Other·July 24, 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: CA00535758 Representing the California Department of Public Health: Surveyor: 37427 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 for entity reported incident number CA00535758.

F333 SS=G RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.45(f)(2)

F333 09/15/2017 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to administer medication as prescribed to two of four sampled residents (Resident 1 and Resident 2), when Resident 1 was given medications 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: DMFH11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/30/2017 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 prescribed to Resident 2 and Resident 2 did not receive medications as prescribed by the physician. This failure resulted in Resident 2 not receiving medications as prescribed and Resident 1 experienced slurred speech, blurred vision and a pulse of 42. Resident 1 was sent to the hospital for evaluation and treatment. Findings: During a review of the clinical record for Resident 1, the Facesheet (admission record), dated February 14, 2017, indicated the resident had an allergy to Haldol (an antipsychotic medication) and had a diagnosis of heart failure. During an interview with the Director of Nursing (DON) on May 12, 2017 at 3:00 PM, he stated that Resident 1 was given the wrong medications on May 11, 2017 at 9:00 AM. The medications included; 1. Buspar (an antidepressant) 2. Lasix (used to treat fluid retention in people with heart failure). 3. Lopressor (blood pressure medication). 4. Depakote (anti-seizure medication). 5. Haldol, (an antipsychotic medication). 6. Keppra (anti-seizure medication). 7. Klonopin (medication used to treat seizures and panic disorder). 8. Zyprexa (used to treat schizophrenia; a psychological disorder). 9. Dilantin (anti-seizure medication). 10. Nuedexta (used to treat a neurological disorder with symptoms of uncontrollable laughing and crying, contraindicated for people with heart failure). 11. Dietary supplements; fish oil, Oscal D, and Senna. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DMFH11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/30/2017 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 In a review of the clinical record for Resident 1, the "Licensed Nursing Notes", dated May 11, 2017, indicated; "...BP [blood pressure] 124/85, p [heart rate]: 42 , R [respiration] 15..." Also noted was that the resident complained of "slurred speech", and "double vision." The physician was notified and orders were received to send the resident out to the acute care hospital. Review of the facility's investigation letter, dated May 12, 2017, indicated that the Licensed Vocational Nurse (LVN 1) who gave the incorrect medications had asked a Certified Nursing Assistant (CNA) about the identity of Resident 2. The CNA pointed to Resident 1 and the LVN gave all the medications intended for Resident 2 to Resident 1. LVN 1 was terminated after the incident. During an observation and a concurrent interview with Resident 1 on May 30, 2017 at 2:35 PM, she was in her room, sitting in her wheelchair. When asked how she was feeling, she stated, "Much better." When asked about the incident of her receiving the wrong medication, she stated that she did not like going to the hospital, and said she was grateful to be back at the facility. Review of the clinical record for Resident 1, from the acute care hospital, titled "Consultation," dated May 11, 2017 at 4:51 PM, indicated the resident was, "extremely somnolent [drowsy]" and "...in ER, ekg [electrocardiogram; a test which shows heart rhythm] showed sinus bradycardia [slow heart rhythm]." Vital signs were noted as follows: ..."HR [heart rate] 38, RR [resting respiration]: 13, BP: 113/70." Review of the clinical record for Resident 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DMFH11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/30/2017 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 from the acute care hospital, titled, "History and Physical", dated May 11, 2017, at 4:56 PM, indicated, "...THE PATIENT IS ALLERGIC TO HALDOL AND APPARENTLY, SHE RECEIVED HALDOL." "...She became lethargic [drowsy] with slurred speech and upon arrival to the Emergency Department, her vital signs showed bradycardia." "...Assessment: 1. Polypharmacy [multiple medications] overdose. 2. Beta blocker [medication that reduces blood pressure] overdose. 3. Symptomatic bradycardia. Plan: At this time patient will be admitted to Intensive Care Unit. ...We might need to start Isuprel [medication to increase a slow heart rate] infusion to keep the heart rate more than 40." Review of the clinical record for Resident 1, from the acute care hospital, titled, "Transfer of Care Summary," dated, May 13, 2017, at 2:56 PM indicated; "...Diagnosis: Adverse effect of beta-blocker,..."Ingestion, drug, inadvertent or accidental; ...Sinus bradycardia." During an interview with the DON on May 31, 2017 at 9:55 AM, when asked what the facility's policy and procedure was on identifying residents when administering medications, he stated that they used photographs on the Medication Administration Record (MAR) and resident wristbands. The DON also stated that it is not the usual practice to ask another staff member to identify the residents when administering medications. During an interview with the DON, on June 2, 2017 at 3:38 PM, he stated that Resident 2 was not given her usual morning medications as ordered because the window of time had expired when the medication error was discovered. The DON stated that Resident 2 has the same physician as Resident 1, and the physician was notified of the error in medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DMFH11 Facility ID: CA240000066 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: _______________ 555890 (X3) DATE SURVEY COMPLETED 06/30/2017 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 administration at the time it was discovered. Record review of the facility policy and procedure, titled "Administering Medications," dated 2001, indicated; "...5. The individual administering medications must verify the identity before giving the resident his/her medications. This is done by photo in the MAR and wristband." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DMFH11 Facility ID: CA240000066 If continuation sheet 5 of 5