed over to her at that time. When inquired whether she received in-services on hourly monitoring, she stated she received the in-services recently. 2. An observation of CNA's hourly rounding and concurrent record review of the hourly rounding check list was done on May 11, 2018, at 2:30 PM. Review of the hourly rounding sheets indicated that one out of three check in sheets was documented completely through 2:45 PM (Next scheduled time after 2 PM was 2:45 PM). During an interview with RNC, on May 11, 2018, at 2:32 PM, she reviewed the record and stated, documenting ahead of time is not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 15 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 accepted. 3. On May 11, 2018, at 3:06 PM, it was observed that three CNAs and two LVN's were standing at the nurse's station and giving hand off report to the next shift. The staff were not observed to do walking rounds during the change of shift. 4. On May 11, 2018, at 3:11 PM, CNA 2, was observed to be leaving the facility with her bags. When asked she stated she was going home after her shift duty (7 AM- 3 PM). When asked whom did she give report to on the next shift (3 PM-11 PM), she stated she did not give report to anybody and she did not know who was coming to take over her residents for the next shift. A record review of the assignment sheet was conducted with LVN 4 and RN 1, on May 11, 2018, at 3:18 PM, which indicated the assignment sheet was incomplete. LVN 4 stated that it was the LVN's responsibility to complete the assignment sheet prior to the shift change. 5. During an interview with CNA 4, on May 11, 2018, at 3:20 PM, she stated that she did not do the walking rounds during the change of shift. She acknowledged that she received many in-services recently. When asked if the walking rounds were included in the inservices, she did not answer. After observations, interviews, and record reviews to confirm the corrective action plan had been implemented conducted the IJ was abated on May 14, 2018, at 5:11 PM, in the presence of the Administrator, DON, RNC, Director of Clinical Operations 1(DCP 1) and RN 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CRN411 Facility ID: CA240000029 If continuation sheet 16 of 17 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 06/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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: CRN411 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000029 (X5) COMPLETE DATE If continuation sheet 17 of 17