Other·May 3, 2017

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 an entity reported incident. Entity Reported Incident Number CA00523274 Representing the California Department of Public Health: Surveyor: 37251 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 entity reported incident number CA00523274

F223 SS=D FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 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: F78I11 Facility ID: CA240000059 If continuation sheet 1 of 5 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: _______________ 555195 (X3) DATE SURVEY COMPLETED 04/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL ROSA VILLA 2018 Del Rosa Ave San Bernardino, CA 92404 (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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from harm when a Certified Nursing Assistant (CNA 1) responded to being hit by Resident 1, by hitting Resident 1 on the right hand during patient care. This failure had the potential for resident harm. Findings: On February 24, 2017, at 10:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of possible physical abuse for Resident 1. During an interview with the Administrator (ADM), on February 24, 2017, at 10:00 AM, she stated two nursing assistant students went with the Certified Nursing Assistant (CNA 1) to change Resident 1. One student allegedly saw the CNA hit the resident. The other student did not see what had happened. The students went to report the incident to the Director of Staff Development (DSD). The Director of Nursing (DON) and the ADM were then notified. The CNA 1 was asked what had happened and stated Resident 1 was trying to hit CNA 1 and CNA 1 tried to stop the hit and did not use any force. She was removed from resident care immediately. During an observation on February 24, 2017 at 10:15 AM, Resident 1 was lying in bed, she responded to her name but could not answer appropriately to questions. There were no marks observed on top of the right hand. During a telephone interview with the Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F78I11 Facility ID: CA240000059 If continuation sheet 2 of 5 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: _______________ 555195 (X3) DATE SURVEY COMPLETED 04/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL ROSA VILLA 2018 Del Rosa Ave San Bernardino, CA 92404 (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 Student (NAS 1), on February 24, 2017, at 11:28 AM, she stated CNA 1, NAS 2, and herself were changing Resident 1's underwear in her room. The NAS 1 further stated Resident 1 was calling CNA 1 names and hit CNA 1. She then witnessed CNA 1 hit the resident on top of her right hand. During a telephone interview on March 9, 2017, at 12:52 PM, NAS 2 stated she did not see CNA 1 hit Resident 1. She witnessed Resident 1 hit CNA 1. She bent down to pick up a black bag, she heard a second "popping noise", and when she got back up, CNA 1 told her and NAS 1 "You are not suppose to do that," but NAS 2 did not know what CNA 1 meant. During an interview with the DSD, on February 24, 2017, at 11:00 AM, she stated NAS 1 witnessed CNA 1 hit the resident on top of the right hand. She further stated the last inservice CNA 1 received regarding abuse training was at the end of October 2016 when CNA 1 was hired. She further stated almost every day she educates staff about how to handle resident behaviors and actions to take during abuse retraining. During an interview with the DON, on March,9, 2017, at 10:20 AM, when asked about the facility's "Walk-Away" policy, she stated it is a policy where if the resident is acting up, having an inappropriate behavior, or a CNA cannot handle the resident's behavior, the staff can walk away from the situation. The staff should inform a change nurse and not just leave the resident alone. During an interview with the ADM, on March 9, 2017, at 10:30 AM, she stated after her investigation that she could not determine for certain if CNA 1 hit the resident, or it was a tap, or it was a "reflex" on Resident 1's right hand. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F78I11 Facility ID: CA240000059 If continuation sheet 3 of 5 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: _______________ 555195 (X3) DATE SURVEY COMPLETED 04/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL ROSA VILLA 2018 Del Rosa Ave San Bernardino, CA 92404 (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 She further stated after talking to CNA 1, CNA 1 did not decide to use the "Walk Away" policy. A review of the facility's investigation document dated February 15, 2017, provided by the DSD, it reflected that the DSD conducted an interview with CNA 1 and it indicated, "[Name of CNA 1] stated that yes resident did hit her and that she attempted to stop the hit. 'I did not use any force.'" During further review of the facility's investigation note, a signed statement from NAS 1 indicated "...I saw CNA [1] slap resident (Resident 1) back on the top of right hand." A review of the signed statement from NAS 1, on February 15, 2017, indicated that CNA 1 told NAS 1 and NAS 2 "Ya'll don't do that, but she's one of the troubled one's that gives us a hard time." During a telephone interview with NAS 1, on March 23, 2017, at 4:02 PM, she stated when CNA 1 made the comment that they should not do that, CNA 1 was referring to hitting the resident. NAS 1 further stated the resident was still agitated after being hit, but had calmed down before they left the resident's room. The facility policy and procedure titled "WalkAway" Policy and Procedures, undated, indicated, "...any staff member who becomes frustrated when assisting a resident, visitor or other staff members must walk away from the situation, absent an emergency, and request assistance so as to prevent a resident from being subject to inappropriate conduct which includes, but is not limited to...physical abuse..." The facility policy and procedure titled "Abuse Prevention" dated December 31, 2015, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F78I11 Facility ID: CA240000059 If continuation sheet 4 of 5 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: _______________ 555195 (X3) DATE SURVEY COMPLETED 04/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL ROSA VILLA 2018 Del Rosa Ave San Bernardino, CA 92404 (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 "Policy: Each resident has the right to be free from verbal, sexual, physical, and mental abuse ...Residents must not be subjected to abuse by anyone, included, but not limited to, facility staff, other residents..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F78I11 Facility ID: CA240000059 If continuation sheet 5 of 5