Other·April 26, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on March 6, 2017 through March 15, 2017. Representing the Department of Public Health Surveyors: 37363, 33787, 33483, 25459, 37553, 37837 Census: 51 Sampled Residents: 13 Unsampled Residents: 14 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 483.24, Quality of Life (refer to F 309 - Provide Care /Services for Highest Well Being) on March 14, 2017 at 3:28 PM, and verbally notified in the presence of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Quality Assurance. The facility failed to ensure that two (2) of 13 sampled residents (Resident 9, and 12) injuries were thoroughly investigated and addressed according to the facility's policy and procedure when: 1. For Resident 12, the charge nurse failed to notify the physician, endorse to the next shift, and document the fall incident. Resident 12 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: CBC811 Facility ID: CA240000106 If continuation sheet 1 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was diagnosed with a left hip fracture six (6) days after the fall incident occurred. 2. For Resident 9, the charge nurse failed to notify the physician and the DON when the resident reported that her right knee was bumped in to by another resident's wheelchair. There was no documented evidence to show that an incident report or investigation was completed. Resident 9 was diagnosed with a right femur fracture nine (9) days after the incident occurred. The corrective action plan was received on March 14, 2017 at 5:10 PM. After review and deliberation, the corrective action plan lacked specific details as to it's implementation and was discussed and returned to the administrator in the presence of the QAC, DON and administrator-in-training (AIT) on March 14, 2017 at 5:50 PM. An amended corrective action plan was received and accepted on March 15, 2017 at 8:26 AM, with the following information. a. All identified incidents will have an incident report completed by the licensed nurse at the time of the event. At the time of the incident report, a post fall assessment and fall risk assessment must be completed by the licensed nurse. Included in the incident report is a check off list to guide the licensed nurses through the process. All assessments such as pain, skin and any part of associate injuries must be done with accurate documentation. b. The resident will be placed on Q shift (every shift) monitoring by the licensed nurse for a minimum of 72 hours. This will be monitored by the medical records daily Monday thru Friday using the change of condition audit with results forwarded to the DON for review and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 2 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE follow up. c. Body checks will be done daily with irregularities reported to the Licensed Nurse. Certified Nurse Assistant (CNA) conduct personal care to their assigned residents throughout their shift and are required to notify their charge nurse of any change in resident's condition daily. d. Weekly assessments (summaries) by licensed nurses include full body assessment and are completed on a daily basis per the medical records calendar. Medical records will audit for the completion of the weekly assessment Monday through Friday. e. In the event of a serious injury, fall with fracture, fracture with unknown cause would be considered as unusual occurrence. The Director of Nursing and administrator must be notified immediately. The IJ was removed on March 15, 2017 at 12:33 PM in the presence of the Administrator, Director of Nursing, Assistant Director of Nursing, and Quality Assurance Coordinator.

F156 SS=F NOTICE OF RIGHTS, RULES, SERVICES, CHARGES FORM CMS-2567(02-99) Previous Versions Obsolete

F156 Event ID: CBC811 04/07/2017 Facility ID: CA240000106 If continuation sheet 3 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18) (d)(3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. §483.10(g) Information and Communication. (1) The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. (g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 4 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) [§483.10(g)(4)(ii) will be implemented beginning November 28, 2017 (Phase 2)] (iii) Information regarding Medicare and Medicaid eligibility and coverage; [§483.10(g)(4)(iii) will be implemented beginning November 28, 2017 (Phase 2)] (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; [§483.10(g)(4)(iv) will be implemented beginning November 28, 2017 (Phase 2)] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 5 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) Contact information for the Medicaid Fraud Control Unit; and [§483.10(g)(4)(v) will be implemented beginning November 28, 2017 (Phase 2)] (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 6 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (g)(16) The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident’s stay. (i) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. (ii) The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. (iii) Receipt of such information, and any amendments to it, must be acknowledged in writing; (g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 7 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in paragraphs (g)(17)(i)(A) and (B) of this section. (g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility’s per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility’s per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident’s date of discharge from the facility. v) The terms of an admission contract by or on behalf of an individual seeking admission to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 8 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must not conflict with the requirements of these regulations. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure that a posting of the resident advocacy group was available when the name, address and contact numbers of the Protection and Advocacy Network for Mental Illness was not posted. This failure had the potential to not protect mentally-ill residents from abuse and neglect for 41 residents with documented psychiatric diagnosis in a universe of 51. Findings: During an environmental tour on March 9, 2017 at 9:05 AM, the posting on Protection and Advocacy Network for Mental Illness was not observed posted in the facility bulletin board in the hallway and lobby. During an interview with the Director of Nursing (DON 2) on March 9, 2017 at 9:20 AM, the DON 2 verified that the Protection and Advocacy Network for Mental Illness was not available and not posted in the facility.

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 04/07/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 9 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure three (3) of unsampled residents (Resident A, B, and C) were treated with dignity when: 1. Resident A was observed wearing shorts with exposing her briefs. 2. Resident B was observed on two (2) occasions with food stains on the front of his shirt. 3. Resident C was incontinent of urine and waited for 45 minutes to be changed. 4. Resident C's abdomen was exposed and seen on the hallway during insulin injection administration. These failures had the potential to negatively affect the residents' dignity and well-being. Findings: 1. During an observation of Resident A on March 8, 2017 at 11:30 AM, Resident A was observed ambulating in the hallways wearing a pair of shorts with holes in the back and on the side exposing her briefs. Resident A was alert, but non-interviewable. During an interview with a Certified Nurse Assistant (CNA 1) on March 8, 2017 at 12:25 PM, she stated that she dressed the resident, but did not notice the shorts had holes. In an interview with the Social Services Director (SSD) on March 8, 2017 at 1:30 PM, she stated, "I took care of it, I took it (the shorts) away once before and I don't know how it got back to her." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 10 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. On March 8, 2017 at 12:25 PM, Resident B was seen in the hallway wearing a shirt with a yellowish and pinkish stain on the front. Resident B was again seen in the hallway at 4:30 PM, on the same day, still wearing the same stained shirt. During an interview with Resident B on March 8, 2017 at 4:30 PM, Resident B stated that he told a staff member (does not know the name of the staff member) that his shirt was stained, but nothing was done. An interview was conducted with Certified Nursing Assistant (CNA 2) on March 8, 2017 at 4:45 PM, who verified that the resident's shirt was stained. 3. During an observation on March 7, 2017 at 11:53 AM, Resident C was observed sitting in the hallway in his wheelchair with wet pants. During an interview with Resident C on March 7, 2017 at 11:53 AM, he stated his pants were wet with urine and he had been waiting for 30 minutes to be changed by the Certified Nursing Assistant (CNA 3). During an interview with CNA 3 on March 7, 2017 at 12:00 PM, CAN 3 stated she could not leave Room 102, because the resident required one to one supervision. She stated Resident C has been waiting for 45 minutes to be changed. 4. During a medication pass observation on March 7, 2017 at 6:40 AM, LVN 1 performed an insulin injection (a method of administering medication using a syringe to control blood sugar) to Resident C without closing the privacy curtain exposing the resident's abdomen from the hallway. During an interview with LVN 1 on March 7, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 11 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2017 at 6:52 AM, she confirmed that the privacy curtain must be closed when performing a medical procedure or medication administration on a resident. The policy and procedure titled, "Policy and Procedure on Medication and Treatment Administration," not dated, indicated "...18. Maintain privacy during medication administration".

F253 SS=D HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.10(i)(2)

F253 04/07/2017 (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a sanitary environment for one of 51 sampled residents (Resident 10) when a bedside commode (a portable toilet) had a dried, dark brownish matter and a soda pop lid found inside the commode pail. This failure had the potential to not provide a comfortable environment for the resident. Findings: During initial tour on March 6, 2017 at 8:45 AM in Resident 10's room, the commode pail was observed to have a dried-up dark, brownish matter and a metal soda pop lid. During an interview with Activities Assistant (AA) in Resident 10's room on March 6, 2017 at 8:45 AM, she stated the dried-up, brownish FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 12 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE matter inside the commode pail looked like BM (bowel movement) and the metal lid was from a soda pop. The AA further stated, the bedside commode should be cleaned after use and the CNA (Certified Nursing Assistant) was responsible for it. During an observation in Resident 10's room on March 10, 2017 at 2:00 PM, the bedside commode had a plastic covering on top of the pail, and the contained dried brownish matter and a soda pop lid. During an interview with CNA 6 on March 10, 2017 at 2:30 PM, she stated that the resident's bedside commode needs to be cleaned. A facility policy and procedure titled, "Housekeeping Department", undated, indicated, "5. Clean and sanitize commode ... which includes the bowl ..." "Effective environment sanitation is required to lessen the hazards of exposure to contaminated equipment ..." "Housekeeping is responsible for maintaining equipment and keeping it as bacteria (germ)-free as possible ... "Frequent cleaning of the building's interior will aid in physically removing some of the microorganisms (germs) which might cause these hazards."

F257 SS=E COMFORTABLE & SAFE TEMPERATURE LEVELS CFR(s): 483.10(i)(6)

F257 04/07/2017 (i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 degrees F. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 13 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level of 71-81 degrees Fahrenheit (F) in multiple areas throughout the facility. This failure had the potential to adversely affect the health and safety of residents by placing them at risk for hypothermia (dangerously low body temperature causing medical emergency). Findings: During initial tour with the Assistant Director of Nursing (ADON) on March 6, 2017 at 8:45 AM, the temperatures in Rooms 118, 122, 127, hallway and lobby were as follows: a. Room 118 = 66.2 degrees Fahrenheit (F) b. Room 122 = 66.2 degrees F c. Room 127 = 66.4 degrees F d. Hallway = 69.3 degrees F e. Lobby = 70.7 degrees F a. During an observation in Room 118 on March 6, 2017 at 8:50 AM, Resident L had two sheets and two blankets while in bed. During an interview with the Assistant Director of Nursing (ADON) on March 6, 2017 at 8:55 AM, she confirmed that the temperature readings were below 71 degrees F in Room 118. During an interview with Resident L in Room 118 on March 6, 2017 at 9:00 AM, she stated it was cold in her room all the time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 14 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. During an interview with Resident 8 in Room 122 on March 6, 2017 at 9:05 AM, he stated, "I froze last night and it was uncomfortable!" Resident 8 further stated that he informed staff about the cold temperature last night. c. During an interview with Resident K in Room 127 on March 6, 2017 at 9:10 AM, she stated it was always cold in her room. d/e. During an interview with one of two residents sitting in the lobby on March 6, 2017 at 9:20 AM, Resident M stated, "It's cold here, and I also noticed it's cold all the way in the hallway." During an interview with the Assistant Director of Nursing (ADON) on March 6, 2017 at 9:30 AM, she confirmed that the temperature readings were below 71 degrees F in the hallway and in the lobby. During a concurrent interview with the Maintenance Supervisor (MS), he stated he was unaware that the temperatures were below 71 degrees F in rooms 118, 122, 127, in the hallway and the lobby. MS further stated he monitors the temperatures throughout the facility. A facility policy and procedure on temperature, undated, indicated, "It is the policy of Arrowhead Healthcare Center to maintain the temperature within the facility at a consistent, healthy level both winter and summer ..." "2. The thermostats are set a comfortable setting ..." "7. Residents register complaints concerning the temperature within the facility. The maintenance department is responsible to check the settings on the thermostat. After hours that responsibility falls to the charge nurses ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 15 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F278 ASSESSMENT ACCURACY/COORDINATION/CERTIFIED CFR(s): 483.20(g)-(j)

F278 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/07/2017 (g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 16 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to accurately document a section in the Resident Assessment Instrument (RAI an assessment of the resident's medical status) for one of 13 sampled residents (Resident 10) and 3 of 14 unsampled residents (Resident I, H, and J) when the following RAI Sections was coded incorrectly: 1. Resident I had two (2) falls that were not reflected on the Discharge Assessment, Section J, dated February 16, 2017. 2. Resident H had one (1) fall on August 22, 2106 that was not reflected in the RAI Quarterly Assessment, Section J, dated October 22, 2016. 3. Resident J had one (1) fall on November 2016 was not captured in RAI Quarterly Assessment, Section J. 4. Resident 10 had one fall that was not reflected in the RAI Quarterly Assessment, Section J, dated August 10, 2016. These failures resulted in inaccurate assessment for Resident I, H, J and 10. Findings: 1. During a review of the clinical record for unsampled Resident I on March 15, 2017 at 10:00 AM, the record indicated, Resident I was admitted to the facility on July 5, 2016. A review of Resident I's nurses notes indicated she had 2 falls on February 2, 2017 and February 12, 2017. A review of RAI Section J 1800; of the Discharge Assessment dated February 16, 2017, it indicated, Resident I had zero (0) falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 17 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Licensed Vocational Nurse (LVN 5) on February 15, 2017 at 11:30 AM, LVN 5 stated, that she should have coded it as 2 falls instead of 1. 2. During a clinical record review for Resident H, the quarterly RAI, Section J, dated October 25, 2016, indicated the resident did not have a fall since the last assessment (RAI). The last assessment, prior to October 25, 2016, was an annual RAI completed on July 26, 2016. A review of the Post Fall Observation Assessment, dated August 22, 2016, indicated Resident H had a fall with no injury During an interview and concurrent record review with a Licensed Vocational Nurse (LVN 5), on March 15, 2017 at 4:29 PM, she stated Resident H had a fall with no injury on August 22, 2016 and the quarterly RAI was coded incorrectly on October 25, 2016. LVN 5 stated Section J 1800 (fall since admission or previous MDS (RAI) assessment) should have been coded a one (1), to indicate Resident H had one fall, and Section J 1900 A (number of falls with no injury) should have been coded a one (1), to indicate Resident H had one fall with no injury. 3. During a record review of Resident J's face sheet, Resident J was admitted on August 29, 2016. During a record review of Resident J's Nurses Notes dated November 2, 2016, it indicated Resident J "rolled out of bed" and was recorded as a fall incident. During a record review of Resident J's Nurses Notes dated November 10, 2016, it indicated, "resident fell onto his back ..." and was recorded as a fall incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 18 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a record review of Resident J's Quarterly Assessment RAI dated December 5, 2016, the Section J for fall did not code for two falls that occurred in the month of November, but was coded only as one fall incident. During an interview with LVN 5 on March 15, 2017 at 3:30 PM, she stated Section J was not coded for two falls because Resident's two fall incidents in the month of November 2016 was not captured. 4. During a record review of Resident 10's face sheet, Resident 10 was admitted on December 22, 2014. During a record review of Resident 10's Progress Notes dated August 10, 2016 at 3:34 PM, it indicated Resident 10 fell and was seen lying on the floor mat. During a record review of Resident 10's Quarterly Assessment RAI dated September 13, 2016, the Section J for fall was not coded. During an interview with the MDS Licensed Vocational Nurse (LVN 5) on March 9, 2017 at 3:30 PM, she stated Section J did not reflect Resident J' fall incident on August 10, 2016.

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

F309 04/07/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 19 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide timely care and services in accordance with facility policy and procedure for two (2) of 13 sampled residents (Resident 9 and 12) when: 1. For Resident 12, the charge nurse failed to notify the physician, endorse to the next shift, and document the fall incident. Resident 12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 20 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was diagnosed with a left hip fracture six (6) days after the fall incident occurred. 2. For Resident 9, the charge nurse failed to notify the physician and the DON when the resident reported that her right knee was bumped in to by another resident's wheelchair. There was no documented evidence to show that an incident report or investigation was completed. Resident 9 was diagnosed with a right femur fracture nine (9) days after the incident occurred. Findings: 1. During an interview with Licensed Vocational Nurse (LVN 3) on March 9, 2017 at 3:20 PM, she stated that last January 24, 2017 at 7:51 PM, she went to Resident 12's room to give her medications. Resident 12 was sitting at the edge of her bed. LVN 3 went to put on gloves and noticed Resident 12 began to slip from her bed. LVN 3 said she assisted her (Resident 12) in going down to the floor and she then alerted the closest Certified Nurse Assistant (CNA 7) and they both assisted Resident 12 back to bed. During another interview with LVN 3 on March 9, 2017 at 3:30 PM, she stated she made assessments and Resident 12 did not had any pain or injury. She further stated that the next shift was notified but no documentation was shown to indicate the assessment or notification to the Director of Nursing (DON) or the next shift was notified at the time of the incident. She confirmed that lowering Resident 12 to the floor is considered an assisted fall and must be reported immediately to the Director of Nursing (DON). During a phone interview with Licensed Vocational Nurse (LVN 1, incoming shift 11:00 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 21 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE PM to 7:00 AM charge nurse on January 24, 2017) on March 10, 2017 at 10:15 AM, she stated that she was not aware of the incident and no endorsement was made. A review of the departmental (nurses notes) notes, dated January 30, 2017 and January 31, 2017, indicated the following: a. A late entry of the fall incident for January 24, 2017, was entered on departmental notes on January 30, 2017. b. Resident 12 was transferred to an acute care hospital on January 31, 2017 at 5:30 PM, due to the swelling of her left upper leg. A review of acute hospital's physician notes dated January 31, 2017, indicated that "1. The patient has suffered a mechanical fall in which there was no loss of consciousness, resulting in a left hip intertrochanteric fracture (fracture of the upper part of the thigh bone) with dislocation." A review of another facility's departmental notes revealed that " ...Resident is post surgery for left hip intermedullar rodding (a metal rod placed in the long bone to stabilize or treat a fracture)" prior to her return to the facility on February 3, 2017 at 10:54 PM. A review of the facility's "Rehab Post Fall Screening," signed by the physical therapist on November 21, 2016, indicated that "patient was found by CNA on the bathroom floor" with no injury noted. A fall risk assessments for Resident 12 were completed on September 29, 2016 and November 18, 2016. A review of the clinical record of Resident 12 indicated that she was admitted to the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 22 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on June 17, 2015, which included the diagnosis (identification of an illness) of aged related osteoporosis (thinning or weakening of the bones). The facility policy and procedure titled, "Falls Clinical Protocol", not dated, indicated that "Assessment and Recognition ... 5. The staff will evaluate and document falls that occur while the individual is in the facility." A review of a facility policy and procedure titled, "Dealing with a Fall", not dated, indicated that "Any fall needs to be investigated immediately (lowering a resident to the ground is considered a fall). You must do the fall risk assessment and post fall assessment. Slide the completed incident report under the DON office door". A review of the facility's "Charge Nurse "RN/LVN (Registered Nurse/Licensed Vocational Nurse)" specific job function of a charge nurse includes "... Gives thorough report to oncoming charge nurse and details changes in conditions, incidents, new orders etc." 2. A review of Resident 9's clinical record indicated Resident 9 was admitted to the facility on June 3, 2015, with diagnoses that included osteoarthritis (a form of arthritis involving the cartilage of the knee joint causing a gradual wearing away of the cartilage), schizophrenia (a mental disorder in which a person experiences symptoms, such as hallucinations or delusions, and mood disorders) and a history of right total knee replacement date of surgery 2002. During an observation of Resident 9 on March 9, 2017 at 1:30 PM, Resident 9 was observed lying in bed with a leg immobilizer (an apparatus to prevent movement) on her right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 23 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE leg and a wound dressing over the right knee. Resident 9 was alert and oriented to place and person, answered questions appropriately, and was able to make needs known. During an interview with Resident 9 on March 9, 2017 at 1: 35 PM, when asked what happened to her leg, she stated that someone bumped her knee with their wheelchair. During an interview with Resident 9's family member on March 9, 2017 at 7:30 PM, she stated that no one informed her of the incident that happened on February 11, 2017, when Resident 9 was bumped on the right knee by someone else's wheelchair. The family member stated that when she visited her mom on February 19, 2017, she found the resident in bed with two (2) CNAs trying to help her up to a wheelchair. Her right knee was swollen and she was complaining of pain. The family member stated that the last time she saw her mother was about two weeks ago she was able to stand with assist to a wheelchair. According to the family member, one of the CNA told her, "I don't want to lie to you; but your mom was hurt on the right knee when it got bumped." A review of the nurse's note dated February 11, 2017 at 7:14 AM, by Licensed Vocational Nurse (LVN 1), indicated that the resident was complaining of right knee pain. Upon further assessment the resident stated that she was hit by someone else's wheelchair. Swelling was present. During an interview with a Licensed Vocational Nurse (LVN 1), on February 14, 2017 at 10:30 AM, LVN 1 stated that she was the LVN on duty on February 11, 2017 at 7:14 AM, when the resident complained of pain in her right knee. LVN 1 said the resident stated that someone else's wheelchair bumped her on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 24 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE right knee. The incident was unwitnessed. The resident complained of pain, and the right knee had more swelling than usual when she did the assessment. The resident was medicated for pain and she was placed in bed. LVN 1 stated that she did not initiate an incident report and further stated, "Now I know that I should have initiated one." An interview was conducted with the Assistant Director of Nursing (ADON) on March 10, 2017 at 10:50 AM. The ADON stated that there was no investigation or incident report done because the resident kept changing her story and giving conflicting stories. I did not know or I am not aware that we called and notified anybody when the incident happened. A review of the physician's order dated February 14, 2017 at 7:30 AM, indicated; "Resident may have x-ray (digital image of the internal composition of something) of knee two (2) views for pain." Result of x- ray reading on February 15, 2017 taken by {name of Laboratory facility} on February 15, 2017 indicated, "Right knee 2V (two views) there is a prosthetic right femoral in proper alignment ... There is no fracture or acute dislocation. " There were no nurse's notes to review from February 15, 2017 at 6:18 PM through February 19, 2017. On February 20 2017 at 2:36 PM, the nurse's note indicated, "Resident was having right knee pain 10/10 (pain level indicating severe pain). Resident's right knee was swollen and warm to touch. MD (Medical Doctor) notified. MD advised to send her out. Called AMR (Transport ambulance) and they transferred her to {name of hospital}. A review of the acute hospital's Emergency Department (ED) notes dated February 20, 2017 at 12:05 PM, indicated, "Chief complaint: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 25 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE right leg swelling, pain to touch and movement. Per EMS (Emergency Medical Services) patient's knee was bumped by another wheelchair at the facility." A review of the ED physician's note dated February 21, 2017, indicated, "x-ray of the right knee showed, fracture of the distal diaphysis of the femur with angulation at the fracture site, displacement and override of the fracture fragments as well" (Fracture of the thighbone that occur just above the knee joint). Surgery was advised but the resident's daughter declined at that time. A consult interview was conducted with the Radiologist (a medical doctor that specializes in diagnosing and treating diseases and injuries using medical imaging techniques) at {name of laboratory facility} on March 14, 2017 at 12:15 PM, who stated that it is possible that the fracture could have been blocked by the right knee prosthesis (artificial body part) on the first x-ray, that's why the fracture was not seen on the x-ray taken on February 15, 2017, and there was no follow up x-ray done for comparison. A review of the nurse's notes for Resident 9, dated February 22 to February 27, 2017, showed the resident continued having pain and was medicated with routine MS Contin (an extended release form of morphine, a narcotic used for pain) 15 mg (milligrams-medication to relieve pain), and Tylenol 650 mg, added as a new medication for pain. Resident was dependent with transfer. An interview was conducted with a Restorative Nursing Assistant (RNA 1) on March 14, 2017 at 3:15 PM. RNA 1 stated, "Before February 11, 2017 the resident was not complaining of pain during RNA, but starting on the 11th of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 26 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE February 2017, she was complaining of pain in her right leg so I did not perform exercises on the lower extremities. I only perform exercises on the upper part of the body." Resident was taken to {name of Ortho. clinic} accompanied by a staff member on February 28, 2017 for appointment. A review of physician's progress notes dated February 28, 2017, indicated, "Long spiral fracture extending along the distal diaphysis (the shaft of a long bone) to the prosthesis." Surgery was recommended STAT (as soon as possible) ORIF (An open reduction internal fixationrefers to a surgical procedure to fix a severe bone fracture) was performed at {name of hospital} on February 28, 2017. An interview was conducted with the facility Administrator in the presence of the Director of Nursing (DON) on March 10, 2017 at 4:30 PM. The Administrator stated that the incident of fracture did not occur in the facility, that's why there was no investigation done and there was no incident report generated. The Administrator further stated that the fracture could have happened in the ambulance or at the hospital. The DON stated that there was no assessment done upon return to the facility from {name of hospital} because the resident came back to the facility in less than 24 hours. A review of the facility's policy and procedure titled, "Unexplained Injuries- Investigation", dated January 1, 2012 indicated, "Purpose: to protect the health and safety of our residents by ensuring that all unexplained injuries are promptly and thoroughly investigated and addressed. Procedure: 1. If a resident is observed with unexplained injuries, the Charge Nurse on duty will complete AN-08-Form AIncident & Accident Report Form and record such information into the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 27 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medical record. ll. Documentation must include information relevant to risk factors and conditions that causes or predisposes someone to similar signs and symptoms (e.g. receiving anticoagulants, having osteoporosis, having movement disorder ...). lll. The nursing staff will discuss the situation with the Attending Physician or Medical Director to consider whether medical conditions or other risk factors could account for the findings." An IJ was called on March 14, 2017 at 3:28 PM, and verbally notified in the presence of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Quality Assurance. The corrective action plan was received on March 14, 2017 at 5:10 PM. After review and deliberation, the corrective action plan lacked specific details as to it's implementation and was discussed and returned to the administrator in the presence of the QAC, DON and administrator-in-training (AIT) on March 14, 2017 at 5:50 PM. An amended corrective action plan was received and accepted on March 15, 2017 at 8:26 AM, with the following information. a. All identified incidents will have an incident report completed by the licensed nurse at the time of the event. At the time of the incident report, a post fall assessment and fall risk assessment must be completed by the licensed nurse. Included in the incident report is a check off list to guide the licensed nurses through the process. All assessments such as pain, skin and any part of associate injuries must be done with accurate documentation. b. The resident will be placed on Q shift (every shift) monitoring by the licensed nurse for a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 28 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE minimum of 72 hours. This will be monitored by the medical records daily Monday thru Friday using the change of condition audit with results forwarded to the DON for review and follow up. c. Body checks will be done daily with irregularities reported to the Licensed Nurse. Certified Nurse Assistant (CNA) conduct personal care to their assigned residents throughout their shift and are required to notify their charge nurse of any change in resident's condition daily. d. Weekly assessments (summaries) by licensed nurses include full body assessment and are completed on a daily basis per the medical records calendar. Medical records will audit for the completion of the weekly assessment Monday through Friday. e. In the event of a serious injury, fall with fracture, fracture with unknown cause would be considered as unusual occurrence. The Director of Nursing and administrator must be notified immediately. The IJ was removed on March 15, 2017 at 12:33 PM, in the presence of the Administrator, Director of Nursing, Assistant Director of Nursing, and Quality Assurance Coordinator.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 04/07/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 29 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure two of 13 sampled residents (Residents 11 and 6) had physicians orders that indicated specific targeted behaviors or medication side effects to be monitored for medications the resident was receiving. This failure had the potential to harm the residents' overall health and negatively affect their physical and psychosocial wellFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 30 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE being. Findings: 1. A. A clinical record review was conducted for Resident 11. Resident 11 was admitted to the facility on January 12, 2017 and readmitted to the facility on February 7, 2017 with diagnoses that included alcohol dependence (constant craving for alcohol) with withdrawal (withdrawal symptoms include nausea, sweating, irritability, tremors or shaking that can develop when drinking is stopped or reduced). A review of Resident 11's Physician Orders List and monthly Physician Orders for January, February and March 2017, indicated medication orders for bupropion HCL for depression, dated January 12, 2017 to January 30, 2017 and February 7, 2017 to March 14, 2017, and a medication order for alprazolam for anxiety, dated February 7, 2017 to March 3, 2017. The medication orders did not indicate specific targeted behaviors or medication side effects to be monitored while the resident received the medications. A review of Resident 11's electronic Medication Administration Record (eMAR) dated January, February and March 2017, indicated there were no specific behaviors or medication side effects being monitored while Resident 11 was receiving bupropion HCL and alprazolam. During an interview and concurrent record review of Resident 11's physician orders and eMARs with the Assistant Director of Nursing (ADON), on March 10, 2017 at 12:25 PM, she stated the Physician Orders did not indicate behaviors to be monitored while Resident 11 was taking the alprazolam and the bupropion HCL. The ADON also stated the nurses were not monitoring behaviors or side effects for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 31 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications in January, February and March of 2017. B. A clinical record review was conducted for Resident 6. Resident 6 was admitted to the facility on February 1, 2008 with diagnoses that included major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 6's monthly Physician Orders for May 2016 to March 2017 and an original physician order dated February 1, 2008, indicated an order for paroxetine HCL for depression. The medication orders did not indicate specific targeted behaviors or medication side effects to be monitored while Resident 6 received the medication. A review of Resident 6's electronic Medication Administration Record (eMAR) dated May 2016 through March 2017, indicated there were no specific behaviors or medication side effects being monitored while Resident 6 was receiving paroxetine HCL. During an interview and concurrent record review of Resident 6's physician orders and eMARs with the Assistant Director of Nursing (ADON), on March 10, 2017 at 12:20 PM, she stated the nurses were not monitoring specific behaviors or side effects for the medication from May 2016 to March 2017. The ADON also stated psychoactive medication orders (orders for medications that treat mental illness and mood disorders) should all have a manifested behavior specified, she was unable to find a clarification order for the Paxil (paroxetine HCL) specifying a manifested behavior, and it (the order) should have been clarified. The undated facility policy and procedure titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 32 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Psychoactive Drug Monitoring" indicated, "Residents who receive antidepressant, hypnotic, antianxiety or antipsychotic medications shall be monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum or untoward effects."

F386 SS=D PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS CFR(s): 483.30(b)(1)-(3)

F386 04/07/2017 (b) Physician Visits The physician must-(1) Review the resident’s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the physician orders were signed for one of 13 sampled residents (Resident 8) when the Physician Admission Orders/Medication Record and the Recapitulated Physician Orders (Recapped Physician Orders, a monthly summary of doctor's orders) for January 2017 were not signed and dated by the physician. In addition, the Physical Therapy/Occupational Therapy (PT/OT) Recertification Progress Report and Updated Therapy Plan dated January 26, 2017 to February 22, 2017 was not signed and dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 33 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by the physician. These failures had the potential for physician orders to not being verified for accuracy and correctness by the ordering physician, which could jeopardize health and safety of the resident. Findings: During a clinical record review, the face sheet indicated, Resident 8 was admitted in the facility on November 30, 2016 with diagnoses which included paraplegia (paralysis if the lower body). During a record review of Resident 8's Physician Admission Orders, the following were undated and unsigned that included diet Order: 2 gram (gm) Low Sodium (salt). Regular Texture, TB (Tuberculosis) Skin Test (2-Step PPD) (Purified Protein Derivative, a test to determine if a patient has TB) and Physical Therapy and Occupational Therapy. During a review of Resident 8's Recapped Physician Orders for the month of January 2017, the orders were not signed and dated by the ordering physician for two months. During an interview with the Assistant Director of Nursing (ADON) on March 9, 2017 at 11:30 AM, she stated that the doctor did not sign the January 2017 physician's recap order and admission orders for Resident 8. A facility policy and procedure titled "Physician Orders" undated indicated, "The entry shall contain the instructions from the physician, date, time and the signature and the title transcribing the information ... The physician must sign physician order sheet during monthly visit ..." Further review of Resident 8's PT/OT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 34 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Recertification Progress Report dated January 26, 2017 to February 22, 2017, it was not signed and dated. During an interview with the Assistant Physical Therapist on March 9, 2017 at 9:30 AM, he stated the Recertification Progress Report should have been signed by the physician. A review of the facility policy and procedure titled, "Medicare Certification/Re-certification", dated June 10, 2012, it indicated, "Part B, 10. i. b. Requires a dated signature on the plan of care or some document that indicates approval of the plan of care ..." "Procedure, 2. B. v. Physician signs and dates form." "c. Place the prior completed certification/re-certification form in the record until time to obtain re-certification signature from the physician on or before the 14th day."

F428 SS=D DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON CFR(s): 483.45(c)(1)(3)-(5)

F428 04/07/2017 c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 35 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 36 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to act upon the pharmacist's Drug Regimen Review (DRR, a review of medications by pharmacists) for one of 13 sampled residents (Resident 10) when Resident 10's DRR for Nexium (medicine to reduce stomach acid) 20 milligrams (mg) was not acted upon by the physician in a timely manner. This failure had the potential for Resident 10 to receive unnecessary medications that may affect the resident's health. Findings: During a clinical record review, the face sheet indicated, Resident 10 was admitted on June 2, 2015 with diagnoses which included Gastroesophageal Reflux Disease (GERD, abnormal increase of stomach acid). During a review of Resident 10's Physician Order Sheet, dated November 29, 2016, it indicated, "Nexium 20 mg q AM (every morning) ..." During a review of Resident 10's, "Note To Attending Physician/Prescriber", dated October 17, 2016, it indicated the physician responded and DRR was evaluated on November 29, 2016. During an interview with the Assistant Director of Nursing (ADON) on March 15, 2017, she stated the doctor did not act upon the pharmacist's DRR for the Nexium medication order in a timely manner. During a review of Resident 8's Physician Order Sheet, dated, January 2017, it indicated, "Nexium 20 mg q AM." Further review of Resident 10's "Note To Attending Physician/Prescriber" for January FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 37 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2017, it indicated, "The resident has been receiving the proton pump inhibitor Nexium for more than 12 weeks. Please consider reassessing the need for this therapy at this time..." The Physician response section was not signed and dated. During an interview with the Assistant Director of Nursing (ADON) on March 15, 2017, she stated the doctor did not act upon the pharmacist's DRR for the Nexium medication order. A facility policy and procedure titled, "Drug Regimen Review", undated, indicated, "3. Pharmacy Consultant Report will be acted upon within 72 hours, with communication relayed to each attending physician." "6. Document in the licensed nurse progress notes if physician agrees or disagrees with pharmacy consultant recommendations."

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 04/07/2017 (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: (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: CBC811 Facility ID: CA240000106 If continuation sheet 38 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 39 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure: 1. One of 13 sampled residents (Resident 6) had a floor mat (used for falls) that was free of tears and in good condition. 2. A biohazard (a risk to human health or environment arising from biological work) bin full of used needles and syringes (injection) were not picked up and disposed of by the biohazard waste company for six months. 3. A wet towel with dark brown stains was observed on the bathroom floor shared for Rooms 125 and 127. 4. An industrial fan inside the laundry room contained grayish dust-like particles, was turned on and blowing air in front of the clean linen folding table. These failures had the potential for spreading of infection to the residents. Findings: 1. During initial tour observation on March 6, 2017 at 10:55 AM, a thick, red foam mat with multiple tears was observed on the floor beside Resident 6's bed. The tears in the mat exposed spongy gray porous material (material that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 40 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE liquid can soak into) beneath the tears. During an interview with the housekeeper (HSKPR 1), on March 9, 2017 at 9:21 AM, HSKPR 1 stated infection control was a concern because of the tears in the mat. During an interview with a Certified Nursing Assistant (CNA 1) on March 9, 2017 at 9:46 AM, she stated, "The tears are an infection control issue when something drops, you can't mop it out. It (the mat) needs to go in the trash. If something goes into the tears, it stays inside, then odors and bacteria can form." 2. During environmental tour on March 9, 2017 at 9:15 AM at the facility's backyard, a black biohazard waste bin was observed full of used needles and syringes. During an interview with the Maintenance Supervisor (MS) on March 9, 2017 at 9:20 AM, the MS stated the biohazard bin had not been picked up for almost a year because they switched companies. During an interview with the Assistant Director of Nursing (ADON) on March 15, 2017 at 3:30 PM, the ADON stated she thought the previous company they had contracted with picked up the biohazard bin on their last service on September 26, 2016. The ADON confirmed that the biohazard bin had been in the facility for 6 months. During a record review of the Service Agreement, titled, "Med Waste Management", it indicated, "The collection, transportation and treatment of any and all regulated medical waste generated by the customer at a frequency of 1 time(s) per month." 3. During initial tour on March 6, 2017 at 9:05 AM, a wet towel with dark brown stains was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 41 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observed on the bathroom floor in rooms 125 and 127. During an interview with Housekeeper (HSKPR 1) on March 6, 2017 at 9:05 AM, HSKPR 1 stated the wet, stained towel should be in the soiled barrel and not on the floor. A facility policy and procedure titled, The Laundry Process, dated January 1, 2000 indicated, "Soiled linen must be removed from the units ... to keep the area infection free ..." 4. During environmental tour at the Laundry Room on March 10, 2017 at 10:00 AM, an industrial fan located by the main entry door had grayish, dust-like particles located in the fan blade and front guard. The fan was turned on and was facing the washer, dryer and clean linen folding table. During an interview with the HSKPR 1 on March 10, 2017 at 10:00 AM, HSKPR 1 stated she does not remember when she last cleaned the fan. A facility policy and procedure, titled, "Housekeeping Department", indicated, "Routine schedules must be established for the cleaning of ... fixtures ..." "Effective environmental sanitation is required to lessen the hazards of exposure to contaminated air, dust ...and equipment. Frequent cleaning of the building's interior will aid in physically removing some of the microorganisms (germs) which might cause these hazards ... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CBC811 Facility ID: CA240000106 If continuation sheet 42 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (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: CBC811 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000106 (X5) COMPLETE DATE If continuation sheet 43 of 44 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: _______________ 555896 (X3) DATE SURVEY COMPLETED 03/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROWHEAD HEALTHCARE CENTER, LLC 4343 N Sierra Way San Bernardino, CA 92407 (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: CBC811 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000106 (X5) COMPLETE DATE If continuation sheet 44 of 44