Other·July 20, 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 annual recertification survey on June 4, 2018 to June 7, 2018. Representing the California Department of Public Health: 36321, HFEN 38321, HFEN 38249, HFEN Sampled: 29 Census: 88 There were 22 deficiencies issued. An Immediate Jeopardy (IJ, a situation that has threatened or is likely to threaten the health and safety of a client) was called on June 4, 2018 at 8:05 AM, and verbally notified in the presence of the Administrator and the Director of Nurses for the following reason: The facility failed to ensure their policy and procedure for Abuse was implemented to protect Residents' 55, 59, and 203, when verbal abuse towards the residents were not reported, investigated and no assessments were completed by social services nor a plan in place to ensure the safety of the residents. The corrective action plan (CAP) included the following: 1. The involved residents were assessed and 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: RF2R11 Facility ID: CA240000089 If continuation sheet 1 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 interviewed to ensure their safety and the involved staff were immediately refrained from interacting with residents. Social Service Director (SSD 1) interviewed the three residents involved to provide emotional support. 2. SOC 341 was completed and sent to California Department of Public Health (CDPH) and Ombudsman on June 5, 2018. 3. SSD 1, Admissions, and Marketing Director conducted resident interviews on June 5, 2018 to check if any other residents had concerns regarding staff's behaviors towards them. No other residents were found affected by this action. 4. A one on one in-service was provided to the involved staff members regarding facility Policy on Abuse Prevention and Abuse Allegation Reporting. The Administrator was counseled on abuse reporting and investigating time frames. 5. Effective immediately, the Director of Nurses will assume the position as Abuse Coordinator. 6. An in-service was initiated on June 5, 2018 and conducted on June 6, 2018 to all staff by Director of Nursing and designee regarding facility policy on Abuse Prevention and Abuse Allegation reporting. 7. The Director of Nursing and Interdisciplinary Team reviewed the Concern Record regarding alleged incidents and inappropriate resolutions were indicated. 8. The Regional Director of Operations evaluated the incident involving the Administrator for failure to follow facility policy in reporting allegations of abuse. The employees infraction of facility policy led to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 2 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 discharge and was discussed June 6, 2018. A notice to Employees as a Change in Relationship was signed by both Regional Director of Operations and the employee. The final check was provided at the time of termination. EED pamphlets were provided and COBRA was discussed. 9. Any other employee who were not able to attend in-service on June 5, 2018 and June 6, 2018 will not be able to return to work until they have received an in-service by Director of Staff Development regarding facility on Abuse Prevention. The IJ was lifted on June 7, 2018 at 12:42 PM in the presence of Administrator Designee, Director of Nurses, Quality Assurance Nurse, and Regional Director of Operations, after review and verification of the elements in the CAP were in place. An extended survey was conducted on June 5, 2018 through June 7, 2018. Sampled: 29 Census: 88 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 3 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F554 Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/29/2018 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure their policy and procedure for self-administration of medications were followed, when one of 29 sampled residents (Resident 21) was found with medication Vicks Vapor Rub (a mentholated topical cream intended to relieve head, throat, and chest stiffness) in a jar was unattended at the bedside. This failure had the potential to affect the health and safety of residents if the medication was ingested accidentally. Findings: During an observation of Resident 21 on June 4, 2018, at 10:11 AM, Resident 21 was in the rest room. A jar of [Menthol Rub] over the counter medication (OTC) was observed on her bed side table unattended. During an interview with Resident 21 on June 4, 2018, at 10:15 AM, Resident 21 was in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 4 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 wheelchair that she could self propel and was Spanish speaking only. Resident 21's room mate was sitting in a chair next to her bed, and was Spanish speaking only as well. During an interview with Licensed Vocational Nurse (LVN 2) on June 4, 2018, at 10:18 AM, LVN 2 verified the [Menthol Rub] was not allowed to be at residents bed sides. LVN 2 stated, the facility's process for residents to self - administer medication, was to have a Medical Doctor's (MD) order, an assessment for mental capacity, a care plan, and a nurse had to educate the resident on the administering the medication. LVN 2 confirmed the findings and stated, "We have no orders for Resident 21 to self-administer any medication." LVN 2 also verified not being aware that Resident 21 had the OTC jar of [Menthol Rub] at her bed side. During an interview with Resident 21 on June 4, 2018, at 10:22 AM, through an interpreter that spoke Spanish, Resident 21 stated her family brought in the OTC jar of [Menthol Rub] and she would put it on her chest at night because her chest would get cold. A clinical record review for Resident 21's Physician Orders dated, May 31, 2018, indicated no order for [Menthol Rub]. A review of Minimum Data Set (MDS-is a comprehensive assessment of each resident's functional capabilities), Resident 21's BIM score was 10. During June 4, 2018 and June 7, 2018, observed some residents wandering in other residents rooms and other residents were just visiting with other residents. During an interview with the Director Of Nurses (DON), on June 4, 2018, at 10:15 AM, the DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 5 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 confirmed OTC Vicks Vapor is a medication that can not be at a resident's bed side. The facility policy and procedure titled, "Med Pass," undated, indicated..."c. Do not leave medications at bedside for residents unless ordered by Physician that sublingual and / or inhalation therapy may be left at bedside. Always observe resident taking medication, even when medication may be administrated independently."

F559 SS=D Choose/Be Notified of Room/Roommate Change CFR(s): 483.10(e)(4)-(6)

F559 06/28/2018 §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. §483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. §483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to get consent before a transfer to another room was done for two (Resident 203 and Resident 195) of 88 residents. This failure had the potential for these two residents not to be given enough time to know FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 6 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 their new roommates and adjust to their new rooms. Findings: 1. During an observation with Resident 203 in her new room on June 5, 2018 at 8:30 AM, she was anxious and uneasy. A concurrent interview with Resident 203 was done, and she stated that she was surprised last night (June 4, 2018) of the sudden move to a different room. She stated she was continuously asked by the Social Service Designee (SSD) and felt she will not stop asking her to move that's why she finally agreed to the transfer that same night. During an interview with the SSD she stated that she was not able to ask Resident 203 to sign the form, entitled "Notification of Room Change" on June 4, 2018. The SSD stated that Resident 203 was not given enough time about the room change. A review of Resident 203's clinical record indicated she was admitted to the facility on May 4, 2018, with diagnoses of major depression, and hypertension (high blood pressure). It also indicated that Resident 203 was responsible for decision making. A review of Resident 203's nurses progress notes showed no documentation of her move to a different room was written on the date of transfer. A review of a clinical record entitled, "Notification of Room Change", dated June 5, 2018, indicated, no signature from Resident 203 was done prior to her transfer to a different FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 7 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 room. A review of the Social Service notes showed no documentation of why or when the transfer of Resident 203's room was done. 2. During an observation of Resident 195, in her new room on June 5, 2018 at 10:00 AM, Resident 195 was constantly yelling and did not want to be interviewed. A review of Resident 195's clinical record indicated she was admitted to the facility on May 30, 2018 with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with daily activities.), major depression, and schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand reality.) It also indicated that it is Resident 195's mother who has the responsibility for decision making for her. During an interview with the SSD on June 5, 2018 at 10:30 AM, she stated that she was not able to contact the responsible party of Resident 195. The SSD stated that she had not mailed the notification of room change form to the responsible party, prior to her move to a different room. The facility policy and procedure entitled, "Room or Roommate Changes- Notification", undated, indicated under Policy, "This facility will provide notice to resident prior to any room change or roommate change."

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete

F583 Event ID: RF2R11 06/28/2018 Facility ID: CA240000089 If continuation sheet 8 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to ensure medical records confidentiality for one (1) of 29 sampled residents (Resident 243) when the Licensed Vocational Nurse (LVN 2) left the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 9 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Medication Administration Record (MAR) open while giving medication inside Resident 243's room. This failure had the potential for unauthorized access and use of protected health information of one resident (Resident 243) in a universe of 88 residents. Findings: During an observation in the facility hallway, on June 4, 2018, at 11:10 AM, the facility staff, visitors, and residents were walking by the hallway. LVN 2 was giving medication to Resident 243 and the medication cart was in front of Resident 243's room with the MAR left open, exposing Resident 243's name, room number, diagnoses, and medications. During an interview with the LVN 2, on June 4, 2018 at 11:15 AM, the LVN 2 stated "The MAR should be closed, especially that a lot of people passing by." During an interview with the Medical Record (MR) facility staff, on June 4, 2018, at 11:30 AM, the MR stated, "We do not expose any records, we need to protect it. We must maintain confidentiality." A record review of facility's policy titled, "Policy: HIPAA (Health Insurance Portability and Accountability Act) Privacy", indicated "Content:...G. A general rule is that this facility may not use or disclose protected health information unless the resident has given consent, authorization or verbal agreement or; unless it is permitted or required by law." A review of facility document titled, "Job Description: Licensed Vocational Nurse (LVN)", dated August 23, 2011, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 10 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 "Competencies: Interpersonal Skills- Maintains confidentiality."."

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

F600 06/06/2018 §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, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure facility's policy and procedure related to abuse prevention were implemented by staff, for three of 29 sampled residents (Resident 59, Resident 203, Resident 55) when: 1. Resident 59 and Resident 203 were told "If you don't shut your mouth, I will not give your pain medication!" and "Shut your mouth, you are not the only resident here!" from facility Licensed Vocational Nurse 7 (LVN 7). 2. Resident 55 was told "You should read the bible and practice what you read" from the facility Administrator (ADM). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 11 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 These failures affected the mental and psychosocial well beings of the residents causing each of them to be anxious, scared, with feelings of degradation and humiliation. Findings: 1. During an observation on June 4, 2018 at 8:30 AM, Resident 59 and Resident 203 were in their beds, awake, alert and able to talk coherently. Concurrent interviews with Resident 59 and Resident 203 were conducted. Resident 59 stated, she was upset with Licensed Vocational Nurse 7 (LVN 7) because LVN 7 yelled and was rude at her. She said LVN 7 refused to give Resident 59's pain medication. Resident 59 stated that on May 24, 2018 at 11 PM to 7 AM shift (night shift), both she and Resident 203 were both in need of pain medications. Resident 59 pushed on her call button to call LVN 7. LVN 7 came to their room and turned off Resident 59's call button and spoke only to Resident 203. LVN 7 ignored Resident 59. Resident 59 stated when LVN 7 was about to leave the room, Resident 203 asked her, "Wait, what about her pain medication? (referring to Resident 59)." LVN 7 ignored Resident 203, and left the room. Resident 59 used her call button again to ask for her pain medication from LVN 7, but LVN 7 did not return to their room. During a concurrent interview with Resident 203, she stated LVN 7 did not return to give her pain medication for an unknown amount of time. Resident 203 yelled for LVN 7 to come to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 12 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 their room. LVN 7 returned to their room and yelled at Resident 59, and stated, "If you don't shut your mouth up, I will not give your pain medication!" Resident 59 got upset with LVN 7 and told her she was not the one who yelled for her but Resident 203 did. Resident 203 stated, "She [LVN 7] then yelled and was nasty at me," and said "Shut your mouth! You are not the only resident here!" Resident 203 further stated that LVN 7 gave the medication to her but not to Resident 59. Resident 59 added, that LVN 7 never returned to their room. Resident 59 used her cell phone to call the nursing station to ask help from another charge nurse to give her pain medication. Resident 59 stated that she asked for her routine pain medication from LVN 7. Resident 59 stated LVN 7 knew she had a scheduled pain medication at 4:00 AM. Resident 59 was already in pain so she asked for it earlier at 3:00 AM. Resident 59 got her pain medication 5:30 AM from a different Licensed Vocational Nurse 5 (LVN 5). Resident 59 and Resident 203 stated they reported the incident to the Licensed Vocational Nurse 6 (LVN 6) in the morning of May 25, 2018. Resident 59 and Resident 203 stated they were both worried LVN 7 will still yell at them since LVN 7 was still on schedule at work and assigned to them. During an interview with LVN 6 on June 4, 2018 at 2:30 PM, she stated that she was working on May 25, 2018 and the two residents (Resident 59 and Resident 203) reported about their incident with LVN 7. LVN 6 stated she reported the incident to the Director of Nursing (DON) on May 25, 2018. During an interview with the DON on June 5, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 13 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2018 at 7:00 AM, he stated, he interviewed both Resident 59 and Resident 203. He stated, he did not follow the facility abuse policy and procedure of reporting to California Department of Public Health (CDPH) the alleged abuse, and not suspending the alleged abuser while his investigation was still going on, but instead he just reassigned LVN 7 to different patients and allowed her to work in the facility. The DON stated that he has not completed his investigation of the alleged abuse. During an interview of LVN 7 on June 5, 2018 at 11:00 AM, LVN 7 stated she worked on May 24, 2018 at the 11- 7 shift. LVN 7 stated she was just explaining to Resident 59 and Resident 203 why she was late giving them their medications and it was Resident 59 and Resident 203 who were mad at her. LVN 7 stated that she had plenty of residents who needed her help that was why she was late attending to Resident 59 and Resident 203. Review of the clinical record of Resident 59 indicated, she was admitted to the facility on February 24, 2018 with diagnoses which included chronic pain syndrome and osteoarthritis (bone pain). A review of Resident 59's Minimum Data Set (MDS, a comprehensive resident clinical assessment) under section C0500 Brief interview for mental status (BIMS), indicated she had 14 out of 15 total score, which was considered oriented and coherent. A review of Resident 59's Physician Order, dated April 1, 2018, indicated an order of dilaudid (pain medication) four (4) milligrams (unit dose) by mouth every four hours. A review of Resident 59's care plan, dated February, 2018 indicated, she has pain and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 14 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 discomfort because of chronic pain syndrome and osteoarthritis and that she needed her ordered pain medications to be given as ordered. A review of Resident 203's clinical record indicated she was admitted to the facility on May 4, 2018 with diagnoses, which included chronic pain syndrome and rheumatoid arthritis (joint pains). A review of Resident 203's MDS, under section C0500, BIMS, indicated she had 13 out of a total score 15, which was considered oriented and coherent. A review of Resident 203's Physician order, dated May 21, 2018, indicated an order of Percocet (pain medication)10 325 milligrams (unit dose) one tablet by mouth every six hours as needed for pain. A review of Resident 203's care plan dated February 23, 2018, indicated, she has pain and discomfort because of arthritis and one intervention is to give the pain medication as ordered. A review of the work schedule of LVN 7, entitled," Punch Detail", time period from May 1, 2018 thru May 31, 2018, indicated, LVN 7 worked May 24, 2018, May 30, 2018, and May 31, 2018. The facility and procedure titled, "Abuse Allegation Investigation", undated, indicated under content, " ...3. Interview staff members accused of alleged abuse, document findings, suspend staff members pending outcome of investigation..." 2. During an observation of Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 was alert and oriented. Resident 55 was in bed, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 15 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 a bible and magnifying glass on top of his over bed table. Resident 55 had above the left knee amputation, and a wheelchair on the side of the bed. Resident 55 was able to answer questions. He was alert, and oriented. A record review of Resident 55's medical records, on June 04, 2018, at 10:00 AM, the facesheet (demographic medical information) indicated that Resident 55 was admitted on September 24, 2012, with diagnoses which included diabetes mellitus type 2 (blood sugar problem), dysphagia (swallowing difficulty), chronic obstructive pulmonary disease (lung disease), hypertension (increased blood pressure), acquired absence of unspecified left leg above the knee (amputated left leg), and blindness of left eye. A review of Resident 55's medical records titled, "History and Physical", dated August 31, 2017, indicated "This resident: 1. Has the capacity to understand and make decisions." A review of Resident 55's document titled, "Quarterly Minimum Data Set", dated April 4, 2018, indicated "Section C Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score 14." During an interview with Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 stated he had a recent incident that bothered him, and kept thinking about the incidents. The Administrator (ADM), Social Services Designee 2 (SSD 2), and the CNA 1 visited Resident 55 spoke to him in his room. The Resident 55 further stated the ADM stated, "You are the problem here, not my staff. You should not do that to my staff. You read the bible and practice what you are reading." The Resident 55 stated: "I felt so little. I felt that I am nothing in this world. I felt humiliated, I want to cry, but I just FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 16 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 kept it in my chest." Resident 55 further stated the ADM spoke to him because of the incident two weeks ago and the most recent one with Certified Nursing Assistant (CNA 1). Resident 55 stated the first incident was two weeks ago during bathing, Resident 55 held CNA 1 wrists and yelled at her [CNA 1] that he still wanted more time for shower. Resident 55 said the second incident happened few days ago when Resident 55 called the CNA 1 "snake like my sister". During an interview with the Licensed Vocational Nurse (LVN 1), on June 4, 2018 at 3:55 PM, the LVN 1 was asked about Resident 55's behavior and he [LVN 1] stated, "The resident is very particular with his ADLs (Activities of Daily Living), but a very nice guy and very religious." During a follow up interview with Resident 55, on June 4, 2018, at 4:02 PM, he stated, "I feel humiliated and I feel offended. The words that she [Administrator] said keeps running to my head. She [Administrator] said 'You should read the bible and practice what you read.' I felt that she tried to humiliate me in front of [name of the SSD 2] and [name of the CNA 1]." Resident 55 further stated, "I am not comfortable talking to her [Administrator] anymore. I am thinking of what she [Administrator] told me to read the bible and practice what I am reading. She [Administrator] was very tough in saying that. That is why if I feel that if she [Administrator] was walking in the hallway and I am in my wheelchair I would just turn my back and pretend to watch television and wishing that she will not come to my room. She [Administrator] is very firm and told me, "If I would have been here years ago, I will kick you out." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 17 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 During an interview with the ADM, on June 4, 2018 at 4:23 PM, the ADM was asked about the allegations of Resident 55, and she [ADM] did not confirmed the allegations. The ADM stated "The CNA came to us [the ADM and the SSD 2] and then we went to his room to talk to him. And I cannot say those words to him." During an interview with the SSD 2, on June 5, 2018, at 7:55 AM, the SSD 2 stated "As what I remember, [name of the Administrator] said to him [Resident 55] 'this is not an acceptable behavior and that is not the way you talk to the staff that is providing care for you." The SSD 2 further stated the ADM is always firm in talking to people. During an interview with the CNA 1, on June 5, 2018, at 8:30 AM, CNA 1 was asked if she [CNA 1] heard what the ADM told Resident 55, and she stated "Yes. But I cannot remember it all, she said 'don't do that to my staff' and I cannot remember the rest." The CNA 1 further stated the ADM pointed out that Resident 55 should not do that again. During a concurrent interview with the SSD 1 and record review of Resident 55's medical records, on June 5, 2018, at 9:30 AM, the SSD 1 stated the CNA 1 spoke to her [SSD 1] and was aware of the incident. The SSD 1 also stated "I did not document it. I know that I must document it and must follow up. But I was not able to document it." There was no documented evidence that the incident in the shower room was documented in the SSD notes nor the nurses' notes, and it was not care planned. A review of facility's policy and procedures titled "Policy: Abuse Allegation Investigation", indicated "Purpose: To ensure that a complete and thorough investigation is conducted for all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 18 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 allegation of abuse ... 2. Interview resident and document allegations. 3. Interview staff member (s) accused of alleged abuse; document findings, suspend staff member (s) pending outcome of investigation ...." A review of facility policy and procedures titled "Policy: Abuse & Mistreatment of Residents", indicated "Purpose: To uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion." "Definitions: 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability." A review of facility document titled "Job Description: Administrator", dated October 12, 2011, indicated "Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and Procedure; review and document appropriate investigation and follow up as needed ...Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed ...Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures." An Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment or death to a resident) was called related to verbal abuse, on June 5, 2018 at 8:05 AM, in the presence of the Administrator and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 19 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Director of Nursing. A corrective action plan was requested from the facility to lift the immediacy of the situation. The facility provided an acceptable corrective action plan. The Immediate Jeopardy (IJ) was abated on June 7, 2018 at 12:42 PM, in the presence of the Regional Director of Operations and the Director of Nursing (DON) after review and verification of the elements submitted in the corrective action plan. The facility's corrective action plan stated as follows: - The involved residents were assessed and interviewed to ensure their safety and the involved staff were immediately refrained from interacting with residents. The Social Service Designee (SSD1) interviewed the three residents involved to provide emotional support. - Statement of Correction (SOC 341) was completed and sent to California Department of Public Health (CDPH) and Ombudsman on June 5, 2018. - SSD1, Admissions, and Marketing Director conducted resident interviews on June 5, 2018 to check if any other residents had concerns regarding staff's behaviors towards them. No other residents were found affected by the action. - A one on one in-service was provided to the involved staff members regarding facility policy and Abuse Prevention and Abuse Allegation Reporting. The Administrator was counseled on abuse reporting and investigation time frames. - Effective immediately, the Director of Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 20 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 will assume the position as Abuse Coordinator. -An in-service was initiated on June 5, 2018 and concluded on June 6, 2018 to all staff by Director of Nursing and designee regarding facility policy on Abuse Prevention and Abuse Allegation reporting. - The Director of Nursing and Interdisciplinary Team (IDT) reviewed the Concern Record regarding alleged incidents and appropriate resolutions were indicated. - The Regional Director of Operations evaluated the incident involving the Administrator for failure to follow facility policy in reporting allegations of abuse. The employee's infraction of facility policy led to discharge and was discussed June 6, 2018. A notice to employee as a Change in Relationship was signed by both Regional Director of Operations and the employee. The final check was provided at the time of termination. EED pamphlets were provided and COBRA was discussed. - Any other employees who were not able to attend in-service on June 5, 2018 and June 6, 2018 will not be able to return to work until they have received an in-service by the Director of Staff Development (DSD) regarding facility policy on Abuse Prevention and Abuse Allegation.

F607 SS=E Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F607 Event ID: RF2R11 06/10/2018 Facility ID: CA240000089 If continuation sheet 21 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: 2. During an observation of Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 was alert and oriented. Resident 55 was in bed, with a bible and magnifying glass on top of his over bed table. Resident 55 had above the left knee amputation, and a wheelchair on the side of the bed. Resident 55 was able to answer questions, and was alert and oriented. During an interview with Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 stated he had a recent incident that bothered him, and kept thinking about the incidents. Resident 55 further stated two weeks ago the CNA 1 (Certified Nursing Assistant) bathed him [Resident 55]. During bathing, the CNA 1 turned off the shower and held Resident 55's wheelchair away from the shower area. The Resident 55 held CNA 1 wrists and yelled at her [CNA 1]. Resident 55 said the second incident happened few days ago. Resident 55 said he called the CNA 1 a snake like his sister. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 22 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Per Resident 55 after the last incident brought the Administrator (ADM), Social Services Designee 2 (SSD 2), and the CNA 1 visited the Resident 55 in his room. Resident 55 further stated the ADM stated, "You are the problem here, not my staff. You should not do that to my staff. You read the bible and practice what you are reading." Resident 55 stated, "I felt so little. I felt that I am nothing in this world. I felt humiliated, I want to cry but I just kept it in my chest." A review of Resident 55's medical records titled "History and Physical", dated August 31, 2017, indicated "This resident: 1. Has the capacity to understand and make decisions." A review of Resident 55's document titled "Quarterly Minimum Data Set", dated April 4, 2018, indicated "Section C Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score 14." During a follow up interview with Resident 55, on June 4, 2018, at 4:02 PM, he stated "I feel humiliated and I feel offended. The words that she [Administrator] said keeps running to my head, she [Administrator] said 'You should read the bible and practice what you read.' I felt that she tried to humiliate me in front of [name of the SSD 2] and [name of the CNA 1]." Resident 55 further stated, "I am not comfortable talking to her [Administrator] anymore. I am thinking what she [Administrator] told me to read the bible and practice what I am reading. She [Administrator] is very tough in saying that. That is why if I feel that when she [Administrator] is walking in the hallway and I am in my wheelchair I just turn my back and pretend to watch television and wishing that she will not come to my room. She [Administrator] is very firm and told me, "If I would have been here years ago, I will kick you out." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 23 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 During an interview with the ADM, on June 4, 2018 at 4:23 PM, the ADM was asked about the allegations of Resident 55 and she [ADM] did not confirmed the allegations. During a record review of Resident 55's medical records with the ADM and the MDS 1 (Minimum Data Set), on June 4, 2018 at 4:36 PM, the medical records showed no evidence of a care plan, thorough investigations of the incident, nor follow up with Resident 55. During a concurrent interview with the SSD 1 and record review of Resident 55's medical records, on June 5, 2018, at 9:30 AM, the SSD 1 stated the CNA 1 spoke to her [SSD 1] and was aware of the incident. The SSD 1 also stated "I did not document it. I know that I must document it and must follow up. But I was not able to document it." There was no documented evidence to show that the incident in the shower room was documented in the SSD notes, nurses' notes, and it was not care planned. A review of facility's policy and procedures titled, "Policy: Abuse Allegation Investigation", indicated "Purpose: To ensure that a complete and thorough investigation is conducted for all allegation of abuse ... 2. Interview resident and document allegations. 3. Interview staff member (s) accused of alleged abuse; document findings, suspend staff member (s) pending outcome of investigation ...." A review of facility policy and procedures titled "Policy: Abuse & Mistreatment of Residents", indicated "Purpose: To uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion." "Definitions: 2. Verbal Abuse is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 24 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability." A review of facility document titled "Job Description: Administrator", dated October 12, 2011, indicated "Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and Procedure; review and document appropriate investigation and follow up as needed ...Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed ...Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures." Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedure for three of 88 residents (Resident 203, Resident 55 and Resident 59), when they were subjected to verbal abuse from staff. This failure affected the mental and psychosocial well beings of the residents. Findings: 1. During an observation on June 4, 2018 at 8:30 AM, Resident 59 and Resident 203 were in their beds, awake, alert and able to talk coherently. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 25 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 A concurrent interview with Resident 59 and Resident 203 were conducted. Resident 59 stated, she was upset with Licensed Vocational Nurse 7 (LVN 7) because LVN 7 yelled and was rude at her. LVN 7 refused to give Resident 59's pain medication. Resident 59 stated that on May 24, 2018 at 117 shift both she and Resident 203 were both in need of pain medications. Resident 59 pushed on her call button to call LVN 7. LVN 7 came to their room and turned off Resident 59's call button and spoke only to Resident 203. LVN 7 ignored Resident 59. When LVN 7 was about to leave the room, Resident 203 asked her, "Wait, what about her pain medication? (referring to Resident 59)." LVN 7 ignored Resident 203, and left the room. Resident 59 used her call button again to ask for her pain medication from LVN 7. During a concurrent interview with Resident 203, she stated LVN 7 has not returned yet to give her pain medication for an unknown amount of time. Resident 203 yelled to LVN 7 to come to their room. LVN 7 returned to their room and yelled at Resident 59, and stated, "If you don't shut your mouth up, I will not give your pain medication!" Resident 59 got upset with LVN 7 and told her she was not the one who yelled but her but Resident 203 did. Resident 203 stated, "She [LVN 7] then yelled and was nasty at me," and said "Shut your mouth! You are not the only resident here!" Resident 203 further stated that LVN 7 gave the medication to her but not to Resident 59. Resident 59 added, that LVN 7 never returned to their room. Resident 59 used her cell phone to call the nursing station to ask the help of another charge nurse to give her pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 26 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 medication. Resident 59 stated that she asked for her routine pain medication from LVN 7. Resident 59 stated LVN 7 knew she had a scheduled pain medication by 4:00 PM. Resident 59 was already in pain so she asked for it earlier at 3:00 AM. Resident 59 got it only by 5:30 AM by a different charge nurse. Resident 59 and Resident 203 stated they reported the incident to the Licensed Vocational Nurse 6 (LVN 6) in the morning of May 25, 2018. Resident 59 and Resident 203 stated they were both worried LVN 7 will still yell at them since LVN 7 was still on schedule at work and assigned to them. During an interview with LVN 6 on June 5, 2018 at 10:00 AM, she stated that she was working on May 25, 2018 and the two residents (Resident 59 and Resident 203) reported about their incident with LVN 7. LVN 6 stated she reported the incident to the Director of Nursing (DON). During an interview with the DON on June 5, 2018 at 10:30 AM, he stated, he interviewed both Resident 59 and Resident 203. He stated, he did not follow the facility abuse policy and procedure instead he just reassigned LVN 7 to different patients and allowed her to work in the facility while doing the investigation of the alleged abuse. During an interview of LVN 7 on June 5, 2018 at 11:00 AM, LVN 7 stated she worked on May 24, 2018 at 11-7 shift. LVN 7 stated she was just explaining to Resident 59 and Resident 203 why she was late giving them their medications and it was Resident 59 and Resident 203 who were mad at her. The clinical record of Resident 59 indicated, she was admitted to the facility on February 24, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 27 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2018 with diagnoses of chronic pain syndrome and osteoarthritis (bone pains). A review of Resident 59's Minimum Data Set (MDS -comprehensive resident clinical assessment) under section C0500 Brief interview for mental status (BIMS), indicated she had 14 out of 15 total score which was considered oriented and coherent. A review of Resident 59's Physician Order, dated, April 1, 2018, indicated an order of dilaudid (pain medication) four (4) milligrams (unit dose) by mouth every four hours. A review of Resident 203's clinical record indicated she was admitted to the facility on May 4, 2018 with diagnoses of chronic pain syndrome and rheumatoid arthritis (joint pains). A review of Resident 203's MDS, under section C0500, BIMS, indicated she had 13 out of total score 15 which was considered oriented and coherent. A review of Resident 203's Physician order, dated May 21, 2018, indicated an order of Percocet 10-325 milligrams (unit dose) one tablet by mouth every six hours as needed for pain. A review of Resident 203's care plan dated February 23, 2018, indicated, she has pain and discomfort because of arthritis and one intervention is to give the pain medication as ordered. A review of the work schedule of LVN 7, entitled," Punch Detail", time period from May 1, 2018 thru May 31, 2018, indicated, LVN 7 worked May 24, 2018, May 30, 2018, May 31, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 28 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 The facility and procedure titled, "Abuse Allegation Investigation", undated, indicated under content, " ...3. Interview staff members accused of alleged abuse, document findings, suspend staff members pending outcome of investigation ..."

F609 SS=E Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 06/10/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 29 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2. During an observation of Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 was alert and oriented. Resident 55 was in bed, with a bible and magnifying glass on top of his over bed table. Resident 55 had above the left knee amputation, and a wheelchair on the side of the bed. Resident 55 was able to answer questions, and was alert and oriented. During an interview with Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 stated he had a recent incident that bothered him, and kept thinking about the incidents. The Resident 55 further stated two weeks ago the Certified Nursing Assistant (CNA 1) bathe him [Resident 55]. During bathing, the CNA 1 turned off the shower and held Resident 55's wheelchair away from the shower area. The Resident 55 held CNA 1 wrists and yelled at her [CNA 1] that he still wanted more time for shower. During an interview the Resident 55, Resident 55 said he felt sorry for yelling at the CNA 1. Resident 55 told the second incident happened few days ago. Resident 55 noticed that every time he [Resident 55] asked something, CNA 1 will just come and go but never come back. Resident 55 stated "I asked her for extra coffee and she did not comeback to me. I pressed the call light and she just turned it off and keeps on saying she will be back. So when I saw her again I told her that she is a 'snake like my sister', because she comes and leave right away." A review of Resident 55's medical records titled "History and Physical", dated August 31, 2017, indicated "This resident: 1. Has the capacity to understand and make decisions." A review of Resident 55's document titled "Quarterly Minimum Data Set", dated April 4, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 30 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2018, indicated "Section C Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score 14." Per Resident 55 after the last incident brought the Administrator (ADM), Social Services Designee 2 (SSD 2), and the CNA 1 visited the Resident 55 in his room. The ADM discussed the situation with him. During an interview with the Licensed Vocational Nurse (LVN 1), on June 4, 2018, at 3:55 PM, the LVN 1 was asked about Resident 55's behavior and he [LVN 1] stated "The resident is very particular with his ADLs (Activities of Daily Living), but a very nice guy and very religious." During a follow up interview with Resident 55, June 4, 2018, at 4:02 PM, he stated "I feel humiliated and I feel offended. The words that she [Administrator] said keeps running to my head. She [Administrator] said 'You should read the bible and practice what you read.' I felt that she tried to humiliate me in front of [name of the SSD 2] and [name of the CNA 1]." Resident 55 further stated "I am not comfortable talking to her [Administrator] anymore. I am thinking what she [Administrator] told me to read the bible and practice what I am reading. She [Administrator] is very tough in saying that. That is why if I feel that when she [Administrator] is walking in the hallway and I am in my wheelchair I would just turn my back and pretend to watch television and wishing that she will not come to my room. She [Administrator] is very firm and told me, "If I would have been here years ago, I will kick you out." During an interview with the ADM, on June 4, 2018 at 4:23 PM, the ADM stated, "We went there to talk to him about the incident between FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 31 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Resident 55 and CNA 1 [incident in the shower room and calling the CNA 1 a 'snake' by Resident 55], and everything was fine." The ADM was asked about the allegations of Resident 55, and she [ADM] did not confirm the allegations. The ADM stated "The CNA came to us [the ADM and the SSD 2] and then we went to his room to talk to him. And I cannot say those words to him." During a record review of Resident 55's medical records with the ADM and the MDS 1 (Minimum Data Set), on June 4, 2018 at 4:36 PM, there were SSD notes, IDT (Interdisciplinary Team) meeting notes dated June 1, 2018, and signed by Social Services Designee 1 (SSD 1). The medical records showed no evidence of a care plan, thorough investigations of the incident, following up of the incident, and reporting of unusual occurrence to California Department of Public Health (CDPH). A review of facility's policy and procedures titled "Policy: Abuse Allegation Investigation", indicated "Purpose: To ensure that a complete and thorough investigation is conducted for all allegation of abuse ... 2. Interview resident and document allegations. 3. Interview staff member (s) accused of alleged abuse; document findings, suspend staff member (s) pending outcome of investigation ...." A review of facility policy and procedures titled "Policy: Abuse & Mistreatment of Residents", indicated "Purpose: To uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion." "Definitions: 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 32 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 their age, ability to comprehend, or disability." A review of facility document titled "Job Description: Administrator", dated October 12, 2011, indicated "Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and Procedure; review and document appropriate investigation and follow up as needed ...Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed ...Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures." A review of facility document titled "Job Description: Administrator", dated October 12, 2011, indicated "Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and Procedure; review and document appropriate investigation and follow up as needed ...Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed ...Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures." Based on observation, interview, and record review, the facility failed to report allegations of staff to resident abuse to the California FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 33 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Department of public Health (CDPH) for three residents (Resident 203, Resident 55 and Resident 59), in a universe of 88 residents. This failure affected the mental and psychosocial well being of the residents. Findings: 1. During an observation on June 4, 2018 at 8:30 AM, Resident 59 and Resident 203 were in their beds, awake, alert and able to talk coherently. A concurrent interview with Resident 59 and Resident 203 were conducted. Resident 59 stated, she was upset with Licensed Vocational Nurse 7 (LVN 7) because LVN 7 yelled and was rude at her. LVN 7 refused to give Resident 59's pain medication. Resident 59 stated that on May 24, 2018 at 117 shift both she and Resident 203 were both in need of pain medications. Resident 59 pushed on her call button to call LVN 7. LVN 7 came to their room and turned off Resident 59's call button and spoke only to Resident 203. LVN 7 ignored Resident 59. When LVN 7 was about to leave the room, Resident 203 asked her, "Wait, what about her pain medication? (referring to Resident 59)." LVN 7 ignored Resident 203, and left the room. Resident 59 used her call button again to ask for her pain medication from LVN 7. During a concurrent interview with Resident 203, she stated LVN 7 has not returned yet to give her pain medication for an unknown amount of time. Resident 203 yelled to LVN 7 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 34 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 to come to their room. LVN 7 returned to their room and yelled at Resident 59, and stated, "If you don't shut your mouth up, I will not give your pain medication!" Resident 59 got upset with LVN 7 and told her she was not the one who yelled but her but Resident 203 did. Resident 203 stated, "She [LVN 7] then yelled and was nasty at me," and said "Shut your mouth! You are not the only resident here!" Resident 203 further stated that LVN 7 gave the medication to her but not to Resident 59. Resident 59 added, that LVN 7 never returned to their room. Resident 59 used her cell phone to call the nursing station to ask the help of another charge nurse to give her pain medication. Resident 59 stated that she asked for her routine pain medication from LVN 7. Resident 59 stated LVN 7 knew she had a scheduled pain medication by 4:00 PM. Resident 59 was already in pain so she asked for it earlier at 3:00 AM. Resident 59 got it only by 5:30 AM by a different charge nurse. Resident 59 and Resident 203 stated they reported the incident to the Licensed Vocational Nurse 6 (LVN 6) in the morning of May 25, 2018. Resident 59 and Resident 203 stated they were both worried LVN 7 will still yell at them since LVN 7 was still on schedule at work and assigned to them. During an interview with LVN 6 on June 5, 2018 at 10:00 AM, she stated that she was working on May 25, 2018 and the two residents (Resident 59 and Resident 203) reported about their incident with LVN 7. LVN 6 stated she reported the incident to the Director of Nursing (DON). During an interview with the DON on June 5, 2018 at 10:30 AM, he stated, he interviewed both Resident 59 and Resident 203. He stated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 35 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 he did not follow the facility abuse policy and procedure instead he just reassigned LVN 7 to different patients and allowed her to work in the facility while doing the investigation of the alleged abuse. During an interview of LVN 7 on June 5, 2018 at 11:00 AM, LVN 7 stated she worked on May 24, 2018 at 11-7 shift. LVN 7 stated she was just explaining to Resident 59 and Resident 203 why she was late giving them their medications and it was Resident 59 and Resident 203 who were mad at her. Review of the clinical record of Resident 59 indicated, she was admitted to the facility on February 24, 2018 with diagnoses of chronic pain syndrome and osteoarthritis (bone pains). A review of Resident 59's Minimum Data Set (MDS -comprehensive resident clinical assessment) under section C0500 Brief interview for mental status (BIMS), indicated she had 14 out of 15 total score which was considered oriented and coherent. A review of Resident 59's Physician Order, dated, April 1, 2018, indicated an order of dilaudid (pain medication) four (4) milligrams (unit dose) by mouth every four hours. A review of Resident 203's clinical record indicated she was admitted to the facility on May 4, 2018 with diagnoses of chronic pain syndrome and rheumatoid arthritis (joint pains). A review of Resident 203's MDS, under section C0500, BIMS, indicated she had 13 out of total score 15 which was considered oriented and coherent. A review of Resident 203's Physician order, dated May 21, 2018, indicated an order of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 36 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Percocet 10-325 milligrams (unit dose) one tablet by mouth every six hours as needed for pain. A review of Resident 203's care plan dated February 23, 2018, indicated, she has pain and discomfort because of arthritis and one intervention is to give the pain medication as ordered. A review of the work schedule of LVN 7, entitled," Punch Detail", time period from May 1, 2018 thru May 31, 2018, indicated, LVN 7 worked May 24, 2018, May 30, 2018, May 31, 2018. The facility and procedure titled, "Abuse Allegation Investigation", undated, indicated under content, " ...3. Interview staff members accused of alleged abuse, document findings, suspend staff members pending outcome of investigation ..."

F610 SS=E Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 06/10/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 37 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 taken. This REQUIREMENT is not met as evidenced by: 2. During an observation of Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 was alert and oriented. Resident 55 was in bed, with a bible and magnifying glass on top of his over bed table. Resident 55 had above the left knee amputation, and a wheelchair on the side of the bed. Resident 55 was able to answer questions, alert, and oriented. During an interview with Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 stated he had a recent incident that bothered him, and kept thinking about the incidents. The Resident 55 further stated two weeks ago the Certified Nursing Assistant (CNA 1) bathe him [Resident 55]. During bathing, the CNA 1 turned off the shower and held Resident 55's wheelchair away from the shower area. The Resident 55 held CNA 1 wrists and yelled at her [CNA 1] that he still wanted more time for shower. During an interview Resident 55 said he felt sorry for yelling at the CNA 1. Resident 55 told the second incident happened few days ago. Resident 55 noticed that every time he [Resident 55] asked something, CNA 1 will just come and go but never come back. Resident 55 stated "I asked her for extra coffee and she did not come back to me. I pressed the call light and she just turned it off and keeps on saying she will be back. So when I saw her again I told her that she is a 'snake like my sister', because she comes and leave right away." Per Resident 55 after the last incident brought the Administrator (ADM), Social Services Designee 2 (SSD 2), and the CNA 1 visited the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 38 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Resident 55 in his room. The Resident 55 further stated the ADM stated "You are the problem here, not my staff. You should not do that to my staff. You read the bible and practice what you are reading." The Resident 55 stated "I felt so little. I felt that I am nothing in this world. I felt humiliated, I want to cry but I just kept it in my chest." A review of Resident 55's medical records titled "History and Physical", dated August 31, 2017, indicated "This resident: 1. Has the capacity to understand and make decisions." A review of Resident 55's document titled "Quarterly Minimum Data Set", dated April 4, 2018, indicated "Section C Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score 14." During an interview with the Licensed Vocational Nurse (LVN 1), on June 4, 2018, at 3:55 PM, the LVN 1 was asked about Resident 55's behavior and he [LVN 1] stated "The resident is very particular with his ADLs (Activities of Daily Living), but a very nice guy and very religious." During a follow up interview with Resident 55, June 4, 2018, at 4:02 PM, he stated "I feel humiliated and I feel offended. The words that she [Administrator] said keeps running to my head. She [Administrator] said 'You should read the bible and practice what you read.' I felt that she tried to humiliate me in front of [name of the SSD 2] and [name of the CNA 1]." Resident 55 further stated "I am not comfortable talking to her [Administrator] anymore. I am thinking what she [Administrator] told me to read the bible and practice what I am reading. She [Administrator] is very tough in saying that. That is why if I feel that when she [Administrator] is walking in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 39 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 hallway and I am in my wheelchair I would just turn my back and pretend to watch television and wishing that she will not come to my room. She [Administrator] is very firm and told me, "If I would have been here years ago, I will kick you out." During an interview with the ADM, on June 4, 2018 at 4:23 PM, the ADM stated "We went there to talk to him about the incident between Resident 55 and CNA 1 [incident in the shower room and calling the CNA 1 a 'snake' by Resident 55], and everything was fine." The ADM was asked about the allegations of Resident 55, and she [ADM] did not confirm the allegations. The ADM stated "The CNA [CNA 1] and the resident [Resident 55] had an incident during shower. The ADM further stated "For what I remembered, the resident grabbed the wrists of the CNA, and called her a 'snake'. The CNA came to us [the ADM and the SSD 2] and then we went to his room to talk to him. And I cannot say those words to him." During a record review of Resident 55's medical records with the ADM and the MDS 1 (Minimum Data Set), on June 4, 2018 at 4:36 PM, there were SSD notes, IDT (Interdisciplinary Team) meeting notes dated June 1, 2018, and signed by Social Services Designee 1 (SSD 1). The medical records showed no evidence of care plan, thorough investigations of the incident, follow up, and reporting of unusual occurrence to California Department of Public Health (CDPH). During an interview with the SSD 2, on June 5, 2018, at 7:55 AM, the SSD 2 stated "As what I remember, [name of the Administrator] said to him [Resident 55] 'this is not an acceptable behavior and that is not the way you talk to the staff that is providing care for you." The SSD 2 further stated the ADM always firm in talking to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 40 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 people. During a concurrent interview with the SSD 1 and record review of Resident 55's medical records, on June 5, 2018, at 9:30 AM, the SSD 1 stated the CNA 1 spoke to her [SSD 1] and was aware of the incident. The SSD 1 also stated "I did not document it. I know that I must document it and must follow up. But I was not able to document it." There was no documented evidence that incident in the shower room was documented in SSD notes, nurses' notes, and was not care planned. A review of facility's policy and procedures titled "Policy: Abuse Allegation Investigation", indicated "Purpose: To ensure that a complete and thorough investigation is conducted for all allegation of abuse ... 2. Interview resident and document allegations. 3. Interview staff member (s) accused of alleged abuse; document findings, suspend staff member (s) pending outcome of investigation ...." A review of facility policy and procedures titled "Policy: Abuse & Mistreatment of Residents", indicated "Purpose: To uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion." "Definitions: 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability." A review of facility document titled "Job Description: Administrator", dated October 12, 2011, indicated "Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 41 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Procedure; review and document appropriate investigation and follow up as needed ...Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed ...Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures." Based on observation, interview, and record review, the facility failed to prevent abuse for three residents (Resident 203, Resident 55 and Resident 59) in a universe of 88 residents. This failure affected the mental and psychosocial well being of the residents. Findings: 1. During an observation on June 4, 2018 at 8:30 AM, Resident 59 and Resident 203 were in their beds, awake, alert and able to talk coherently. A concurrent interview with Resident 59 and Resident 203 were conducted. Resident 59 stated, she was upset with Licensed Vocational Nurse 7 (LVN 7) because LVN 7 yelled and was rude at her. LVN 7 refused to give Resident 59's pain medication. Resident 59 stated that on May 24, 2018 at 117 shift both she and Resident 203 were both in need of pain medications. Resident 59 pushed on her call button to call LVN 7. LVN 7 came to their room and turned off Resident 59's call button and spoke only to Resident 203. LVN 7 ignored Resident 59. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 42 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 When LVN 7 was about to leave the room, Resident 203 asked her," Wait, what about her pain medication? (referring to Resident 59)," LVN 7 ignored Resident 203, and left the room. Resident 59 used her call button again to ask for her pain medication from LVN 7. During a concurrent interview with Resident 203, she stated LVN 7 has not returned yet to give her pain medication for an unknown amount of time. Resident 203 yelled to LVN 7 to come to their room. LVN 7 returned to their room and yelled at Resident 59, and stated, "If you don't shut your mouth up, I will not give your pain medication!" Resident 59 got upset with LVN 7 and told her she was not the one who yelled but her but Resident 203 did. Resident 203 stated, "She [LVN 7] then yelled and was nasty at me," and said "Shut your mouth! You are not the only resident here!" Resident 203 further stated that LVN 7 gave the medication to her but not to Resident 59. Resident 59 added, that LVN 7 never returned to their room. Resident 59 used her cell phone to call the nursing station to ask the help of another charge nurse to give her pain medication. Resident 59 stated that asked for her routine pain medication from LVN 7. Resident 59 stated LVN 7 knew she had a scheduled pain medication by 4:00 PM. Resident 59 was already in pain so she asked for it earlier at 3:00 AM. Resident 59 got it only by 5:30 AM by a different charge nurse. Resident 59 and Resident 203 stated they reported the incident to the Licensed Vocational Nurse 6 (LVN 6) in the morning of May 25, 2018. Resident 59 and Resident 203 stated they were both worried LVN 7 will still yell at them since LVN 7 was still on schedule at work and assigned to them. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 43 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 During an interview with LVN 6 on June 5, 2018 at 10:00 AM, she stated that she was working on May 25, 2018 and the two residents (Resident 59 and Resident 203) reported about their incident with LVN 7. LVN 6 stated she reported the incident to the Director of Nursing (DON). During an interview with the DON on June 5, 2018 at 10:30 AM, he stated, he interviewed both Resident 59 and Resident 203. He stated, he did not follow the facility abuse policy and procedure instead he just reassigned LVN 7 to different patients and allowed her to work in the facility while doing the investigation of the alleged abuse. During an interview of LVN 7 on June 5, 2018 at 11:00 AM, LVN 7 stated she worked on May 24, 2018 at 11-7 shift. LVN 7 stated she was just explaining to Resident 59 and Resident 203 why she was late giving them their medications and it was Resident 59 and Resident 203 who were mad at her. Review of the clinical record of Resident 59 indicated, she was admitted to the facility on February 24, 2018 with diagnoses of chronic pain syndrome and osteoarthritis (bone pains). A review of Resident 59's Minimum Data Set (MDS -comprehensive resident clinical assessment) under section C0500 Brief interview for mental status (BIMS), indicated she had 14 out of 15 total score which was considered oriented and coherent. A review of Resident 59's Physician Order, dated, April 1, 2018, indicated an order of dilaudid (pain medication) four (4) milligrams (unit dose) by mouth every four hours. A review of Resident 203's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 44 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 she was admitted to the facility on May 4, 2018 with diagnoses of chronic pain syndrome and rheumatoid arthritis (joint pains). A review of Resident 203's MDS, under section C0500, BIMS, indicated she had 13 out of total score 15 which was considered oriented and coherent. A review of Resident 203's Physician order, dated May 21, 2018, indicated an order of Percocet 10-325 milligrams (unit dose) one tablet by mouth every six hours as needed for pain. A review of Resident 203's care plan dated February 23, 2018, indicated, she has pain and discomfort because of arthritis and one intervention is to give the pain medication as ordered. A review of the work schedule of LVN 7, entitled," Punch Detail", time period from May 1, 2018 thru May 31, 2018, indicated, LVN 7 worked May 24, 2018, May 30, 2018, May 31, 2018. The facility and procedure titled, "Abuse Allegation Investigation", undated, indicated under content, " ...3. Interview staff members accused of alleged abuse, document findings, suspend staff members pending outcome of investigation ..."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/28/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 45 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an updated care plan (a plan to improve current clinical condition of the resident) was developed to meet the needs of one of 29 sampled residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 46 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 (Resident 30) after a change of condition was assessed in his behavioral status. The failure has the potential for the facility not to provide the necessary care needed by the resident. Findings: During a clinical record review for Resident 30, it indicated Resident 30 was admitted to the facility on February 8, 2018, with diagnoses which included, transient cerebral ischemic attack (TIA-brief stroke-like attack), peripheral vascular disease (PVD-narrowed blood vessels reduce blood flow to the extremities) and epilepsy (nerve cell activity in the brain is disturbed). During an observation on June 4, 2018 at 3:39 PM, Resident 30 was awake dressed in his wheelchair and in the activities room. Resident 30 had a sling on his left elbow. Resident 30 stated he was seeing a psychiatrist and has periods of being mad. He states he is taking medication for his moods. A record review indicated a psychiatrist note dated April,15, 2018 indicated,"Resident is stable but, he is displaying inappropriate sexual behavior." A record review of an Interdisciplinary team (IDT is a team of professionals that meet with important insights to contribute to the residents care) meeting held on May 17, 2018 for Resident 30's change of condition indicated," Behavior Present, yes: Inappropriate sexual behavior." Psychotropic medications: Prozac (medication for depression, mood/behavior (M/B) and inappropriate sexual behavior). During an interview with Licensed Vocational Nurse (LVN 3), on June 7, 2018, at 4:00 PM, LVN 3 stated Resident 30 had a change of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 47 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 condition recently for inappropriate sexual behavior towards a female staff nurse. LVN 3 stated they had an IDT meeting and decided to keep the female nurse and Resident 30 apart. A record review of Resident 30's Restorative Nurse Assistant (RNA) referral: behavior: Resident fluctuates: and will not keep his sling on his left elbow. A record review of Resident 30's Medical Doctor (MD) titled," Medication Orders Summary", dated June 1, 2108, indicated: Prozac capsule 30 Milligrams (mg- a unit of measure) given by mouth daily for depression, mood/behavior (M/B) inappropriate sexual behavior. Informed consent was signed. During an interview with LVN 3, on June 7, 2018, at 4:30 PM, LVN 3 stated she could not provide any care plan that was implemented after a change of condition was done for Resident 30 after he was assessed for inappropriate sexual behavior. LVN 3 verified that after Resident 30's IDT meeting he should have had a care plan initiated. During an interview with the Assistant Director of Staff Development (ADSD), on June 7, 2018, at 4:40 PM, the ADSD verified Resident 30 should have had a Care Plan initiated and implemented after Resident 30 was assessed for inappropriate sexual behavior. The facility policy and procedure titled,"Change of Condition"dated January 24, 2017, indicated ..." Purpose: To ensure proper assessment and follow-through for any resident with a change of condition. Definition: A change of condition is a sudden or marked difference in resident's: 2. Behavior, E Documentation shall be performed by the Licensed Vocational Nurse: 4. Care Plan evident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 48 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE .

F658 SS=D 06/28/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure physician's order has been followed for two (2) of 29 sampled residents (Resident 18 and Resident 25) when: 1. Resident 18's physician order for Keppra (for seizures) level test every three (3) months was not done; 2. Resident 25's physician order for HgbA1C (Glycosylated Hemoglobin- blood sugar test) level every three (3) month was not done. These failures had the potential for the residents to have inaccurate assessment, care, and treatment from the facility physician and staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 49 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Findings: 1. During a record review of Resident 18's medical records, on June 7, 2018, at 2:20 PM, indicated the Resident 55 was admitted on October 15, 2017, with diagnoses of pneumonia (lung disease), seizures, multiple sclerosis (progressive disease involving damage to the nerve cells in the brain and spinal cord), dementia (forgetfulness), major depressive disorder, anxiety disorder, pseudobulbar affect (uncontrollable episodes of crying and/or laughing, or other emotional displays), and unspecified convulsions (seizures). The Resident 18 does not have the capacity to understand and make decisions. A review of facility document titled "Order Summary Report", dated June 1, 2018, indicated "Start Date 11/17/18, Laboratory: Keppra Level then Q (every) 3 months", and "Keppra Solution (Levetiracetam) give 15 ml (millimeters - unit of measurement) G-Tube (gastrostomy tube- feeding tube is a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth) two times a day for seizure." A review of facility document titled "Medication Administration Records (MAR)", dated May 2018, and indicated the Resident 18 was receiving Keppra Solution 15 ml via G-Tube two times a day for seizure disorder. During a concurrent interview with the Licensed Vocational Nurse 1 (LVN) and Resident 18's medical record review, on June 7, 2018, at 2:35PM, indicated no laboratories for Keppra level from January to May 2018. The LVN 1 stated "There was no laboratory results for Keppra level. And we do not know the current Keppra level." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 50 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 During an interview with the LVN 8, on June 7, 2018 at 3:15 PM, the LVN 8 stated "It is very important to check the laboratory level per doctor's order. In that way we can manage the patient if there is high or low on their conditions." A review of facility's policy and procedures titled "Policy & Procedure: Laboratory Tests", undated, indicated "Policy: Laboratory requests will be completed as ordered or by month-end." "Procedure: 4. Unless a specific date for laboratory tests is ordered, laboratory test will be completed by month's end." 2. During a record review of Resident 25's medical record, on June 7, 2018, at 2:45 PM, indicated the Resident 18 was admitted November 5, 2017 with diagnoses of spinal stenosis (narrowing of the spaces within your spine, which can put pressure on the nerves and causes pain), acute kidney failure, hypertension (increased blood pressure), and type 2 diabetes mellitus (blood sugar problem). The Resident 25 has the capacity to understand and make decision. A review of facility document titled "Order Summary Report", dated May, 2018, indicated "Start Date 11/05/17, Laboratory: HgbA1c (Glycosylated Hemoglobin- blood sugar test) Level Q (every) 3 months, May-Aug-Nov-Feb." A review of facility document titled "Physician Order", dated April 27, 2018, at 7:30 AM, indicated the insulin Lispro (to lower blood sugar) to be discontinued, also indicated the Resident 25 may have HgbA1c on April 30, 2018. During an interview with the Licensed Vocational Nurse 1 (LVN), on June 7, 2018, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 51 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2:35 PM, indicated no laboratories for HgbA1c level from January to May 2018. The LVN 1 stated "There was no laboratory results for HgbA1c level." During an interview with the LVN 8, on June 7, 2018 at 3:15 PM, the LVN 8 stated "It is very important to check the laboratory level per doctor's order. In that way we can manage the patient if there is high or low on their conditions." A review of facility's policy and procedures titled "Policy & Procedure: Laboratory Tests", undated, indicated "Policy: Laboratory requests will be completed as ordered or by month-end." "Procedure: 4. Unless a specific date for laboratory tests is ordered, laboratory test will be completed by month's end." Based on observation, interview, and record review, the facility failed to ensure one of 19 residents (Resident 20) had a fall risk assessment completed on admission with a diagnosis of history of falls, generalized weakness and a physicians order for a bed alarm when an alarm was found on Resident 20's bed. This failure had a potential to risk the health and safety of Resident 20. Findings: During an observation of Resident 20 on June 4, 2018, at 9:00 AM, Resident 20 was observed getting out of bed wobbly on her feet,unassisted by staff, bed in low position, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 52 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 matt on the floor on both sides of the bed, half side rails up, wheel chair next to the wall, call light tied to the bed rail, and a bed alarm in place. The alarm did not make any sound when Resident 20 got out of her bed to use the rest room. A clinical record review of Resident 20 indicated, Resident 20 was admitted to the facility initially on August 3, 2017 with diagnoses which included muscle weakness, primary osteoarthritis (cartilage at the end of your bones wears down), and pulmonary coccidioidomycosis (infection in the lungs caused by a fungus. Commonly known as valley fever). During an interview with Resident 20 on June 4, 2018, at 9:12 AM, Resident 20 stated,"I can walk fine on my own." Resident 20 stated the bed alarm was to let staff know when she got in and out of bed. Resident 20 stated staff rarely came into her room when the alarm went off and that staff showed her how to shut the alarm off when she gets out of bed. During an interview with the Director of Nurses (DON) on June 4, 2018, at 9:20 AM, the DON verified that was a bed alarm on Resident 20's bed. The DON checked the battery in the alarm and it still good. The DON stated,"Resident 20 is suppose to be assisted by one staff to use the rest room so she does not fall." During an observation of Resident 20 on June 7, 2018, at 9:30 AM, Resident 20 was observed getting out of bed, wobbly, alone without staff assistance to use the rest room and her bed alarm did not go off. During an interview with Licensed Vocational Nurse (LVN 4) on June 7, 2018, at 10:21 AM, LVN 4 stated Resident 20's bed alarm should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 53 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 go off when she gets in and out of bed to alert staff. LVN 4 stated," Resident 20 needs one person assistance to the rest room." A clinical record review of Resident 20's Physicians orders dated May 24, 2018, indicated under admission diagnoses: Hepatic Encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood), Altered mental status,Trauma, and History of falls. Under equipment orders: Low bed with side mattress. A clinical record review of Resident 20 indicated no fall risk assessment was done on admission. During an interview with LVN 4 on June 7, 2018, at 10:25 AM, LVN 4 verified no fall risk assessment was completed and no Physicians order was written for a bed alarm. LVN 4 verified Resident 20 should of had a fall risk assessment completed on admission having a diagnoses of a history of falls and generalized muscle weakness. LVN 4 could not provide any care plan's for safety awareness. A clinical record review for Resident 20's Minimum Data Set (MDS-is a comprehensive assessment of each resident's functional capabilities), indicated Resident 20 needed one person assist when going to the rest room. During an interview with DON on June 7, 2018, at 12:30 PM, the DON could not provide any documentation that a fall risk assessment was completed for Resident 20 on admission and that no Physicians order was written for a bed alarm. The facility policy and procedure titled, "Personal Alarm," undated, indicated..."Policy: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 54 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a resident rising out of the bed/wheel chair reminding the resident to return to a safe position while alerting staff to a potential fall. Procedure: Licensed nurses and therapists will assess the resident for potential safety issues. 4. Check alarm system every day for proper functioning. 5. Attend resident promptly when alarm sounds and provide appropriate assistance. 9. Care plan will be developed."

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 06/28/2018 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 55 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on observation, intervention, and record review, the facility failed to ensure communication system for one (1) of 17 nonEnglish speaking residents (Resident 14) in the universe of 88 residents. This failure had the potential for the facility staff to not understand Resident 14 needs for the activities of daily living. Findings: During an observation of Resident 14's room, on June 4, 2018, at 9:30 AM, Resident 14 was in bed, with wheelchair on the side of bed, and no communication board posted. During an interview with Resident 14 and Resident 14's roommate, on June 4, 2018, at 9:35 AM, the Resident 14 was asked about current conditions in the facility and he [Resident 14] was not answering back. The Resident 14's roommate stated "He cannot understand English. I talk to him most of the time and he does not understand me." During an interview with Social Services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 56 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Designee 1 (SSD), on June 4, 2018, at 2:45 PM, the SSD 1 stated "Yes there was no communication board posted." The SSD 1 further stated "Yes, the facility has no system on how to communicate with him [Resident 14]. We [facility staff] look the translation in the internet using our personal phone and data." During an interview with Resident 14 and SSD 1, on June 4, 2018, at 3:00 PM, the SSD 1 asked the Resident 14 "Did you eat your lunch?" Resident 14 answered the SSD 1 "Sister." During an interview with Activity Director (ACT), on June 4, 2018, at 3:15 PM, the ACT stated "He understand a little bit of English." A review of facility document titled "Resident with Communication Deficit", undated, indicated Resident 14 was not listed. A review of facility policy and procedures titled "Policy: Accommodation of Needs Related to Communication Deficits", undated, indicated "Policy: Communication needs will be identified and appropriate interventions, including care planning, will be developed in order to accommodate the needs of the Resident." "Procedures: 1.Communication needs will be assessed as follows: a. Psycho-Social Assessment form; Resident identifying Date Language Spoken ...b. Communication section on Social Service Progress Notes."

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 06/14/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 57 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, facility failed to ensure facility group activities to one (1) of 29 sampled residents (Resident 12). This failure had the potential for Resident 12 to have low self-esteem, and affect well-being. Findings: During observation of Resident 12, on June 4, 2018, at 9:03 AM, the Resident 12 was in bed sleeping, bed was on low level, with fall mat on the floor. A review of Resident 12's medical records indicated Resident 12 was admitted February 9, 2018, with diagnoses of dementia (forgetfulness), type 2 diabetes mellitus (blood sugar problem), fecal impaction (solid, immobile bulk of human feces that can develop in the rectum as a result of chronic constipation), and dysphagia (difficulty swallowing). The Resident 12 does not have the capacity to understand and make decisions. A review of facility document titled "Activity Participation Record (list of activities and names of residents brought to activity room and receive activities with other residents)", dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 58 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 May 2018 and June 2018, indicated no activity participation dates listed except for May 31, 2018. During a concurrent interview with the Activity Director (ACT) and record review of document titled "Activities", July 7, 2018, at 9:08 AM, the ACT stated "The Activity records that we have here is May 18 and May 31 2018 only." The document titled "Activities" indicated Resident 12's name was listed on May 18 and May 31, 2018. The activies recorded on May 18 and 31, 2018, with Resident 12 were watching movies, paintings, games, and birthdays. No other documented evidence of Resident 12's activity participation. During an interview with Activity Aide (ACTA), on June 7, 2018, at 9:40 AM, the ACTA stated "We [Activity Staff] took their [residents] names if they are attending the activities or if we are visiting them [residents]." The ACTA further stated "It is very important to document who is coming or not to keep track who is attending or not." A review of facility policy and procedures titled "Activity Program: Purpose and Policies", undated, indicated "Purpose: Provides a planned schedule of recreational, social, educational, and therapeutic activities." "Policies:...3. The Activity Coordinator shall develop and write a planned schedule of activities for the facility." A facility document titled "Job Description: Activity Director/Coordinator", dated October 12, 2011, indicated "Summary: Plans, coordinates, conducts, and implements a therapeutic activity program to meet both group and individual patient's needs and interests." "Essential Duties and Responsibilities include the following: Establishes and maintains an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 59 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 effective room visit program, with documentation as needed ...Acts as an advocates for residents' wellbeing and rights."

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/28/2018 §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: 2. During an observation of Resident 20 on June 4, 2018, at 9:00 AM, Resident 20 was observed getting out of bed wobbly on her feet,unassisted by staff, bed in low position, fall matt on the floor on both sides of the bed, half side rails up, wheelchair (W/C) next to the wall, call light tied to the bed rail, and a bed alarm in place. The alarm did not make any sound when Resident 20 got out of her bed to use the rest room. A clinical record review of Resident 20 indicated, Resident 20 was admitted to the facility initially on August 3, 2017 but was readmitted on May 31, 2018, with diagnoses which included muscle weakness, primary osteoarthritis (cartilage at the end of your bones wears down), and pulmonary coccidioidomycosis (infection in the lungs caused by a fungus. Commonly known as valley fever). During an interview with Resident 20 on June FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 60 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 4, 2018, at 9:12 AM, Resident 20 stated,"I can walk fine on my own." Resident 20 stated the bed alarm was to let staff know when she got in and out of bed. Resident 20 stated staff rarely came into her room when the alarm went off and that staff showed her how to shut the alarm off when she gets out of bed. During an interview with the Director of Nurses (DON) on June 4, 2018, at 9:20 AM, the DON verified that Resident 20's has a bed alarm. The DON checked the battery in the alarm and it still good. The DON stated,"Resident 20 is suppose to be assisted by one staff to use the rest room so she does not fall." During an observation of Resident 20 on June 7, 2018, at 9:30 AM, Resident 20 was observed getting out of bed, wobbly, alone without staff assistance to use the rest room and her bed alarm did not go off. During an interview with Licensed Vocational Nurse (LVN 4) on June 7, 2018, at 10:21 AM, LVN 4 stated Resident 20's bed alarm should go off when she gets in and out of bed to alert staff. LVN 4 stated," Resident 20 needs one person assistance to the rest room." A clinical record review of Resident 20's Physicians orders dated May 24, 2018, indicated under admission diagnoses: Hepatic Encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood), Altered mental status,Trauma, and History of falls. Under equipment orders: Low bed with side mattress. A clinical record review of Resident 20 indicated no fall risk assessment was done on admission. During an interview with LVN 4 on June 7, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 61 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2018, at 10:25 AM, LVN 4 verified no fall risk assessment was completed and no Physicians order was written for a bed alarm. LVN 4 verified Resident 20 should of had a fall risk assessment completed on admission having a diagnoses of a history of falls and generalized muscle weakness. LVN 4 could not provide any care plan's for safety awareness. A clinical record review for Resident 20's Minimum Data Set (MDS-is a comprehensive assessment of each resident's functional capabilities), indicated Resident 20 needed one person assist when going to the rest room. During an interview with DON on June 7, 2018, at 12:30 PM, the DON could not provide any documentation that a fall risk assessment was completed for Resident 20 on admission and that no Physicians order was written for a bed alarm. The facility policy and procedure titled, "Personal Alarm," undated, indicated..."Policy: This facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a resident rising out of the bed/wheel chair reminding the resident to return to a safe position while alerting staff to a potential fall. Procedure: Licensed nurses and therapists will assess the resident for potential safety issues. 4. Check alarm system every day for proper functioning. 5. Attend resident promptly when alarm sounds and provide appropriate assistance. 9. Care plan will be developed." Based on observation, interview, and record review, the facility failed to ensure safety and hazards for two of 29 sampled residents (Resident 45 and Resident 20), when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 62 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 1. Four (4) empty tanks of oxygen found inside Resident 45's room; and 2. Fall risk assessment was not completed and when bed alarm system can be manipulated by Resident 20. These failures had the potential for the residents to be at risk to accident and injury. Findings: 1. During an observation of the Resident 45's room, on June 4, 2018, at 9:30 AM, Resident 45 was lying in bed, sleeping, with oxygen tubing on the nose attached to the oxygen concentrator (to supply an oxygen). On the foot area of the Resident 45's bed found his personal belongings, wheelchair, and four empty tanks of oxygen. The four empty tanks of oxygen were 2.5 feet (unit of measure) tall, unsecured and closes the Resident 45's wheelchair and restroom door. A review of Resident 45's medical record, on June 4, 2018, at 9:40 AM, indicated Resident 45 was admitted to the facility on February 25, 2018, with diagnoses of hypertension (increased blood pressure), acute respiratory infection, and cirrhosis (liver disease) secondary to ETOH (Ethanol- refers to a person's history of over consumption of alcoholic beverages). The resident has the capacity to understand and make decisions. During an interview with the Assistant Director of Staff Development (ADSD), on June 4, 2018, at 10:50 AM, and asked where should the empty tanks be placed, the ADSD stated "It should be in the storage room." During an interview with the Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 63 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Vocational Nurse 2 (LVN) on June 4, 2018, at 11:05 AM, the LVN 2 stated "I am new here, but for safety purposes it must be placed in the storage area." A review of facility's policy and procedure titled "Policy: Oxygen Cylinders: Safe Storage, undated, indicated "Policy: The facility will store oxygen cylinders in a safe manner." A review of facility document titled "Job Description: Licensed Vocational Nurse (LVN)", dated August 23, 2011, indicated "Nursing Care: Maintains awareness of comfort and safety needs of patient."

F725 SS=E Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2)

F725 06/25/2018 §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 64 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure sufficient staffing on four (4) different days in the month of May 2018 (May 9, 12, 15, and 21, 2018) when the facility Hours Per Patient Day (HPPD) were below State minimum mandated PPD (Per Patient Day- State mandated nursing care hours for each resident per day) of 3.2 hours. These failures had the potential for residents in the universe of 88 residents not to receive sufficient nursing care. Findings: During record review of facility document titled "HPPD Report", on June 7, 2018, indicated "May 09 Direct Care: 3.022; May 12 Direct Care: 3.186; May 15 Direct Care: 3.177; May 21 Direct Care: 3.188." During an interview with the Director of Staff Development (DSD), on June 7, 2018, at 10:32 AM, the DSD confirmed the HPPD on May 9, 12, 15, and 21, 2018. The DSD stated "I should be on top of everything, those are below 3.2." The DSD was asked about the reasons of below expected hours of PPD, she stated "I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 65 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 cant remember what happened of during that time. A review of facility policy and procedure titled "Policy: SNF (Skilled Nursing Facility) Staffing", undated, indicated "Procedure: 1. Daily staffing is projected to at least meet the Statemandated 3.2 NHPPD (Nursing Hour Per Patient Day)." A review of facility document titled "Job Description: Director of Staff Development (DSD)", dated August 23, 2011, indicated "Essential Duties and Responsibilities include the following: Creates and oversees daily schedule to ensure sufficient staff to enable proper coverage of resident care. Ensures schedule coverage for called-in absences."

F732 SS=D Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4)

F732 06/28/2018 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 66 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a complete current staffing information when: 1. There was no posted daily staffing information in a prominent place; and 2. There were missing nurse staffing information on the month of April (9 days), on May (14 days), and on June (3 days) 2018. This failure had the potential not to make staffing information readily available for visitors and for residents in the universe of 88 residents. Findings: 1. During an observation of the facility daily staffing posting, on June 7, 2018, at 11:00 AM, the facility admission front door, nurses' stations, and facility corkboards near Director of Nursing (DON) office showed no posted daily staffing information and Hours Per Patient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 67 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Day (HPPD). During a concurrent record review and an interview with Assistant Director of Staff Development (ADSD), on June 7, 2018, at 11:12 AM, indicated no record of nurse staffing information on June 7, 2018, and the ADSD stated "Maybe it is in the medical records." During an interview with Director of Staff Development (ADSD), on June 7, 2018, at 11:14 AM, the DSD stated "We [DSD staff] post it near the DON's office." During an interview with the Medical Records 2 (MR), on June 7, 2018, at 11:27, the MR 2 looked for nurse staffing information and stated "We [Medical Records staff] do not have nurse staffing information here [medical record office]." A review of facility's policy and procedure titled " Daily Staffing Posting", undated, indicated "Policy: This facility will post daily, at the beginning of each shift, the facility-specific shift schedule for the 24-hour period, including the number and categories of nursing staff employed, as well as the total number of hours worked by the licensed and unlicensed staff who are directly responsible for resident care." 2. During a concurrent record review and an interview with Assistant Director of Staff Development (ADSD), on June 7, 2018, at 11:12 AM, indicated there were no record of nurse staffing information retained by the facility on the following dates: -May 1, 2, 6, 8, 9, 13, 14, 16, 19, 20, 25, 26, 27, and 31, 2018 and -June 1, 6, and 7, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 68 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 The ADSD stated "Maybe it is in the medical records." During an interview with the Medical Records 2 (MR), on June 7, 2018, at 11:27, the MR 2 looked for nurse staffing information, and stated "We [Medical Records staff] do not have nurse staffing information here [medical record office]." During a concurrent record review and an interview with Director of Staff Development (DSD), on June 7, 2018, at 11:43 AM, the DSD acknowledged no documented evidence of nurse staffing information were retained by the facility on the following dates: - April 4, 7, 10, 11, 13, 14, 20, 25, and 26, 2018; - May 1, 2, 6, 8, 9, 13, 14, 16, 19, 20, 25, 26, 27, 31, 2018; and - June 1, 6, and 7, 2018. The DSD stated "Yes it [nurse staffing information] were not there." And further stated that DSD department are responsible in keeping the staffing information. A review of facility's policy and procedure title "Daily Staffing Posting", undated, indicated "Procedure: 4. Retention of data for 18 months or as required by state law, whichever is greater. This period will cover the annual survey period and allows surveyors to review the records as needed."

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F755 Event ID: RF2R11 06/26/2018 Facility ID: CA240000089 If continuation sheet 69 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to remove expired medications from two medication rooms and one medication cart. This failure has the potential for these expired medications be accidentally given to a universe of 88 residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 70 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Findings: During an observation of medication room one (1) on June 5, 2018 at 2:30 PM, there were five boxes of influenza (viral infection) vaccines that were expired as of March, 2018 inside the refrigerator. During an observation of the medication cart one (1) on June 5, 2018 at 3:00 PM, there was one of Resident 26's medications, morphine sulfate (pain medication) 20 milligram per milliliter (unit dose), that expired March 12, 2018 that was still inside the narcotic box. During a concurrent interview with Licensed Vocational Nurse 8 (LVN 8), she stated that those expired medications should had been removed from the refrigerator and medication cart to prevent accidentally be given to the residents. During an observation of the medication room two (2) on June 6, 2018 at 11:00 AM, there was one box of influenza vaccine that was expired as of March, 2018 inside the refrigerator. During a concurrent interview with the Assistant Director of Staff Developer(ADSD), he stated that the licensed staff should had given the expired medication to the Director of Nursing (DON) for disposal. The facility policy and procedure, entitled, "Medication Storage in the Facility", dated April 2008, indicated under procedures," ...M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 71 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 immediately removed from stocks, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists."

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 06/12/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure professional standards for food service requirements and safety inside the facility kitchen where foods are stored, prepared and served when: 1. Thirty-six (36) hotdog buns were found passed used-by date; 2. Pureed meat was not completely mashed and had a gritty, sand-like taste of the meat, and pureed pancake was hard to swallow and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 72 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 gummy; and 3. Four (4) hand sanitizers found mounted on the wall inside the kitchen, use by kitchen staff to clean and sanitize their hands. These failures had the potential to cause foodborne illnesses (stomach infection), to cause poor palatability (taste), quality of food served, and cross-chemical contamination that can negatively affect the health and safety of 88 medically-compromised residents. Findings: 1. During an observation of facility kitchen, on June 4, 2018, at 8:35 AM, the following bread were observed in the bread rack outside the dry storage: a. Twenty-four (24) hotdog buns with the usedby date of May 19, 2018: eighteen (18) days passed thru the used-by date; and b. Twelve (12) hotdog buns with the used-by date of May 17, 2018: twenty (20) days passed thru used-by date. During an interview with the Dietary Cook 1 (DC), on June 4, 2018, at 8:41 AM, the DC 1 stated "These [hotdog buns] passed the bestby date. It [hotdog buns] should be thrown away." During an interview with the Dietary Services Supervisor (DSS), on June 4, 2018, at 9:13 AM, the DSS stated "We [kitchen staff] goes with best-by date or used-by date. If it [hotdog buns] pass through the used-by date, it should be disposed." A review of facility document titled "Procedures for Dry Storage", undated, indicated "...13. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 73 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Bread will be delivered frequently and used in the order that it is delivered to use freshness. Bread products not used within 5 days can be frozen. Some breads do last 5-7 days. Check manufacturers recommendations. Do not store bread in the refrigerator." A review of facility document titled "Personnel Management", dated 2015, indicated "Responsibilities of the Dietary Service Supervisor: Food purchasing, receiving, storage and preparation; Maintaining acceptable standards of sanitation and food safety." 2. During a test tray observation, on June 6, 2018, at 8:20 AM, the pureed meat and pureed pancake were tested. The pureed meat had a gritty, sand-like texture, and the pureed pancake was dry and had a gummy-like consistency. During an interview with the DSS, on June 6, 2018, at 8:30 AM, the DSS confirmed the test tray findings of gritty, sand-like texture of the pureed meat, and to a dry, gummy-like consistency of pureed pancake. The DSS stated "They [residents with pureed diet] will be having a hard time swallowing." During an interview with the Registered Dietician (RD), on June 6, 2018, at 8:53 AM, the RD described the pureed food as mash-like in consistency, and further stated "If not mashlike, the residents [residents with pureed diet] will be at risk to choking." A record review of facility document titled "Order Listing Report", dated June 7, 2018, indicated eight (8) residents were on puree diet. A record review of facility document titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 74 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 "Regular Pureed Diet", dated 2015, indicated "Description: The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing, and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape." A record review of facility's policy and procedures titled "Personnel Management", dated 2015, indicated "Responsibilities of the Dietary Service Supervisor: Food purchasing, receiving, storage, and preparation." "Maintaining acceptable standards of sanitation and food safety." 3. During a follow up observation of the kitchen, on June 5, 2018, at 3:47 PM, the kitchen had two hand sanitizers were mounted before the two exit doors, and two hand sanitizers above the dishwashing sink total of four (4) handsantizers mounted on the kitchen wall During an interview with the Dietary Aides 1 (DA), on June 5, 2018, at 3:50 PM, the DA 1 stated "Yes I am using that [pointing on mounted hand sanitizers on the wall]. You [referring to surveyor] can use it [mounted hand sanitizer] too." During an interview with the DA 2, on June 5, 2018, at 3:55 PM, the DA 2 stated "I use it [mounted hand sanitizers] if I am not wearing gloves." During an interview with the Registered Dietician (RD), on June 5, 2018, at 4:00 PM, the RD stated "There should be no hand sanitizers in the kitchen because of contamination. Hand washing must be performed." A record review of facility's policy and procedures titled "Personnel Management", FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 75 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 dated 2015, indicated "Responsibilities of the Dietary Service Supervisor: Food purchasing, receiving, storage, and preparation." "Maintaining acceptable standards of sanitation and food safety." And also indicated "Dietary Staff Hygiene: Each employee must follow proper food handling techniques and exhibit sanitary work habits, such as no chewing gum; Dietary personnel must wash their hands in a separate hand washing sink in the dietary department."

F813 SS=E Personal Food Policy CFR(s): 483.60(i)(3)

F813 06/29/2018 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent two (Resident 64, Resident 39) of 88 residents to store opened perishable foods in their rooms. This failure had the potential for these two residents to have foodborne illness (illness caused by food contaminated by germs) once its consumed. Findings: 1. During an observation of Resident 39 in his room on June 4, 2018 at 8:30 AM, he had opened plastics of cookies, opened plastic bottles of ketchup, opened cartons of biscuits and bread, opened peanut butter jar, opened bottle of hot sauce, packs of powdered coffee and creams all on top of his bed side table. All FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 76 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 food items were not labeled when it was opened. During a concurrent interview with resident 39, he stated, he does not remember the exact dates those food items were opened. During an interview with Licensed Vocational Nurse 6 (LVN 6) on June 4, 2018 at 8:45 AM, LVN 6 stated that they do not have record of when those food items were opened.LVN 6 stated that some of those food items were not within Resident 39's prescribed diet. During a review of Resident 39's clinical record, indicated he was admitted to the facility on June 12, 2010 with diagnoses of polyneuropathy (nerve damage that affects sensation and movement of extremities). A review of Resident 39's" Physician order", indicated, he was on low-fat diet as of November 1, 2016. 2. During an observation of Resident 64 in her room on June 4, 2018 at 9:00 AM, she had an opened plastic bag of 3 pieces of fried chicken, an opened container of cookies on top of her bed side table. All food items were not labeled when opened. During a concurrent interview with Resident 64, she stated that she received all food from her family the night before. During an interview with LVN 6 on June 4, 2018 at 9:15 AM, LVN 6 stated that it is the facility's policy to encourage residents to consume the food same day it was brought to resident. LVN 6 stated that she was not aware that Resident 64 had food brought to her the night before. LVN 6 stated that these food items are not within Resident 64's prescribed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 77 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 diet. During a review of Resident 64's clinical record, indicated she was admitted to the facility on May 25, 2017 with diagnoses of diabetes mellitus (disease that causes increased blood sugar in the body), dysphagia (difficulty of swallowing), hypertension (high blood pressure), hypercholesterolemia (high levels of fatty substances in the blood). A review of Resident 64's physician order, indicated, a diet order of mechanical soft (chopped food), low sugar, low fat diet dated September 1,2017. The facility policy and procedure titled "Food from Outside Sources", undated, indicated under policy," ... Food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of

F835 SS=E Administration CFR(s): 483.70

F835 06/10/2018 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record reviews, the facility administration failed to follow facility's policies and procedures related to verbal abuse for 3 of 29 sampled residents (Resident 55, Resident 59, and Resident 203) when: 1. Resident 55 who received a statement "You should read the bible and practice what you read" from the facility Administrator (ADM); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 78 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2. Resident 59 and Resident 203 who received a statement "If you don't shut your mouth up, I will not give your pain medication!" and "Shut your mouth! You are not the only resident here!" from facility Licensed Vocational Nurse 7 (LVN). These failures affected the physical, mental, and psychosocial well beings of the three residents (Resident 55, Resident 59, and Resident 203) in a universe of 88 residents. Findings: 1. During an observation of Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 was alert and oriented. Resident 55 was in bed, with a bible and magnifying glass on top of his over bed table. Resident 55 had above the left knee amputation, and wheelchair on the side of the bed. Resident 55 was able to answer questions, alert, and oriented. During an interview with Resident 55, on June 04, 2018, at 9:15 AM, Resident 55 stated he had a recent incident that bothered him, and kept thinking about the incidents. The Resident 55 further stated two weeks ago the Certified Nursing Assistant (CNA 1) bathe him [Resident 55]. Per Resident 55 after the last incident brought the Administrator (ADM), Social Services Designee 2 (SSD 2), and the CNA 1 visited the Resident 55 in his room. The Resident 55 further stated the ADM stated "You are the problem here, not my staff. You should not do that to my staff. You read the bible and practice what you are reading." The Resident 55 stated "I felt so little. I felt that I am nothing in this world. I felt humiliated, I want to cry but I just kept it in my chest." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 79 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 A review of Resident 55's medical records titled "History and Physical", dated August 31, 2017, indicated "This resident: 1. Has the capacity to understand and make decisions." A review of Resident 55's document titled "Quarterly Minimum Data Set", dated April 4, 2018, indicated "Section C Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score 14." During a follow up interview with Resident 55, June 4, 2018, at 4:02 PM, he stated "I feel humiliated and I feel offended. The words that she [Administrator] said keeps running to my head. She [Administrator] said 'You should read the bible and practice what you read.' I felt that she tried to humiliate me in front of [name of the SSD 2] and [name of the CNA 1]." Resident 55 further stated "I am not comfortable talking to her [Administrator] anymore. I am thinking what she [Administrator] told me to read the bible and practice what I am reading. She [Administrator] is very tough in saying that. That is why if I feel that she [Administrator] is walking in the hallway and I am in my wheelchair I would just turn my back and pretend to watch television and wishing that she will not come to my room. She [Administrator] is very firm and told me "If I would have been here years ago, I will kick you out." During an interview with the ADM, on June 4, 2018 at 4:23 PM, the ADM stated "We went there to talk to him about the incident between Resident 55 and CNA 1 [incident in the shower room and calling the CNA 1 a 'snake' by Resident 55], and everything was fine." The ADM was asked about the allegations of Resident 55, and she [ADM] did not confirmed the allegations. The ADM stated "The CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 80 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 [CNA 1] and the resident [Resident 55] had an incident during shower. The ADM further stated "For what I remembered, the resident grabbed the wrists of the CNA, and called her a 'snake'. The CNA came to us [the ADM and the SSD 2] and then we went to his room to talk to him. And I cannot say those words to him." During a record review of Resident 55's medical records with the ADM and the MDS 1 (Minimum Data Set), on June 4, 2018 at 4:36 PM, there were SSD notes, IDT (Interdisciplinary Team) meeting notes dated June 1, 2018, and signed by Social Services Designee 1 (SSD 1). The medical records showed no evidence of care plan, thorough investigations of the incident, follow-up, and reporting of unusual occurence between Resident 55 and CNA 1 to California Department of Public Health (CDPH). During a concurrent interview with the SSD 1 and record review of Resident 55's medical records, on June 5, 2018, at 9:30 AM, the SSD 1 stated the CNA 1 spoke to her [SSD 1] and was aware of the incident. The SSD 1 also stated "I did not document it. I know that I must document it and must follow up. But I was not able to document it." There was no documented evidence that incident in the shower room was documented in SSD notes, nurses' notes, and care planned. The facility failed to follow the facility policy and procedure related to investigation of allegation of abuse; The facility failed to ensure Resident 55 to be free from verbal abuse that resulted in feelings of fear, shame, degradation, and helplessness. The facility failed to identify verbal abuse, monitor and evaluate Resident 55. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 81 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 The facility failed to report verbal abuse. A review of facility's policy and procedures titled "Policy: Abuse Allegation Investigation", indicated "Purpose: To ensure that a complete and thorough investigation is conducted for all allegation of abuse ... 2. Interview resident and document allegations. 3. Interview staff member (s) accused of alleged abuse; document findings, suspend staff member (s) pending outcome of investigation ...." A review of facility policy and procedures titled "Policy: Abuse & Mistreatment of Residents", indicated "Purpose: To uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion." "Definitions: 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability." A review of facility document titled "Job Description: Administrator", dated October 12, 2011, indicated "Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and Procedure; review and document appropriate investigation and follow up as needed ...Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed ...Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 82 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F837 Governing Body CFR(s): 483.70(d)(1)(2)

F837 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/03/2018 §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility Governing Body failed to oversee the facility Administrator, manage and effectively govern for 88 residents' by safe guarding them by ensuring the facility's policy and procedure titled,"Abuse Reporting Prevention and Investigation," undated, was operationalized and consistently implemented. This failure resulted in multiple residents of the facility feeling unsafe and the potential for the abuse to continue. Findings: During initial tour on June 4, 2018, Resident's 55, Resident 59 and Resident 203 verbalized allegations of being verbally abused by staff and the residents stated they had all reported it to either a Charge Nurse or the Director of Nurses (DON). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 83 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 Further interviews with Resident 55, Resident 59, and Resident 203, the DON and the Administrator as well as record reviews all completed on June 4, 2018, verified the facility did not follow their Abuse policy and procedure for reporting and fully investigating all alleged allegations of abuse. During an interview with the Regional Director (RD 1) on June 7, 2018, at 5:30 PM, RD 1 stated the corporate office had to terminate the Administrator because not only was she allegedly accused of verbal abuse by Resident 59, but the Administrator failed to follow the facility's policy and procedure of abuse. RD 1 stated the corporate office had been evaluating the Administrator for not effectively performing her job. RD 1 verified the Administrator was overly controlling to staff and they did not have a very trusting relationship. RD 1 verified she would visit the facility and was not happy with the way the Administrator was handling her job. RD 1 when asked if she felt the Administration was very effective, RD 1 stated,"We have a lot of work to do." RD 1 stated," The Administrator did not keep us informed of what was happening in the facility, I had to visit the facility to find out." The facility Governing Body failed to ensure that the appointed Administration implemented the approved facility policies for abuse prevention. The facility also failed to ensure that all allegations of abuse were investigated, reported to the appropriate state agency. This failure resulted in multiple residents' of the facility to experience feelings of fear do to numerous verbal abusive actions towards by staff and reports of abuse to go uninvestigated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 84 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F838 Facility Assessment CFR(s): 483.70(e)(1)-(3)

F838 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/25/2018 §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 85 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure their correct name was on their transportation contract. This transportation company were responsible for driving two of four residents (Resident 38 and Resident 54) who go to their regular dialysis (process of removing waste products and excess fluids from the body) appointments. This failure had the potential for these four dialysis residents to have no available transportation and affect their health of not having dialysis. Findings: 1. During an observation of Resident 38 on June 7, 2:30 PM, she was observed being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 86 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 safely wheeled out from a transportation van. A concurrent interview with Resident 38 was done, she stated that she came back from her dialysis appointment. A clinical record review of Resident 38 indicated she was admitted to the facility on March 31, 2017 with diagnoses of dependence to renal (kidney) dialysis. A review of Resident 38's Physician Order indicated an order for her to have dialysis every Tuesday, Thursday and Saturday at [name of dialysis center] since March 31, 2017 During an interview with the Regional Director (RD), she stated that the reason they have not renewed their contract with the transportation company was that they were waiting for the facility's identification number since it was under a different name. 2. During an observation of Resident 54 on June 4, 2018, at 9:25 AM, Resident 54 was very sleepy, lying in bed with half side rails up and call light within reach. Resident 54 has lots of personal belongings in her room. A concurrent interview with Resident 54, Resident 54 stated she just returned from [Name of Hospital] and has dialysis treatments three times a week. A clinical record review of Resident 54 indicated she was readmitted on June 3, 2018 to the facility with diagnoses which included End Stage Renal Disease (ESRD-Long standing disease of the kidneys leading to renal failure), and Dialysis. A review of Resident 54's Physician Orders dated June 1, 2018, indicated an order for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 87 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 dialysis every Tuesday, Thursday, and Saturday at [name of dialysis facility]. During an interview with the Medical Director (MD 1), on June 7, 2018, at 12: 45 PM, MD stated, "I do not handle transportation contract's, it is the responsibility of the Administrator." A review of the facility's contract with dialysis transportation companies indicated name on contract is the previous name of the facility prior to their name change conducted, on March 5, 2018, dated 2013 and will be automatically renewed annually. The facility document titled,"Facility Assessment," undated, indicated,..."5. Facility Resources: c. Facility does not own vehicles. 8. Contracts: t.Transportation."

F840 SS=F Use of Outside Resources CFR(s): 483.70(g)(1)(2)

F840 06/25/2018 §483.70(g) Use of outside resources. §483.70(g)(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section. §483.70(g)(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for(i) Obtaining services that meet professional standards and principles that apply to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 88 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 professionals providing services in such a facility; and (ii) The timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure their correct name was on their transportation contract. This transportation company were responsible for driving two of four residents (Resident 38 and Resident 54) who go to their regular dialysis (process of removing waste products and excess fluids from the body) appointments. This failure had the potential for these four dialysis residents to have no available transportation and affect their health of not having dialysis. Findings: 1. During an observation of Resident 38 on June 7, 2:30 PM, she was observed being safely wheeled out from [Name of transportation] van. A concurrent interview with Resident 38 was done, she stated that she came back from her dialysis appointment. A clinical record review of Resident 38 indicated she was admitted to the facility on March 31, 2017 with diagnoses of dependence to renal (kidney) dialysis. A review of Resident 38's Physician Order indicated an order for her to have dialysis every Tuesday, Thursday and Saturday at [name of dialysis center] since March 31, 2017 During an interview with the Regional Director (RD 1), on June 7, 2018, at 12:30 PM, she stated that the reason they have not renewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 89 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 their contract with the transportation companies were that they were waiting for the facility's identification number since it was under a different name. RD 1 stated the facility had a name change in March 2018. 2. During an observation of Resident 54 on June 4, 2018, at 9:25 AM, Resident 54 was very sleepy, lying in bed with half side rails up and call light within reach. Resident 54 has lots of personal belongings in her room. A concurrent interview with Resident 54, Resident 54 stated she just returned from [Name of Hospital] and has dialysis treatments three times a week. A clinical record review of Resident 54 indicated she was readmitted on June 3, 2018 to the facility with diagnoses which included End Stage Renal Disease (ESRD-Long standing disease of the kidneys leading to renal failure), and Dialysis. A review of Resident 54's Physician Orders dated June 1, 2018, indicated an order for dialysis every Tuesday, Thursday, and Saturday at [name of dialysis facility]. During an interview with the Medical Director (MD 1), on June 7, 2018, at 12: 45 PM, MD 1 stated, "I do not handle transportation contract's, it is the responsibility of the Administrator." A review of the facility's contract with dialysis transportation companies indicated name on the contract's were the previous name of the facility prior to their name change conducted, on March 5, 2018, as follows: 1. Agreement between [Previous name of facility] and [Name of transportation] medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 90 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 transportation for dialysis residents commences on July 10, 2013, will continue for one one year and contract will renew automatically thereafter. 2 .Agreement between [Previous name of facility] and [Name of transportation] medical transportation for dialysis residents undated. The facility document titled,"Facility Assessment," undated, indicated,..."5. Facility Resources: c. Facility does not own vehicles. 8. Contracts: t.Transportation."

F880 SS=F Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 06/26/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 91 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 92 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 observation, interview, and record review, the facility failed to ensure infection control practices were followed as evidenced by: 1. Resident 31's oxygen (chemical element) tubing and concentrator (device that supplies a continuous flow of oxygen through a tube) was found to have no label with date, time and initials of the staff who changed it last . 2 Alcohol based gel solution were not properly used during dining hours. These failures had the potential to cause infection and the spread of diseases to all residents in a universe of 88 residents. Findings: 1. During a observation of the facility on June 4, 2018, at 10:19 AM, Resident 31 was observed lying in bed, half side rails up, call light within reach. Resident 31 was observed receiving oxygen at two (2) Liters (L-unit of measure) through a nasal cannula (N/C-a device that delivers oxygen through a tubing into the nose) via a concentrator unlabeled. Resident 31 is Spanish speaking only. During a record review of Resident 31's "Admission Record", it indicated that Resident 31 was admitted to the facility initially on February 20, 2018 with diagnoses which included cardiac pacemaker (an artificial device for stimulating the heart), shortness of breath, and dementia (a decline in memory loss). During an interview with Licensed Vocational Nurse (LVN 2), on June 4, 2018, at 10:22 AM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 93 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 2 verified Resident 31's oxygen tubing and concentrator were not labeled. LVN 2 stated the facility's policy and procedure states that oxygen tubing and concentrator should be labeled with date, time and staff initials who changed it. During an interview with the Director of Nurses (DON), on June 7, 2018, at 12:30 PM, DON verified oxygen tubing and concentrator need to be labeled with date, time , and staff initials on them. A clinical record review of resident 31's Physician orders dated , May 31, 2018 indicated Oxygen (O2) administer O2 at 2 L/min via N/C continuously. The facility policy and procedure titled,"Oxygen Administration," undated, indicated..."Oxygen will be administered to residents as needed per attending physician's orders by licensed personnel. 10. The date and time, and initials should be noted on oxygen equipment when it is initially used and when changed." 2. During a meal observation in the dining room on June 4 2018, at 12:15 PM , an alcohol gel based hand sanitizer container was on the wall by both entrance ways and available for staff's use. The servers were observed serving the resident's plates, taking the lids off of the trays and placing the plate on the table in front of the resident's. They used the hand sanitizer and immediately served the food without completely drying their hands after using the alcohol gel hand sanitizer to clean their hands. Certified Nurses Assistants (CNA) were also observed using the gel sanitizer,without completely drying their hands and then assisting the residents during the lunch meal as well as an Activities Aide (AA). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 94 of 95 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: _______________ 555089 (X3) DATE SURVEY COMPLETED 06/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWS RIDGE CARE CENTER 1700 E Washington St Colton, CA 92324 (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 During an interview with with Activities Aide (AA) on June 4, 2018 at 12:37 PM, AA stated she has worked in this facility for six months. The AA was observed using the gel hand sanitizer then within seconds opened a residents milk carton in which the resident drank the milk from the carton. AA stated she does not know the policy and procedure for using gel hand sanitizer in the dining room. During an interview with the Registered Dietitian ( RD), on June 6, 2018 at 8:02 AM, the RD stated, staff should let their hands dry completely after using the hand sanitizer and before serving the residents in the dining room. During an interview with the Director of Nursing (DON), on June 7, 2018, at 12: 15 PM, the DON verified staff should not be using the alcohol gel hand sanitizer in the dining hall. During an interview with Assistant Director Staff Development (ADSD), on June 7, 2018, at 4:45 PM, the ADSD stated staff should be washing their hands with soap and water when assisting residents in the dining. ADSD further stated, "Staff can use the gel hand sanitizer but, staff need to follow the manufactures guidelines for drying time." The facility policy and procedure titled, "Hand Hygiene," undated, indicated..."Definition: Hand hygiene is a vigorous brief rubbing together of all surfaces of lathered hands with soap, followed by rinsing under running water. 2. Some situations that require hand washing include: g. Before and after assisting a resident with meals." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RF2R11 Facility ID: CA240000089 If continuation sheet 95 of 95