Other·January 2, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey conducted on August 29, 2018 to December 6, 2018. Representing the California Department of Public Health: Surveyor 25179 An immediate Jeopardy was called on August 31, 2018 at 4:25 PM, for not developing an intervention specific care plan that included supervising the resident when nearing an exit, contributing to Resident 1's elopement from the facility. The Immediate Jeopardy was abated on August 31, 2018 at 5:48 PM, after receiving an acceptable corrective action plan.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/27/2018 §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: 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: AWDF11 Facility ID: CA240000047 If continuation sheet 1 of 6 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 12/06/2018 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 Based on observation, interview, and record review, the facility failed to ensure, for one of three sampled residents (Resident 1), that Resident 1, assessed as a high risk for elopement (leaving the facility without supervision) received supervision to prevent the resident from eloping from the facility. This failure had the potential to result in an accident or death. Findings: On August 29, 2018 at 8:50 AM, the facility was entered to investigate a facility reported incident of Resident 1's elopement from the facility on August 27, 2018 at approximately 4:30 PM. During an observation on August 29, 2018 at 8:50 AM, of the facility entry and lobby area, it was observed that the main facility entrance was a glass door into a lobby area. There were double wooden doors that were closed but allowed entry into the facility. There was a receptionist window in the lobby. During a review of Resident 1's Face Sheet (a document that gives a patient's information at a quick glance), it showed the resident was admitted to the facility on September 22, 2017, with diagnoses that included difficulty walking, muscle weakness, psychosis (a mental disorder) and schizophrenia (a mental disorder). Review of the Charge Nurse's Notes dated August 27, 2018 at 11:14 PM, showed the following: "around 3pm received resident lay on her bed comfortably awake alert verbally responsive with episodes of forgetfulness/confusion. talking to herself. 4pm went to resident room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AWDF11 Facility ID: CA240000047 If continuation sheet 2 of 6 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 12/06/2018 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 admin (administered) meds (medications) via po (by mouth) & compliance (took the medication). 4:15pm charge (nurse) seen resident out of her room ambulate (walk) with her walker facing by the station (Nurse's station) towards front door seen cna (Certified Nursing Assistant) chasing resident stopping her going out of the front door. one of the employees stated it's ok she just want her money in front office, cna noticed resident not back to her room. Notify charge nurse, supervisor check all rooms bathroom, facility premises, units, check watched camera in the whole facility noted resident passing through the front office employees drove to the stores, remain never to be found, MD (physician) conservator (responsible party) spoke to on call by (conservator's name) notify made aware, RN (Registered Nurse) notify (name of city) police to report missing resident officer (name) came in to the facility to get information about resident with case number # (number), & patient reported to have wander guard (device that sets off an alarm when the resident gets too close to an exit door) on her left ankle & active Will continue to look for resident." A review of the Medication Administration Record (MAR) dated August 27, 2018, showed the charge nurse documentation of Resident 1's whereabouts. The resident was missing about 4:30 PM on August 27, 2018 and the charge nurse documented the resident's whereabouts every two hours until 10:00 PM. The entry for 6:00 PM, 8:00 PM and 10:00 PM were crossed out and the reason for the crossed out entries was documented as an error as the resident was no longer in the facility. In a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on August 29, 2018 at 3:45 PM, LVN 1 stated when she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AWDF11 Facility ID: CA240000047 If continuation sheet 3 of 6 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 12/06/2018 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 received report at the change of shift, she saw her (Resident 1) in bed. When she talked to Resident 1 the resident was laughing and in a good mood. A little later she when she gave the resident medication she was in bed. She stated shortly after that she saw the Certified Nursing Assistant 1 (CNA 1) chasing her down the hallway because the wander guard alarmed. The resident went to business office to get money for dinner, she often did that. CNA 1 said it was OK she was just getting some money. She did not come back. It was about 4:30 PM. Called a Code Green (emergency code for a missing resident) and we searched for her. That is all I know. When asked about her crossed out entries on the MAR, she stated she doesn't remember crossing out her initials on the MAR. A review of Resident 1's Care Plan for "At risk for elopement/wandering AEB (As Evidenced By) impaired safety awareness," initiated on June 4, 2018, showed the following interventions: "At high risk for elopement-Visual checks every 2 hours and document whereabouts/location. Charge nurses/QA (Quality Assessment nurse) & or RN check placement & function of Wander-guard q (every) shift. Psych (Psychiatric physician) consult and as needed. WANDER ALERT: Device located Lt. (left) ankle. Apply wander guard (a device worn by a resident that sets off an alarm when the resident approaches an exit door) at all times. Identify pattern of wandering: Is wandering FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AWDF11 Facility ID: CA240000047 If continuation sheet 4 of 6 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 12/06/2018 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 purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor resident location Q (every) 2 hours. Document whereabouts/location/wandering behavior and attempted diversionary interventions in behavior log/MAR. Reorient resident to room as needed. Keep a hazard free environment ..." The care plan did not address actions for staff to take when the wander guard alarm sounded, such as redirecting the resident or accompanying them to the outside to prevent leaving the facility premises. On August 31, 2018 at 4:25 PM, an Immediate Jeopardy was called in the presence of the Director of Nurses (DON) and the Infection Control/QA nurse, for not developing an intervention specific care plan that included supervising the resident when nearing an exit, contributing to Resident 1's elopement from the facility. The Immediate Jeopardy was abated on August 31, 2018 at 5:48 PM, after receiving an acceptable corrective action plan and conducting record review and interviews to ensure the corrective action plan was implemented. The action plan was as follows: "All residents are been assessed for elopement risks. Provided education to current staff on elopement risks and will continue to educate staff throughout each shift on how to assist and monitor elopement risks residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AWDF11 Facility ID: CA240000047 If continuation sheet 5 of 6 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 12/06/2018 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 Licensed nurses are doing visual checks of residents and documenting in the MAR every 2 hours. Certified nurse assistants are educated to go to the exit doors as soon as the wander guard alarm goes off to assist the resident. After assisting the resident, report to the charge nurse. Do not leave the patient alone by themselves. Re-direct them." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AWDF11 Facility ID: CA240000047 If continuation sheet 6 of 6