Other·February 23, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended The following reflects the findings of the California Department of Public Health during a complaint investigation. Complaint Number: CA00560149 Representing the California Department of Public Health: Surveyor: 38017 The inspection was limited to the specific complaint and does not reflect the findings of a full inspection of the facility. One deficiency was issued as a result of complaint number: CA00560149

F281 SS=G SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 02/28/2018 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide care and service in accordance with acceptable 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: 1KTO11 Facility ID: CA240000152 If continuation sheet 1 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE professional standards of quality for one of three sampled residents (Resident A) when: 1. For Resident A, the facility failed to ensure assessment and monitoring was provided for Resident A according to his plan of care when Resident A complained of a sore penis on September 22, 2017, and perineal site discomfort on October 3, 2017. 2. For Resident A, the facility failed to ensure Resident A received urinary catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care in accordance with the facility policy and procedure and professional standards to include the use of a leg strap to prevent trauma to the urinary meatus (external orifice of the urethra from which the urine is ejected during urination) from pressure. These failures resulted in Resident A to be transferred to the general acute care hospital (GACH) on October 6, 2017 due to a urethral erosion (adverse complication associated with long term use of urinary catheter wherein there is tearing of the urethra (tube that leads from the bladder and transports and discharges urine outside the body). Findings: An unannounced visit was made to the facility on November 9, 2017 at 2:25 PM, to investigate a complaint regarding quality of care for Resident A. 1. During a review of the clinical record for Resident A, it reflected Resident A was initially admitted to the facility on April 11, 2017, with diagnoses that included debility (physical weakness), hypospadias (condition in which opening of the penis is on the underside rather FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 2 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE than the tip), seizure disorder (changes in the brain's electrical activity that can cause symptoms such as muscle spasms, limb twitches, and loss of consciousness), and left eye blindness. During an observation and concurrent interview with Resident A on November 9, 2017 at 3:45 PM, Resident A was seen in bed, in fowler's (semi-upright) position. Resident A stated it has been three days since the licensed nurses have checked on his penis. During an observation with Treatment Nurse 1 (TXN 1) on November 9, 2017 at 4 PM, Resident A's penis was noted to be swollen. An indwelling urinary catheter was noted inserted below the tip of Resident A's penis, covered by foreskin. Resident A denied any pain or discomfort on his penis. A review of Resident A's physician order sheet, dated April 12, 2017, indicated "Foley catheter (type of indwelling urinary catheter to drain urine from the bladder) 16F/10cc (French 16 (size of tubing) with 10 cc (cubic centimeters unit of measurement) water). Drainage to gravity. Change catheter and drainage bag on the 10th of every month. Dx: (Diagnosis) Stage 4 Pressure ulcer (injury to the skin and underlying tissue down to bone and muscle resulting from prolonged pressure on the skin)." A review of Resident A's care plan for the Foley catheter, initiated on April 12, 2017, reflected a goal that included "Will be provided with adequate catheter care." Further review indicated "Intervention: ... Observe evidence of change in resident's condition like presence of fever, change in urine output; report to MD..." Further review reflected the care plan did not indicate how often catheter care will be provided to Resident A and how often Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 3 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A's catheter must be assessed or monitored. A review of Resident A's physician progress notes, dated September 22, 2017, documented by the medical doctor (MD), indicated "Penile area is sore with blood secondary to catheter Need Urology follow-up". Further review indicated "A/P (Assessment and Plan) ... Urethral tear Urology (field of medicine that focuses on diseases of the urinary tract and the male reproductive tract)." A review of Resident A's nursing notes, documented by TXN 1, dated October 3, 2017 at 11:41 AM, indicated "received a complaint from resident regarding discomfort to peri (perineal) site. client (resident) has a standing order for an indwelling foly (foley) cath (catheter) to maintain skin integrity to resident's wounds. Wound care nurse reached out to MD for a request to schedule resident with urology consult. MD has approved. Order was noted and appointment coordinator notified. Awaint (await) appointment date. will follow up." There was no documented evidence on Resident A's chart regarding an assessment or monitoring of Resident A's penis when he complained of discomfort to TXN 1 on October 3, 2017. A review of Resident A's social service notes, dated October 4, 2017 at 8:33 AM, reflected a request for authorization was faxed to the case manager of Resident A's insurance for the urology consult. A note dated October 4, 2017 at 11:37 AM, reflected Resident A's insurance authorized for the urology consultation. The available appointment given to the social service staff was December 11, 2017 at 2:10 PM. Further review indicated the social service staff documented, "Suggested we should call primary doctor, have him call attending FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 4 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician in their clinic to schedule apt (appointment) sooner. Endorsed to treatment nurse. Will continue to follow up." A review of Resident A's nursing notes, from October 4, 2017 to October 6, 2017, was conducted. There were no documented evidence that TXN 1 had contacted the MD to inquire if he could call urology for an earlier appointment. A review of Resident A's nursing notes, dated October 6, 2017 at 5 PM, reflected Resident A called the paramedics to take him to the hospital at 3 PM. Further review indicated "Resident stated that he was bleeding from his penis and no one was doing anything about it so he called 911." There was no documented evidence that a licensed nurse assessed Resident A's penis to confirm if he was bleeding, swollen or had any change in his condition. A review of Resident A's GACH emergency department notes, dated October 6, 2017, indicated "Genitourinary (genitals and urinary organs): swelling of gland, shaft and base of penis, Penis: Ventral (bottom side), glans, shaft, erosion of ventral surface of glans and shaft down to foley catheter with surrounding scant purulent discharge, Urinary catheter: Indwelling." Further review indicated "Examination demonstrates erosion of ventral surface of penile glans and shaft. Patient's urethra is open. Minimal purulent discharge surrounding wound. Swelling of wound." A review of Resident A's GACH history and physical, dated October 7, 2017, indicated "ventral area of penis is open and has yellowish pus looking stuffs all around it... CT (Computerized Tomography scan - procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 5 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that assists in diagnosing tumors, fractures, bony structures, and infections) pelvic showed soft tissue swelling and gas in scrotal region." Further review reflected CT scan impression indicated "The tip and balloon of the Foley catheter are in the urethra and not in the bladder." A review of Resident A's clinical chart reflected Resident A was readmitted to the facility October 10, 2017 at 9:26 PM. There was no documented evidence on Resident A's chart regarding an order for treatments for his penis. Further review reflected oral antibiotics were ordered for Resident A's penis. A review of Resident A's urology consultation notes, dated November 2, 2017, reflected the characteristic of Resident A's urethra was described as "hypospadias - penoscrotal (penis to scrotum) (due to erosion from a foley catheter)." Further review indicated "Current plans... 18F Foley changed and bladder irrigated. Foley attached to a leg bag to minimize any further urethral erosion. Pt (patient) told to have the bag drained as often as necessary to prevent erosion due to weight of the bag..." A review of Resident A's urology consultation notes, dated December 3, 2017, indicated "Pt (patient) underwent cytoscopy (procedure to examine the lining of the bladder and the tube that carries urine out of the body) with dilatation and debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of a urethral erosion secondary to chronic foley catheter. His urethra is eroded to the penoscrotal junction." During an interview with TXN 1 on December 29, 2017, at 3:30 PM, TXN 1 reviewed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 6 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE clinical record of Resident A and was unable to find documentation that Resident A was assessed and monitored by the nurses after Resident A was diagnosed by the MD with urethral tear on September 22, 2017, and after Resident A complained of discomfort on his penis with TXN 1 on October 3, 2017. TXN 1 stated he assessed Resident A when he complained of discomfort on his penis on October 3, 2017. When asked to describe what the appearance of Resident A's penis was on October 3, 2017, TXN 1 was unable answer. When asked if Resident A's foley catheter was checked, the TXN 1 was unable to answer. During a concurrent interview and record review with TXN 1 of the facility policy and procedure titled "Change in a Resident's Condition or Status," undated, TXN 1 stated according to the policy and procedure, Resident A should have been assessed and a change of condition monitoring should have been initiated for the pain on his penis. TXN 1 stated he should have initiated it but he got busy being the lead treatment nurse and being on the floor. During an interview with the Director of Nursing (DON) on December 29, 2017 at 4:20 PM, the review of the facility policy and procedure titled "Change in Resident's Condition or Status" was conducted. The DON stated the licensed nurses would sometimes assess the residents but would not always document about it. The DON stated the soreness on Resident A's penis was considered a change of condition and monitoring should have been initiated. The facility policy and procedure titled "Change in a Resident's Condition or Status," undated, indicated "A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 7 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intervention by staff or by implementing standard disease-related clinical intervention (is not "self-limiting"); ... The Nurse Supervisor/Charge Nurse will record in the resident's medical record information related to changes in the resident's medical/mental condition or status." The facility policy and procedure titled "Urinary Catheter Care" revised October 2010, indicated "Review the resident's care plan to assess for any special needs of the resident... Observe the resident for complications associated with urinary catheters... Report any complaints the resident may have of burning, tenderness, or pain the urethral area.. " During a telephone interview with a Licensed Vocational Nurse (LVN 1), on January 4, 2018 at 2:02 PM, LVN 1 stated Resident A complained of pain on his penis in between late September 2017 to early October 2017 . LVN 1 stated she was able to assess Resident A's penis. LVN 1 stated "The side of the penis had damage." When asked to clarify what she meant by damage, she stated she was uncomfortable in answering the question. LVN 1 stated she talked to TXN 1 and was informed that there was an order for a urology consultation. LVN 1 stated she did not document about the incident because TXN 1 already addressed the change in Resident A's condition. During a telephone interview with Resident A, on January 17, 2018 at 10:25 AM, Resident A stated he told the MD that his penis was sore when he was seen by the MD on September 22, 2017. Resident A stated there was a tear on his penis where the foley catheter was placed. Resident A stated he told TXN 1 of his penis discomfort prior to October 3, 2017. Resident A stated TXN 1 did not check and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 8 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assess his penis when he complained about it. 2. During a review of the clinical record for Resident A, it reflected Resident A was initially admitted to the facility on April 11, 2017, with diagnoses that included debility (physical weakness), hypospadias (condition in which opening of the penis is on the underside rather than the tip), seizure disorder (changes in the brain's electrical activity that can cause symptoms such as muscle spasms, limb twitches, and loss of consciousness), and left eye blindness. During an observation and concurrent interview with Resident A on November 9, 2017 at 3:45 PM, Resident A was seen in bed, in fowler's (semi-upright) position. Resident A stated it has been three days since the licensed nurses have checked on his penis. During an observation with Treatment Nurse 1 (TXN 1) on November 9, 2017 at 4 PM, the observation of Resident A's penis was conducted. Resident A was in bed with his urinary catheter bag attached at the left side of the bed. Resident A's penis was noted to be swollen. An indwelling urinary catheter was noted inserted below the tip of Resident A's penis, covered by foreskin. Resident A denied any pain or discomfort on his penis. There was no leg strap or other anchoring device in place to relieve tension from the urinary catheter on the urinary meatus. A review of Resident A's physician order sheet, dated April 12, 2017, indicated "Foley catheter (type of indwelling urinary catheter to drain urine from the bladder) 16F/10cc (French 16 (size of tubing) with 10 cc water). Drainage to gravity. Change catheter and drainage bag on the 10th of every month. Dx: (Diagnosis) Stage 4 Pressure ulcer (injury to the skin and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 9 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE underlying tissue down to bone and muscle resulting from prolonged pressure on the skin)." A review of Resident A's physician progress notes, dated September 22, 2017, documented by the medical doctor (MD), indicated "Penile area is sore with blood secondary to catheter Need Urology follow-up". Further review indicated "A/P (Assessment and Plan) ... Urethral tear Urology (field of medicine that focuses on diseases of the urinary tract and the male reproductive tract)." A review of Resident A's nursing notes, dated October 6, 2017 at 5 PM, reflected Resident A called the paramedics to take him to the hospital at 3 PM. Further review indicated "Resident stated that he was bleeding from his penis and no one was doing anything about it so he called 911." The facility policy and procedure titled "Urinary Catheter Care" revised October 2010, indicated "Review the resident's care plan to assess for any special needs of the resident... Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh." There were no documented evidence on Resident A's chart showing the leg strap for the urinary catheter was offered and refused by Resident A. During a telephone interview with LVN 2, on January 18, 2018 at 5:30 PM, LVN 2 stated "It's up to the resident if they want us to place a leg strap. Whatever the resident requests. That is what we do." LVN 2 stated it is not a common practice to place a leg strap on a resident who has a urinary catheter. LVN 2 stated she doubts that a leg strap was used for Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 10 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A's foley catheter. During an interview with Certified Nursing Assistant (CNA 1) on January 19, 2018 at 10:30 AM, a leg strap was not being provided for Resident A's foley catheter tubing. CNA 1 stated "Sometimes when the residents come from the hospital or from the doctor's clinic, they would have that. But we don't really use it [leg strap]." During an interview with LVN 3, on January 19, 2018 at 10:40 AM, LVN 3 stated "We have it [leg strap] on some residents but not all. I haven't seen a lot of residents with it." LVN 3 stated she has not seen a leg strap used for Resident A's foley catheter tubing. During an interview with LVN 1 on January 19, 2018 at 10:50 AM, LVN 1 stated not all residents with foley catheter are provided with leg straps. LVN 1 stated she does not think Resident A was provided with a leg strap. During an interview with TXN 1 on January 19, 2018 at 11 AM, TXN 1 stated "Not everybody has it [leg strap]. We only place it on residents that pulls them [urinary catheter tubing] out. TXN 1 stated Resident A only used the leg strap for a few times. TXN 1 stated, "He is alert and oriented. He doesn't really pull his catheter out." A review of Resident A's GACH emergency department notes, dated October 6, 2017, indicated "Genitourinary: swelling of gland, shaft and base of penis, Penis: Ventral, glans, shaft, erosion of ventral surface of glans and shaft down to foley catheter with surrounding scant purulent discharge, Urinary catheter: Indwelling." Further review indicated "Examination demonstrates eriosn of ventral surface of penile glans and shaft. Patient's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 11 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE urethra is open. Minimal purulent discharge surrounding wound. Swelling of wound." A review of Resident A's GACH history and physical, dated October 7, 2017, indicated "ventral area of penis is open and has yellowish pus looking stuffs all around it... CT (Computerized Tomography scan - procedure that assists in diagnosing tumors, fractures, bony structures, and infections) pelvic showed soft tissue swelling and gas in scrotal region." Further review reflected CT scan impression indicated "The tip and balloon of the Foley catheter are in the urethra and not in the bladder." A review of Resident A's urology consultation notes, dated November 2, 2017, reflected the characteristic of Resident A's urethra was described as "hypospadias - penoscrotal (penis to scrotum) (due to erosion from a foley catheter)." Further review indicated "Current plans... 18F Foley changed and bladder irrigated. Foley attached to a leg bag to minimize any further urethral erosion. Pt (patient) told to have the bag drained as often as necessary to prevent erosion due to weight of the bag..." A review of Resident A's urology consultation notes, dated December 3, 2017, indicated "pt underwent cytoscopy (procedure to examine the lining of the bladder and the tube that carries urine out of the body) with dilatation and debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of a urethral erosion secondary to chronic foley catheter. His urethra is eroded to the penoscrotal junction." A review of Resident A's clinical chart reflected Resident A was readmitted to the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 12 of 13 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: _______________ 056183 (X3) DATE SURVEY COMPLETED 01/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY HEALTHCARE CENTER 1680 N Waterman Ave San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE October 10, 2017 at 9:26 PM. There was no documented evidence on Resident A's chart regarding an order for treatments for his penis. Further review reflected oral antibiotics were ordered for Resident A's penis. The clinical practice guidelines from the Society of Urologic Nurses titled "Care of the Patient with an Indwelling Catheter," dated 2015, indicated "Secure the catheter to either the patient's thigh or the abdomen. This helps to decrease the risk of bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1KTO11 Facility ID: CA240000152 If continuation sheet 13 of 13