Other·October 10, 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 complaint. Complaint Number: CA00576878 Representing the California Department of Public Health: 38480 The inspection was limited to the complaint number investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint number CA00576878

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 10/19/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. 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: SMNU11 Facility ID: CA240000047 If continuation sheet 1 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to honor the request of one of three sampled residents (Resident A) by not following the Physicians Orders for Life Sustaining Treatment (POLST) and performing cardiopulmonary resuscitation (CPRemergency intervention to re-start respiration and heart). This failure resulted in Resident A receiving unwanted CPR for 15 minutes while in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 2 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 skilled nursing facility. Findings: During a review of the clinical record for Resident A, the Admission Record (demographics) dated March 7, 2018 indicated Resident A was admitted to the facility on April 16, 2017 with diagnoses including heart failure (heart not pumping blood adequately), acute respiratory failure with hypoxia (breathing stopping suddenly and lack of oxygen), and chronic kidney disease (failure of the kidneys to flush toxins out of the body). During a review of the clinical record for Resident A, the POLST dated July 20, 2017, and signed by Resident A's daughter and the Attending Physician on July 20, 2017, indicated under section A...Cardiopulmonary Resuscitation (CPR): If patient has no pulse and is not breathing. Do Not Attempt Resuscitation/DNR (Allow Natural Death). During a phone interview with Resident A's daughter on April 16, 2018 at 5:15 PM, she stated she was called by the skilled nursing facility and was told CPR had been performed on her father and he was transferred to the [name of hospital] local hospital. Resident A's daughter stated she asked the facility why was CPR started on her father since she signed the POLST for a Do Not Resuscitate (DNR) on July 20, 2017. The daughter stated she was not given an answer by the facility. During an interview with the Registered Nurse Supervisor 2 (RNS 2) on April 18, 2018 at 1:00 PM, she stated she found Resident A unresponsive with no pulse, no blood pressure, and no respiration on February 27, 2018 at 11:10 AM. RNS 2 stated she initiated CPR without checking Resident A's chart for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 3 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 POLST. During a review of the clinical record for Resident A, the Emergency Medical Service (EMS-the fire department paramedics) dated February 27, 2018 at 11:05 AM, indicated Resident A received CPR from the skilled nursing facility for 15 minutes prior to EMS arriving. Resident A received an additional 30 minutes of CPR before transferring Resident A to the [name of hospital] local acute hospital.

F684 SS=G Quality of Care CFR(s): 483.25

F684 10/19/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interviews and record review, the facility failed to ensure the physician orders were followed for one of three residents (Resident A) who was to be transferred to the acute care hospital as ordered, due to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 4 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 abnormal laboratory values and increased confusion following a fall. This failure resulted in a delay of treatment and for Resident A to receive cardiopulmonary resuscitation (CPR- chest compressions and artificial breathing when a heart and breathing stops) against his Advanced Directives (written directions on what to do in a life threatening emergency). Resident A was pronounced dead at the emergency room (one day after the physician ordered him to be transferred). Findings: During a review of the clinical record for Resident A, the Admission Record (demographics), dated April 16, 2017, indicated, Resident A was admitted to the facility with diagnoses including heart failure (heart not pumping blood adequately), hyperkalemia (high potassium), diabetes (unstable blood sugar), and Alzheimer's Disease (a brain disorder affecting memory). During a review of the clinical record for Resident A, the progress notes dated February 25, 2018 at 6:48 AM, indicated, "Resident was alert with periods of confusion, resident kept crawling out of his bed this shift. Mattress placed on the floor. Resident blood sugars were within normal limits. VS (vital signs) temperature (T) 98 degrees Fahrenheit (normal 97.1-98.6), pulse (P) 76 (normal 60-100 beats per minute), respiration (R) 18 (normal 12-20 breaths per minute), blood pressure (B/P)108/68 (normal 120/80)." During a review of the nurses notes dated February 25, 2018 at 2:47 PM, Resident A was being transferred back to bed from his wheelchair by one Certified Nursing Assistant (CNA 1) when Resident A leaned forward in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 5 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 wheelchair and fell onto the mattress pad on the floor hitting his forehead. The nurses progress notes further indicated Resident A complained of pain and dizziness. During a review of Resident A's nurses progress note dated February 26, 2018 at 3:01 AM, indicated Resident A had increased confusion after sustaining the fall on February 25, 2018 at 2:47 PM. VS= T 96.2, P 66, R 20, B/P 118/50. "Urine collected. Resident will have x-ray of the skull and labs to be done [as ordered by the physician]." During a review of Resident A's nurses progress notes dated February 26, 2018 at 7:52 AM, indicate, "May have mattress on floor for safety precautions. Patient has been continuously rolling or getting out of bed onto the mat on the floor. Per MD (physician) order, place the mattress on the floor for safety precautions." A review of Resident A's Interdisciplinary Team Note (IDT- comprised of clinical staff) dated February 26, 2018 at 4:12 PM, indicated Resident A was alert with confusion. Has history of falls and at risk for further falls due to impaired cognition and noncompliance with care. DX of htn (high blood pressure), dm (diabetes-unstable blood sugar), pulmonary disease (impaired gas exchange in the lungs) and other co-morbidities. Resident [A] experienced a fall from bed. CNA reported to charge nurse during transfer, Resident A fell forward to the floor and landing and bumping his head on the floor mat next to his bed. Charge nurse assessed Resident [A] and noted a small red bump to the forehead. MD notified with no new orders. Recommendations: Monitor for COC (change of condition) for 3 days, 72 hour neuro check (a neurological check for pupil reaction and ability to move FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 6 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 extremities to command), ensure bed in lowest position, floor mat in place. Daughter notified and is in agreement with POC (plan of care). Resident is at risk for further falls due to weakness, impaired condition, poor safety awareness and poor impulse control. During a review of the clinical record for Resident A the nurses progress notes dated February 26, 2018 at 7:31 PM, indicated the physician was contacted (29 hours after Resident A fell) to give the results of a critical lab value ordered. An order was obtained to transfer Resident A to [name of the hospital] for an elevated BUN of 82 (blood, urea, and nitrogen level. Normal BUN is 10-26) for evaluation and treatment ASAP (as soon as possible). However, the nurses note indicated when the Registered Nurse Supervisor (RNS 1) called the [name of hospital] and the RNS 1 informed the supervisor at the [name of hospital] the admission was to be a direct admit and she "will call back to follow up for bed via direct admit and will set up transportation once confirmed." During a review of the clinical record for Resident A, the nurses progress notes dated February 27, 2018 at 11:10 AM, indicated Resident A was found non responsive, pupils were fixed and dilated, and the nurses were unable to obtain a heart sound or blood pressure. No respirations were noted. The skin was warm to touch and a Code Blue (staff are called immediately to start CPR) was initiated. During a phone interview with the attending physician on April 16, 2018 at 5:00 PM, he stated he gave a telephone order to transfer Resident A to [name of the hospital] and if there were no beds available to transfer Resident A to the nearest hospital as soon as possible (ASAP). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 7 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 the Registered Nurse Supervisor (RNS 1) on April 18, 2018 at 12:45 PM, she stated she received a critical laboratory result for Resident A for the BUN level on February 26, 2018 at 7 PM. RNS 1 stated she contacted the physician and gave the physician the BUN result. RNS 1 stated she took a telephone order to transfer Resident A to [name of hospital] as soon as possible (ASAP) for further evaluation regarding the critical lab results. RNS 1 stated she did not write a telephone order to transfer Resident A to the hospital as soon as possible (ASAP), but wrote an order to transfer Resident A to [name of hospital] as a direct admit and further stated she has never written a order ASAP. RNS 1 stated she did not call the physician back to notify him there was no bed available at the [name of hospital]. RNS 1 stated she was told by the supervisor of [name of the hospital] to fax orders to the [name of the hospital] indicating Resident A was to be transferred when a bed was available as a direct admit. When asked for the policy not to document an order to be carried out "ASAP" she was unable to provide a policy. A review of the facility policy and procedure titled, "Telephone Orders" dated revised February 2014, indicated under "Policy Interpretation and Implementation...2 The entry must contain the instructions from the physician, date, time and the signature of the person transcribing the information During an interview and concurrent record review with RNS 2 on April 18, 2018 at 12:50 PM, she stated the evening and night shift staff did not follow up with the [name of the hospital] or notify the physician the [name of the hospital] had no beds available. She reviewed the clinical record for Resident A and was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 8 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 unable to find documentation that there had been follow up by the other shifts to check for bed availability. The facility policy and procedure titled, "Change in a Residents Condition Status" dated December 2016, under the section titled: "Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an) ...d. significant change in the resident's physical/emotional/mental condition..." During a review of the clinical record for Resident A, the Physician's Order for Life Sustaining Treatment (POLST) dated July 20, 2017, indicated Resident A was "Do Not Attempt to Resuscitation/DNR" for CPR. During an interview with RNS 2 on April 18, 2018 at 1:00 PM she reviewed the clinical record, the "POLST"and her nurse's notes dated February 27, 2018 at 11:10 AM, and stated she did CPR without checking Resident A's POLST/DNR status. Resident A was taken to the emergency room and was pronounced dead on February 27, 2018 at 12:12 PM. A review of the death certificate indicated the cause of death to be "acute respiratory failure minutes; chronic obstructive pulmonary disease-months." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 9 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/19/2018 §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 prevent one of three sampled residents (Resident A) from falling when a certified nursing assistant (CNA) was not informed Resident A required two persons to transfer him. This failure resulted in Resident A falling from the wheelchair, hitting his forehead, sustaining a raised area on the forehead and having increased confusion and dizziness. Findings: An unannounced visit was made to the facility on March 3, 2018 at 10:30 AM, to investigate a complaint regarding Resident A having a fall with a head injury. During review of the clinical record, the Admission Record (demographics) dated March 7, 2018, indicated Resident A was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 10 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 admitted to the facility on April 16, 2017, with diagnoses including heart failure (heart not pumping blood adequately), acute respiratory failure with hypoxia (breathing stopped suddenly and lack of oxygen), and chronic kidney disease (failure of the kidney to flush toxins out of the body). During a review of the clinical record the progress notes dated February 25, 2018 at 6:48 AM, indicated Resident A "kept crawling out of his bed onto the mat. Mattress was placed on the floor." Resident A "is alert with periods of confusion." During a review of the clinical record the progress notes for Resident A dated February 25, 2018 at 2:47 PM, indicated Resident A was being transferred from the wheelchair to bed when he leaned forward and fell and hit his head on the mat placed on the floor. Resident A complained of pain and dizziness. During a review of Resident A's nurses progress note dated February 26, 2018 at 3:01 AM, indicated Resident A had increased confusion after sustaining the fall on February 25, 2018 at 2:47 PM. "VS= T (temperature) 96.2, P (pulse) 66, R (respirations) 20, B/P (blood pressure) 118/50... Urine collected. Resident will have x-ray of the skull and labs to be done " During a review of the clinical record, the progress note dated February 26, 2018 at 7:52 AM, indicated Resident A had been continuously rolling or getting out of bed onto the mat on the floor. During a phone interview with a Registered Nurse 1 (RN 1) on April 12, 2018 at 4:00 PM, he stated he did not give a report regarding Resident A's care to the Certified Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 11 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 Assistant 1 (CNA 1) assigned to Resident A on February 25, 2018. RN 1 stated he did not assess Resident A after Resident A fell on February 25, 2018 at 2:47 PM. RN 1 stated he relied on the information given to him by the Licensed Vocational Nurse (LVN) in charge of Resident A. RN 1 further stated it was the responsibility of the LVN charge nurse to give the CNA's instructions regarding care issues. RN 1 stated he did not observe the LVN give a report regarding care to CNA 1 for Resident A. RN 1 stated the LVN assigned to Resident A was no longer employed at the facility. During an interview with CNA 1 on April 18, 2018 at 11:40 AM, she stated on February 25, 2018 on the day shift, she did not receive any report or instruction regarding Resident A's care including transferring the resident from the bed to the wheelchair. CNA 1 stated she found Resident A lying on the floor on a mattress with his eyes closed when she went into his room at 7 AM. CNA 1 stated she came back at 7:30 AM on February 25, 2018 to feed Resident A, he was confused. CNA 1 stated when she entered Resident A's room, he was rolling around on the floor, trying to get up off the floor, and was trying to pick up his mattress off the floor. CNA 1 stated she got Resident A off the floor unassisted and placed him in a wheelchair and fed him. CNA 1 stated after feeding the resident, she took him to the nurses' station to be monitored. CNA 1 stated two hours later Resident A stated he wanted to go back to bed. She wheeled Resident A into his room, he leaned forward and fell forward hitting his head on the mattress pad. She said she yelled for help and two LVNs came and assessed him and put him back to bed, when she asked why there was the mattress on the floor, the LVNs told her because Resident A had fallen out of bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 12 of 13 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: _______________ 055213 (X3) DATE SURVEY COMPLETED 09/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIALTO POST ACUTE CENTER 1471 S Riverside Ave Rialto, CA 92376 (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 the Minimum Data Set nurse (MDS-a tool to assess for cognitive and functional ability) on April 29, 2018 at 5:00 PM, she reviewed the MDS under section G, indicating Resident A required the assistance of two people for transfers. A review of Resident A's care plan titled, "At risk for/actual fall" undated, indicated Resident A was at risk for falls due to "balance problem, change in condition, dizziness, confusion, urinary urgency." Listed on the care plan was "actual fall- 2/17/18 (February 17, 2018) and 2/25/18 (February 25, 2018) Resident had witnessed fall." There was no intervention listed for a two person transfer as identified on the MDS. Interventions included: "May place mattress on floor for safety precautions," however, also included under the interventions was listed, "adjustable high/low bed" and "keep bed in lowest position with wheels locked." The facility policy and procedure titled, "Accidents: Fall Risk Assessment" dated December, 2017, indicated under the section titled "Policy Interpretation and Implementation...4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMNU11 Facility ID: CA240000047 If continuation sheet 13 of 13