Other·June 15, 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 the investigation of an entity reported incident (ERI). ERI number: CA00510652 Representing the California Department of Public Health: Surveyor 36159 Surveyor 25179 The inspection was limited to the specific incident and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of ERI number: CA00510652

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide adequate 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: 9C7O11 Facility ID: CA240000106 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555896 (X3) DATE SURVEY COMPLETED 05/05/2017 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 supervision to prevent 1 of 2 sampled residents (Resident A) elopement as evidenced by not implementing the every 15 minute observation checks as per the facility policy and procedure for residents who are at risk for elopement. This failure contributed to the resident eloping from the facility and placing him at risk for serious harm. Finding: On November 15, 2016 at 2:00 PM, an unannounced visit to the facility was made to investigate Resident A's elopement from the facility. During an interview with the Assistant Director of Nursing (ADON) on November 15, 2016 at 2:15 PM, she stated, they did not know how he [Resident A] exited. She said the Licensed Vocational Nurse (LVN 1) said she locked the doors at 5:00 PM, but stated that the resident [Resident A] was gone prior to that. Resident A was not found when the dinner trays were passed at 5:00 PM. A review of Resident A's clinical record showed he was admitted to the facility on October 13, 2016 with diagnoses which included epilepsy (seizure disorder), hypertension (high blood pressure), Type II diabetes mellitus (blood glucose levels above normal), dementia (gradual decrease in the ability to think and remember), COPD (a group of respiratory diseases of the lungs), and muscle weakness. A review of Resident A's History and Physical dated November 14, 2016, showed the resident has fluctuating capacity to understand and make decisions, but can make immediate needs known. A review of the Nurse's Notes for Resident A, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9C7O11 Facility ID: CA240000106 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555896 (X3) DATE SURVEY COMPLETED 05/05/2017 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 dated October 13, 2016 at 18:45 [6:45 PM], documented Resident A stated, "Can't I just walk to my mom's from here, she lives right here", resident continued to repeat "my mother is dead" and stated, I live in her house. I have to go see her house now. A review of the Nurse's Notes for Resident A, dated November 11, 2016 at 7:11 PM, reflected at 5 PM the charge nurse went to lock the doors and check on all residents with Q (every) 15 (minutes) checks. The nurse found out that the resident was not in his room. Staff then spread out to look for the resident and could not find the resident. During an interview with the Director of Nursing (DON) on November 15, 2016 at 3:10 PM, when asked why Resident A was placed on Q 15 minute (every 15 minutes) observation checks beginning November 2, 2016, she stated, we had the LVNs complete an elopement risk assessment on all of the residents. She said we started the Q 15 minute checks for the ones deemed at risk. During an interview with Certified Nurse Assistant (CNA 3), on November 15, 2016 at 4:25 PM, who worked the afternoon shift on November 11, 2016, CNA 3 stated, "I did see him when we were passing out waters at 3:45 PM, he [Resident A] was in his room." During an interview with Certified Nurse Assistant (CNA 4), on November 15, 2016 at 4:30 PM, who worked the afternoon shift on November 11, 2016, CNA 4 stated, "..dinner trays were already out and were being passed. . . I personally did not see him . . he was the type of person to be on heightened alert, he had not tried to leave prior, but would stand at the doors watching during the change of shifts." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9C7O11 Facility ID: CA240000106 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555896 (X3) DATE SURVEY COMPLETED 05/05/2017 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 the Certified Nurse Assistant (CNA 5), on November 16, 2016 at 11:00 AM, who worked the afternoon shift on November 11, 2016, CNA 5 stated, Resident A's dinner time was 5:15 PM, and it was noticed then that he was not in his room. CNA 5 further stated, Resident A is always in the hallway and she did not see him that afternoon. During an interview with LVN 2, on November 17, 2016 at 11:30 AM, who worked the afternoon shift on November 11, 2016, LVN 2 stated, " . . I had not seen him that day . . .normally he follows someone asking to leave at least every other day . . . he also carried around an envelope that had an address, and said his mom was passed away and wanted to go there. . ." A review of Resident A's "Elopement Risk Assessment" dated October 31, 2016 at 8:08 PM (18 days after Resident A's admission), indicated the resident was an elopement risk. A review of Resident A's "Wandering Care Plan" (not dated and not signed) indicated the following approaches: Place resident in area where constant observation is possible. Do not allow resident to leave facility. Place resident on Q 15 minute observation. In an interview with LVN 1 on April 12, 2017 at 1:35 PM, she stated that it was the CNA's responsibility to do the Q 15 minute checks and it is the LVN's responsibility to make sure the CNA does them." A review of the "Resident Q 15 Minute Observation Record" for Resident A, showed the 15 minute observation checks were done by the staff of Resident A's presence in the facility beginning November 9, 2016 at 6:30 AM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9C7O11 Facility ID: CA240000106 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555896 (X3) DATE SURVEY COMPLETED 05/05/2017 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 and ending November 10, 2016 at 6:15 AM, and November 10, 2016 beginning at 6:30 AM ending November 11, 2016 at 3:40 PM. There was no documentation to show the 15 minute check observations were done after 3:40 PM on November 11, 2016. In an interview with ADON on April 12, 2017 at 1:35 PM, she stated she did not know why the Q 15 minute checks were not done. She stated it was the CNA's responsibility to do the Q 15 minute checks. A review of a facility policy and procedure titled, "Admission Elopement Risk Policy and Procedure," undated, showed the following: "Procedure: The steps the facility will take to identify residents at risk for elopement on admission will include: An Elopement Risk Observation report will be completed upon admission by admitting nurse. Residents will be put on a Q (every) 15-minute watch for the first 72 hours of placement in the facility per MD (physician)/PSYCH (Psychiatrist) order. This will be documented on the Q 15-minute observation form and signed off at the end of shift by the charge nurse ..." During an interview with the ADON on February 24, 2017, she stated that the resident has not been found. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9C7O11 Facility ID: CA240000106 If continuation sheet 5 of 5