Other·July 13, 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 investigation of a Skilled Nursing Facility entity reported incident. Entity reported incident number: CA00537357 Representing the California Department of Public Health: Surveyor 36968 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of an entity reported incident number CA00537357

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 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 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: 7W2K11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HILLCREST NURSING HOME 4280 Cypress Dr San Bernardino, CA 92407 (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 ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure three of four residents (Residents B, C, and D) were free from abuse when Resident A's physical aggression was not managed by the facility as evidenced by: 1. Resident A's care plans were not updated to reflect each physical altercation, 2. Resident A's care plans were not updated to reflect adjustments to medications, and 3. The facility did not employ new interventions despite Resident A's repeated behavioral episodes. This failure resulted in the physical abuse of Resident B, C, and D. Findings: During an interview with the Director of Nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7W2K11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HILLCREST NURSING HOME 4280 Cypress Dr San Bernardino, CA 92407 (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) on June 6, 2017 at 1:16 PM, he stated Resident B was in an unprovoked physical altercation with Resident A on May 25, 2017. The DON stated Resident A approached Resident B; scratched Resident B's arm and hit Resident B in the mouth. The DON stated Resident B sustained abrasions to her left arm and a bloodied lip. The DON further stated Resident A had been in three previous altercations this year. 1. During a review of Resident A's "Licensed Nurses Progress Notes" dated January 16, 2017 at 11:50 AM, Resident A was involved in a physical altercation with Resident C. It was noted Resident A, "was observed striking out on another resident in the hand and chin." A late entry dated January 19, 2017 at 2:00 PM, indicated Resident A was in a physical altercation with resident D. It was noted Resident A, "wandered into the room of 27A and pulled her hair...". Another progress note dated April 25, 2017 at 12:45 PM, indicated Resident A was involved in a physical altercation with Resident C. It was noted Resident A, "struck another resident [Resident C] in the face and right arm." There was no documented evidence Resident A's care plans had been updated to reflect the physical altercations occurring on January 19, 2017 or May 25, 2017. During an interview with the DON on June 6, 2017 at 1:45 PM, he confirmed Resident A's care plans had not been updated to reflect the physical altercations occurring on January 19, 2017 or May 25, 2017. During an interview with a Licensed Vocational Nurse (LVN 1) on June 14, 2017 at 9:08 AM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7W2K11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HILLCREST NURSING HOME 4280 Cypress Dr San Bernardino, CA 92407 (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 stated LVNs are responsible for completing short term care plans and Registered Nurses (RNs) are responsible for completing long term care plans. 2. During a review of Resident A's "Licensed Nurses Progress Notes" dated January 19, 2017 at 2:00 PM, indicated Resident A's Ativan (a medication used to treat anxiety) was adjusted by the physician. Another progress note dated May 30, 2017 at 10:00 AM, indicated Resident A's Risperdal (a medication used to treat psychosis) was adjusted by the physician. There was no documented evidence Resident A's care plans had been updated to reflect the changes for Ativan or Risperdal. During an interview with the DON on June 6, 2017 at 1:45 PM, he confirmed Resident A's care plans had not been updated to reflect changes in medication for Ativan or Risperdal. During an interview with the Minimum Data Set (MDS, a patient assessment tool) Nurse (MDS) on June 14, 2017 at 9:15 AM, he stated RNs and LVNs are responsible for updating and revising care plans. The MDS Nurse further stated that the medical records staff were responsible for ensuring care plans are in place and up-to-date. The MDS Nurse stated he, too, utilized assessment data from the MDS to complete and update care plans. A review of the facility policy and procedure titled, "Resident Care Plans," undated, under section, "Revisions and Updating of the Resident Care Plans," indicated, "...The plans will be reviewed weekly when the nursing staff record their weekly summaries to determine if the problems are still exist and/or if all new FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7W2K11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HILLCREST NURSING HOME 4280 Cypress Dr San Bernardino, CA 92407 (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 problems have been recorded." 3. A review of Resident A's "Psychotropic (drugs affecting a person's mental state) Summary Sheet" recording the number of behavioral episodes of "striking out" each month, indicated the following: For the month of December 2016, Resident A had a total of 52 episodes. For the month of January 2017, Resident A had a total of 60 episodes. For the month of February 2017, Resident A had a total of 14 episodes. For the month of March 2017, Resident A had a total of 55 episodes. For the month of April 2017, Resident A had no recorded episodes despite a documented physical altercation with Resident C. For the month of May 2017, Resident A had a total of 2 episodes. A review of the documented care plans for Resident A's physical aggression indicated she was to be "monitored for aggression with other residents". No further evidence of interventions protecting other residents from physical aggression could be found. During an interview with the DON on June 8, 2017 at 2:20 PM, he confirmed Resident A's care plans had not been updated to reflect interventions to protect other residents from Resident A's physical aggression. During an interview with LVN 1 on June 14, 2017 at 9:08 AM, she stated Resident A is monitored for aggression by all staff members. LVN 1 stated a "PRN" (as needed) medication is utilized when Resident A exhibits aggressive behavior. She further stated the "PRN" medication is usually administered after an altercation and, therefore, does not prevent the physical aggression. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7W2K11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HILLCREST NURSING HOME 4280 Cypress Dr San Bernardino, CA 92407 (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 further stated Resident A is monitored by a "safety float" staff member. LVN 1 stated this staff member monitors all residents for behaviors and intervenes when necessary. LVN 1 states the "safety float" staff member does not monitor residents on a one-to-one basis. During an interview with the Social Services Designee (SSD) on June 14, 2017 at 9:28 AM, she stated Resident A exhibits territorial behavior. The SSD further stated Resident A is monitored for this territorial behavior and redirected by "safety float" personnel. The SSD confirmed "safety float" personnel monitor all residents at the same time and do not operate on a one-to-one basis. A review of the facility policy and procedure titled, "Resident-to-Resident Altercations," revised December 2007, indicated, "...d. Review the events with the Nursing Supervisor and Director of Nursing including interventions to try to prevent additional incidents... f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7W2K11 Facility ID: CA240000066 If continuation sheet 6 of 6