Other·February 8, 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 facility reported incident. Facility reported incident number: CA00563961 Representing the California Department of Public Health: Surveyor: 38226 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written as a result of facility reported incident number CA00563961

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 02/12/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation 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 medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, 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: 0J0211 Facility ID: CA240000080 If continuation sheet 1 of 4 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: _______________ 056436 (X3) DATE SURVEY COMPLETED 01/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEDICAL CENTER CONVALESCENT HOSPITAL 467 E Gilbert St 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 or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents right to be free from abuse when a Certified Nursing Assistant (CNA 1) slapped Resident 1 and washed him with cold water against his will. This failure resulted in the physical abuse of Resident 1. Findings: During a review of the clinical record for Resident 1, the admission record indicated Resident 1's admission date was November 19, 2017, with diagnoses which included, traumatic amputation (the loss of a body part that occurs as a result of an accident or injury), and difficulty walking. A review of the Minimum Data Set (MDS; an assessment of resident's functional and health status) dated November 30, 2017, indicated the Brief Interview Mental Status (BIMS - a screening tool used to determine mental status) scored 14. A BIMS score of 13 - 15 indicates a person is cognitively intact (intact mental process). During an interview with the Director of Nursing (DON), on December 7, 2017, at 1:55 PM, she reported, she suspended CNA 1 on December 5, 2017 due to an abuse allegation (a claim that someone has mistreated a person). During an interview with a Licensed Vocational Nurse (LVN 1), on December 7, 2017, at 4:05 PM, she stated, she heard Resident 1 yelling for help from his room. She stated when she entered Resident 1's room, she observed CNA 1 continuing to perform a sponge bath (an all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0J0211 Facility ID: CA240000080 If continuation sheet 2 of 4 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: _______________ 056436 (X3) DATE SURVEY COMPLETED 01/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEDICAL CENTER CONVALESCENT HOSPITAL 467 E Gilbert St 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 over washing provided in bed, instead of in the bath or shower, using a sponge or washcloth) on Resident 1 while Resident 1 "was resisting and yelling for her to stop and to leave him alone." LVN 1 stated she told CNA 1 to stop and to leave the room when CNA 1 said Resident 1 was 'always like this but needed to be cleaned.' During an interview with Resident 1, on December 8, 2017, at 9:25 AM, he stated CNA 1 was giving him a sponge bath with cold water. Resident 1 stated he told CNA 1 the water was cold and told CNA 1 to stop bathing him. He stated CNA 1 told him the water was not cold and continued to bathe him. Resident 1 stated he again told CNA 1 to stop giving him a sponge bath but she did not stop so he grabbed the washcloth at that time and threw it across the room onto the floor. Resident 1 stated, CNA 1 "went to pick up the washcloth then came back and slapped me on my forehead with her open hand." Resident 1 stated, CNA 1 continued to wash him with the cold water and he continued to resist, yelling at CNA 1 to stop and to leave him alone several times but CNA 1 "would not stop." Resident 1 stated, "It really upset me." A review of the clinical record for Resident 1, indicated the following: 1. Nurses Note dated December 5, 2017, at 8:30 PM, indicated, " ...CNA [CNA 1] stated that when she went to continue washing the resident [Resident 1], the resident [Resident 1] began yelling. The CNA [CNA 1] stated, 'he is always like this' and 'he does this all the time.' 2. Nurses Note dated December 5, 2017, at 9:11 PM, written by LVN 1 indicated, "At 8:10 PM, heard resident [Resident 1] yelling out for help from his room. Immediately went to assist and upon entering room noticed CNA [CNA 1] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0J0211 Facility ID: CA240000080 If continuation sheet 3 of 4 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: _______________ 056436 (X3) DATE SURVEY COMPLETED 01/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEDICAL CENTER CONVALESCENT HOSPITAL 467 E Gilbert St 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 struggling to provide incontinent [inability to control bowel or bladder] care to resident while resident resisting and repeatedly yelling out 'leave me alone.' I asked resident [Resident 1] what happened and he stated 'tell her to leave me alone, she [CNA 1] hit me.' ...Resident able to verbalize concern. He [Resident 1] stated that CNA [CNA 1] ...got very upset and struck resident [Resident 1] on the forehead with her open palm..." During a review of CNA 1's employee file, it indicated CNA 1 received "Elderly and Dependent Abuse Prevention and Reporting" training upon date of hire, and at least annually thereafter, with the most recent training on November 20, 2016. The facility policy and procedure titled, "Abuse and Neglect Prevention Management" revised December 2014, indicated, "Policy: It is the policy of the facility to ensure our residents safe and free from abuse ...Our residents have the right to be free from abuse and neglect by anyone, including staff members ...Definitions: Physical abuse includes hitting, slapping ...Incident Management ...Educate the staff to avoid using phrases like 'they always complain,' or 'he/she always says that' ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0J0211 Facility ID: CA240000080 If continuation sheet 4 of 4