Other·August 16, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey to investigate a complaint. Complaint Number: CA00589033 Representing the Califoria Department of Public Health: 37837 The inspection was limited to the specific complaint investigated and does not represent a full inspection of the facility. Substandard quality of care and an Immediate Jeopardy (IJ - a crisis situation which has threatened or is likely to theaten the health and safety of a resident) were called for the following: An IJ was called under 483.20, Resident Assessments (refer to F 641 - Accuracy of Assessments) on May 31, 2018 at 10:27 AM, and verbally notified in the presence of the Aministrator and the Director of Nursing. The facility failed to properly assess one of six sampled residents (Resident A) as a conserved resident with a mental disorder when Resident A was able to sign himself out on pass and did not return back to the facility. The Immediate jeopardy was removed on June 1, 2018 at 12:51 PM, in teh presence of teh Adminsitrator adn teh Social Service Director Census: 94 Sampled Residents: 6 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: R6U411 Facility ID: CA240000089 If continuation sheet 1 of 10 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 07/16/2018 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)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=J ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/30/2018 §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: Based on interview, and record review, the facility failed to provide safeguards for one of six sampled Residents (Resident A) who was under conservatorship due to being gravely disabled as a result of a mental disorder when he was allowed to leave the facility unaccompanied on pass and when he did not return, the facility failed to notify the police or conservator. This had the potential for Resident A to be placed in an unsafe circumstance due to his mental disorder as well as, physical danger related to having bilateral nephrostomy tubes (a tube inserted through the skin and into the kidneys to drain urine) he was unable to care for himself. Findings: An abbreviated survey was conducted on May FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 2 of 10 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 07/16/2018 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 30, 2018 at 4:38 PM to investigate a complaint related to resident rights. During an interview with the Social Services Designee (SS1) on May 30, 2018, at 5:00 PM, she stated Resident A had a conservator. Resident A signed himself out on pass on May 29, 2018, and had not returned back to the facility. The SS1 further stated, the staff did not search for Resident A or call the police. SS1 stated, "Our policy states that after 72 hours, he is considered to be on pass against medical advice." During a concurrent record review with SS1, she stated the court orders for conservatorship of Resident A were not in his chart. "They (court orders) should be in his chart." A review of the clinical record for Resident A was conducted. The face sheet (contains demographic information) indicated, Resident A was re-admitted to the facility on April 10, 2018 with an initial admission date of March 15, 2017. Resident A had diagnoses which included bipolar disorder (mood swings which display extreme happiness or sadness), paranoid schizophrenia (a chronic mental disorder in which a person loses touch with reality), anxiety disorder and chronic kidney disease (failure of the kidneys to remove waste.) He had bilateral nephrostomy tubes (a tube inserted through the skin and into the kidneys to drain urine) which required frequent emptying. A review of a document titled, "Multidisciplinary Progress Record" indicated the nurse documented on May 29, 2018 at 5:00 PM, "Resident A had not been seen in the facility since 4 PM. A resident stated he said goodbye FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 3 of 10 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 07/16/2018 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 was catching the bus to head home to Riverside. No family listed in his chart. Left a message for guarantor's office. Dr. made aware. Resident is self aware and has 72 hours to return back to facility." There was no documented evidence that a search for Resident A was done at the time he was noted to be missing. The next entry by any staff was dated on May 30, 2018 at 4:00 PM, (24 hours after the resident was last seen) written by the Social Service Director (SSD) and indicated, "SSD was made aware resident went out on pass on 5-29-18 (May 29, 2018) around 4 PM but resident has not returned back to facility. Nursing staff notified [name of conservator] of resident continuing to be out on pass. Staff called all hospitals near facility." During an interview with the Director of Nursing (DON), on May 30, 2018, at 5:53 PM, he stated "The doctor said [name of Resident A] could go out on pass. [Used name of Resident A] has the mental capacity to sign out." The DON further stated the facility did not call the police after Resident A did not return back to the facility, or start looking for the resident until prompted by the conservator's call on May 30, 2018. The DON confirmed the resident did not leave with his medication and that he had nephrostomy tubes which nursing staff was monitoring and emptying. The facility did not consider it as a problem until the conservator called in regards to Resident A's failure to return from pass. During an interview with the Social Services Director (SSD) on May 31, 2018 at 9:55 AM, she stated, "Admissions or Nursing informs the doctor when a conserved resident is admitted." The SSD stated she does not inform the physician when a conserved resident is admitted under a conservatorship. The SSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 4 of 10 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 07/16/2018 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 stated she did not call the police the morning of May 30, 2018. During an interview with the Medical Director on May 31, 2018 at 11:08 AM, she stated, "It's the responsibility of the facility to inform the physician of conservatorship. He (resident A) should have not been on pass." During an interview with the Assistant Director of Staff Development (ADSD) on May 31, 2018 at 12:30 PM, he stated, "The doctor wrote an order for [name of Resident A] to go out on pass" when he was under the care of a conservator for a mental disability. A concurrent record review for Resident A was done with the ADSD, he stated an elopement assessment was not done. He further stated, Resident A should not have been allowed to go out on pass. During an interview with the Admissions Coordinator (AC) on May 31, 2018 at 2:06 PM, he stated. "We didn't put it in writing (information to the physician regarding Resident A's conservatorship)." During an interview with a Licensed Vocational Nurse (LVN 1) on May 31, 2018 at 4:25 PM, she stated, "[Used name of Resident A] talks to himself once in a while." LVN 1 further stated that Resident A had nephrostomy tubes, "He has pulled them out three times. We empty it for him and sometimes he does it (empties his urine) himself and dislodges the tubes. We were monitoring his input and output to make sure everything (urine) was flowing properly." A Physician's order titled, "Out on Pass" dated, April 9, 2018, indicated, "Based on assessment, the Physician has determined that the Resident: has the capacity to understand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 5 of 10 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 07/16/2018 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 actively participate in decision making...May go out and is self-responsible. If out on pass exceeds 72 hours, unless the physician's orders indicated the dates of absence, with or without signing/completing out-on-pass booklet, resident will be considered discharged AMA." During an interview with the Primary Physician (PMD) for Resident A an on May 31, 2018 at 6:10 PM, he stated, the facility did not inform him that Resident A had a conservator due to a mental disorder. The PMD stated, "They did not tell me. If I would have known I would not have let him go (on pass). " During a review of the clinical record for Resident A, the "Petition for reappointment of Conservator of the person and estate" dated February 15, 2018, indicated "Petitioner...1. On February 16, 2017, the above Conservatee was initially adjucated to be a gravely disabled person and Petitioner was appointed Conservator...Under the section titled "Verification...I am the conservator of the person and the estate of the above-named Conservatee." The facility policy and procedure titled "Out on Pass" undated, indicated "Procedure::.4. Residents/responsible party will be asked to sign out-on-pass book at nurses' station to indicate date, time and destination of out-onpass." The facility policy and procedure titled "Missing Resident" undated listed the "Objective: To reduce possible injury or death of a resident; to provide an organized method for locating a resident. Steps: 1. Verify that resident is missing. Question roommates, other residents, visitors and staff as necessary. 2. Notify Charge Nurse, Nursing Supervisor, Director of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 6 of 10 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 07/16/2018 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 Nursing and Administrator. 3. Search entire building...7. If resident still hasn't been located within an hour of starting search, notify the police, responsible party/residents family, and attending physician. 8. If resident still hasn't been located within two hours of starting search, check hospitals...11. Chart all events and notifications..." Substandard quality of care and an Immediate Jeopardy (IJ - a crisis situation which has threatened or is likely to threaten the health and safety of a resident) were called for the following: An IJ was called under 483.25, Quality of Life (refer to F 689 - Free of Accident Hazards/Supervision) on May 31, 2018 at 10:27 AM, and verbally notified in the presence of the Administrator and the Director of Nursing. An corrective action plan was received and accepted on June 1, 2018 at 12:42 PM, with the following information: a. Medical records completed an audit for all residents on conservatorship and Public guardian. Inservices started for residents out on pass and elopement. b. All residents with conservatorship and public guardian were identified. All physicians were contacted to review and revise History and Physicals to reflect current status. c. Medical records will provide a list of residents to Director of Nursing or Designee with conservatorship and public guardian who should not have an out on pass order. d. The Interdisciplinary Team will review upon admission, quarterly and as needed any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 7 of 10 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 07/16/2018 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 residents with conservatorship and their status. The ID Team will schedule a care conference with resident and conservator on a quarterly basis and as needed. e. Ensure all conservatorship documentation is available in medical records chart for residents. f. Prior to admission all prospective residents will prescreen all residents for history of elopement or wandering risks and behaviors. g. Any residents exhibiting behaviors or signs of elopement will be assessed immediately for appropriate interventions and or placement. h. The results will be reported to the QAPI (Quality Assurance Performance Iimprovement) Committee Quarterly for review, monitoring and recommendations as needed. After interviews and document reviews confirmed that the corrective action plan had been implemented, the IJ was removed on June 1, 2018 at 12:51 PM, in the presence of the Administrator and the Social Services Director. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R6U411 Facility ID: CA240000089 If continuation sheet 8 of 10 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 07/16/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: R6U411 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000089 (X5) COMPLETE DATE If continuation sheet 9 of 10 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 07/16/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: R6U411 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000089 (X5) COMPLETE DATE If continuation sheet 10 of 10