Other·February 25, 2019

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 recertification survey conducted January 7, 2019 through January 11, 2019. Representing the California Department of Public Health: 38592 38444 38249 40368 Census: 97 Sample: 22 The facility had one FRI (Facility Reported Incident) that was investigated as follows: 1. CA00619079 - Substantiated with no regulatory violation The facility had one Complaint that was investigated as follow: 1. CA00619079 - Unsubstantiated 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: GJ4O11 Facility ID: CA240000152 If continuation sheet 1 of 33 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 01/11/2019 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

F623 Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/10/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 2 of 33 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 01/11/2019 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 needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 3 of 33 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 01/11/2019 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 must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the Ombudsman's office of the reason for transfer for three of 14 sampled residents (Residents 45, 51, and 87), when: 1. Resident 45 was transferred to hospital on October 13, 2018. 2. Resident 51 was transferred to the hospital on October 6, 2018, October 21, 2018, and November 21, 2018. 3. Resident 87 was transferred to the hospital on December 31, 2018. These failed practices had the potential for facility initiated transfers to go unchecked. Findings: 1. During an interview with Resident 45 on January 8, 2019, at 8:20 AM, the resident stated he was sent out to the hospital due to bleeding a couple of months ago. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 4 of 33 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 01/11/2019 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 During a review of the clinical record for Resident 45 on January 9, 2019, at 2:06 PM, the Physician Telephone Order (PTO), dated October 13, 2018, indicated, "Resident [45] was transfer[red] to VALL [name of the hospital] due to spitting blood. Bed hold x 7 days." There was no documentation that the ombudsman was notified of the resident's transfer in Resident 45's clinical record. During an interview and a concurrent record review with the Social Services Coordinator (SSC) on January 10, 2019, at 11:43 AM, the SSC verified there was no notification sent to the Ombudsman for Resident 45's emergency transfer on October 13, 2018. The SSC further stated, "I didn't realize I had to notify the Ombudsman for transfers in the hospitals." 2. A review of the clinical record for Resident 51 on January 10, 2019, at 5:04 PM indicated the resident was admitted to the facility on June 27, 2018 for diabetes mellitus (disease affecting blood sugar level), hypertension (high blood pressure), and alcohol abuse. The following PTOs were noted: a. PTO, dated October 6, 2018, indicated an order to transfer Resident 51 to the Emergency Room (ER) for evaluation and possible admission. b. PTO, dated October 21, 2018, indicated an order to transfer Resident 51 to the hospital for evaluation due to fall with head injury. c. PTO, dated November 21, 2018, indicated an order to transfer Resident 51 to the hospital for further evaluation of the left foot. There was no documentation that the ombudsman was notified of Resident 51's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 5 of 33 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 01/11/2019 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 transfer to the hospital on October 6, 2018, October 21, 2018, and November 21, 2018. During an interview and a concurrent record review with the SSC on January 10, 2019, at 11:45 AM, the SSC stated she was the one responsible for notifying the ombudsman of resident transfers. The SSC verified the ombudsman was not notified of Resident 51's transfer to the hospital on October 6, 2018, October 21, 2018, and November 21, 2018. The SSC stated, "I don't notify the Ombudsman for emergency transfers. I did not know I had to do that." 3. A review of the clinical record for Resident 87 on January 9, 2019, at 3:05 PM, indicated a re-admission date of November 18, 2018 with diagnoses of Hyperkalemia (elevated potassium a chemical that is critical to the function of nerve and muscle cells in the blood) and acute kidney failure (kidneys are unable to filter waste products from the blood). The PTO dated December 31, 2018 indicated an order to send the resident to the ER. A review of the facility document titled, "Departmental Notes," dated December 31, 2018, indicated Resident 87 was transferred to the ER on December 31, 2018, at 8:10 AM. No notification to ombudsman was found in Resident 87's clinical record. During an interview with the Social Service Coordinator (SSC) on January 10, 2019, at 3:12 PM, the SSC stated, "I did not know I needed to notify the Ombudsman. No, it's [notification] not done." During an interview with the Administrator, on January 10, 2019, at 3:40 PM, the Administrator stated the facility does not have a specific policy that addresses the notification to the ombudsman during emergency transfer or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 6 of 33 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 01/11/2019 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 discharge. The Administrator further stated the facility should notify the ombudsman of emergency transfers/discharges within 30 days of discharge or at the end of every month. A review of the facility's undated policy and procedure titled, "Making an Emergency Transfer and Discharge" did not indicate that the facility need to notify the ombudsman of emergency transfers or discharges.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/10/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 7 of 33 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 01/11/2019 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 resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop comprehensive and individualized care plans for two of 14 sampled residents (Residents 48 and 48) when: 1. Resident 45 did not have a care plan for outside food kept at bedside; and 2. Resident 48 did not have a care plan for Limited Range of Motion. These failed practices had the potential for unmet care needs. Findings: 1. During a facility tour observation on January 8, 2019, at 9:03 AM, Resident 45 was in bed resting. The resident had boxes of cereals, cup of noodles, and cans of soda and juice by the bedside. Resident 45 stated he was on dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). During another observation and an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 8 of 33 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 01/11/2019 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 with the Minimum Data Set nurse (MDS) on January 9, 2019, at 2:14 PM, the MDS nurse went to Resident 45's room and verified the presence of cans of soda, cup of noodles, juice, and cereals by the resident's bedside. The MDS nurse stated Resident 45 had a care plan for resident's non-compliance. During an interview and clinical record review with the MDS nurse on January 9, 2019, at 2:17 PM, Resident 45's record indicated the resident was re-admitted to the facility on 10/15/18 for End Stage Renal Disease (kidney failure). The care plan for non-compliance, dated October 17, 2018, did not indicate the facility's intervention for Resident 45's noncompliance. The MDS nurse checked the care plan and verified the care plan for Resident 45's non-compliance was incomplete. The MDS stated, "We (the facility) presented the problems and goals, but no intervention was specified to address the non-compliance." The MDS nurse further stated, "We should have completed the care plan." The facility's undated policy and procedure titled, "Care Plans - Comprehensive," indicated, "Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area (s), rather than addressing only symptoms or triggers..." 2. A review of the clinical record for Resident 48 on January 9, 2019, at 12:32 PM, indicated the resident was re-admitted to the facility on April 24, 2018 for muscle weakness. The Minimum Data Set (resident assessment tool), dated November 1, 2018, indicated the resident has impairment on one side for both upper and lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 9 of 33 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 01/11/2019 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 During an interview with the MDS nurse on January 9, 2019, at 12:43 PM, the MDS nurse stated Resident 48 participates in the Range of Motion (ROM) program provided by the Certified Nurse Assistants during care. During an interview with the MDS nurse and a concurrent review of Resident 48's clinical records on January 9, 2019, at 1:03 PM, the MDS nurse verified there's no comprehensive care plan addressing Resident 48's limited ROM. The MDS nurse further stated the resident should have a care plan for limited ROM. The facility's undated policy and procedure titled, "Care Plans - Comprehensive," indicated, "An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident."

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 01/10/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure safety in administering tube feeding when Resident 37's tube feeding bottle was found undated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 10 of 33 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 01/11/2019 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 This failure had the potential to cause confusion of when the resident actually received the tube feeding and when it was time to replace the feeding. Findings: During an observation of the facility, on January 7, 2019, at 8 AM, Resident 37 was in bed, and was sleeping with a GT (Gastrostomy Tube- tube feeding) feeding bottle hanging from an intravenous pole. The GT feeding bottle was labeled, and indicated "Jevity 1.2 calories at 40 cc (cubic centimeter- unit of measure) with start time at 12 PM." During an interview with the Licensed Vocational Nurse (LVN 4), on January 7, 2019, at 8:23 AM, the LVN 4 stated, "We [facility staff] forgot to put the date. There should be a date." During an interview with the Director of Nursing (DON), on January 7, 2019, at 11:27 AM, the DON stated, "The expectation is for them [facility staff] fill out the label. Yes, there must be a date." No facility policy and procedure provided.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/10/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 11 of 33 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 01/11/2019 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure adequate supervision for three of 95 residents (Resident 15, 22, and 43), when Residents 15, 22, and 43 were found outside of facility premises, alongside of the main road, smoking, and waiting for a friend. These findings had the potential for Residents 15, 22, 43 to be at risk for accidents which can result in life-threatening injuries. Findings: During an observation of the facility environment, on January 8, 2019, at 2:40 PM, Resident 15, 22, and 43 were going outside the facility premises heading toward North [name of the street] Street and East [name of the street] Street. The three Residents (Resident 15, 22, and 43) were observed as follows: Resident 15 was sitting in a wheelchair and was wearing a pair of sunglasses. Resident 22 was ambulatory, with a left foot wound dressing, and was pushing the wheelchair of Resident 15. Resident 15 and 22 were on the sidewalk of North [name of the street] Street toward East [name of the street] Street. Resident 43 was in a motorized wheelchair and was cruising in the middle part of the road on North [name of the street] Street toward East [name of the street] Street. Resident 43 took the last ramp on the left side of North [name of the street] Street toward East [name of the street] Street. Resident 15, 22, and 43 were smoking alongside of East [name of the street] Street, and across the street were residential houses. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 12 of 33 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 01/11/2019 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 review of Resident 15's medical records indicated an admission date on June 23, 2016, with diagnoses of rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly), epilepsy (seizure), hypertension (increase blood pressure), cerebrovascular disease (arteries supplying oxygen and nutrients to the brain are often damaged or blocked), and schizoaffective disorder (a chronic mental disorder). A review of Resident 22's medical records indicated an admission date on June 29, 2016, with diagnoses of chronic obstructive lung disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), high blood pressure, left lower leg open wound, muscle weakness, and difficulty in walking. A review of Resident 43' medical records indicated an admission date May 14, 2018, with diagnoses of liver cirrhosis (end stage and condition of chronic liver disease), liver cell carcinoma (liver cancer), chronic obstructive lung disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged causing breathlessness), and schizophrenia (mental disorder). During an interview with a Licensed Vocational Nurse (LVN 1), on January 8, 2018, at 2:57 PM, when asked for the location of the three residents[Resident 15, 22, and 43] LVN 1 stated, "I do not know where they [Residents 15, 22, and 43] are at right now." During an interview with a Registered Nurse (RN 1), on January 8, 2018, at 3 PM, RN 1 stated, "If they [Residents 15, 22, and 43] are not here, they [Residents 15, 22, and 43] are in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 13 of 33 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 01/11/2019 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 the parking lot." The RN 1 also stated, "No one is allowed to go outside the facility premises without a doctor's order." During an interview with the Medical Record (MR) staff, on January 8, 2018, at 3:08 PM, the MR stated, "I am not aware that the residents [Residents 15, 22, and 43] goes there [name of the street]." A review of Resident 15's medical record with the MR staff, the "Interdisciplinary Team Meeting", since Resident 15's admission date, on June 23, 2016, indicated no documented discussions of Resident 15's meeting a friend on East [name of the street] Street. A review of Resident 43's medical record with the MR staff, the "Interdisciplinary Team Meeting", since Resident 43's admission date, on May 14, 2018, indicated no documented discussions of Resident 15's meeting a friend on East [name of the street] Street. A review of Resident 15, 22, and 43's "Physician Orders", indicated there was no physician order allowing the residents [Residents 15, 22, and 43] to leave the facility premises and meet with a friend on East [name of the street] Street. A review of medical records entitled, "Resident Care Plan", indicated: Resident 15's "Resident Care Plan: Activity", dated March 13, 2017, indicated "Resident prefer to go out in the parking lot to socialize with friends and family. Monitor for alteration in safety." A review of Resident 22's "Resident Care Plan: Activity", dated March 16, 2018, indicated "Resident prefer to go out in the parking lot to socialize with friends and family. Monitor for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 14 of 33 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 01/11/2019 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 alteration in safety." A review of Resident 43's "Resident Care Plan: Activity", dated May 15, 2018, indicated "Enjoys going out to parking lot/sidewalks to spend times with friends and family." During an interview with the Licensed Vocational Nurse (LVN 2), on January 8, 2019, at 4 PM, LVN 2 stated, These residents [Residents 15, 22, and 43] "have no out on pass physician order." Requested a policy and procedure for physician order for out on pass. The facility was not able to provide one. During an interview with Resident 15, on January 8, 2019, at 4:12 PM, Resident 15 stated, "Me and my friends [Resident 22 and 43] always go there [name of the street] after lunch, to wait for my fiancé. She [Resident 15's fiancé] lives across the street. We also smoke and eat there." Resident 15 further stated, "People from here [facility] just wave their [facility staff] hands when they see us [Residents 15, 22 and 43] there [street]." During an interview with Resident 22, on January 8, 2019, at 4:18 PM, Resident 22 stated, "We [Resident 15 and 43] wait for her [Resident 15's fiancé] every day after lunch and she gives us cigarettes. Resident 22 stated, "I think they [facility staff] know that we were there." During an interview with the Registered Nurse (RN 2), on January 8, 2019, at 4:35 PM, the RN 2 stated, "If they are [Residents 15, 22, and 43] on [name of the street] without our [facility staff] supervision, there is a possibility of accidents." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 15 of 33 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 01/11/2019 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 review of the facility logbook for "Out on Pass [allowing residents to leave the facility in a certain period of time]", indicated Resident 15 and 22 have no sign in and out records, and Resident 43 had one sign in and out with relatives dated August 27, 2018. During an interview with the Certified Nursing Assistant (CNA 1), on January 9, 2019, at 10:53 AM, CNA 1 stated, "Sometimes, we [facility staff] do not know where they [residents] are at. If we [facility staff] look for them, that is the only time we found out that they are in the parking lot." The CNA 1 further stated, "I am not aware that they [Resident 15, 22, and 43] go to [name of the street] street. During an interview with the Minimum Data Set (MDS) staff, on January 9, 2019, at 11:41 AM, the MDS nurse stated, "We [facility staff] do visual checking, if we notice that they [residents] are not here [facility], we will look for them. We are not aware that they [Residents 15, 22, and 43] were leaving the premises." During an observation of the facility camera monitor in Nurses' Station 1, on January 9, 2019, at 12:23 PM, the monitor showed eight (8) different views from the facility camera as follows: - Camera 1 views the front area of the parking lot; - Camera 2 views the left side corner of the parking lot; - Camera 3 views the front area of the parking lot towards medical group clinic; - Camera 4 views the main door of the facility; - Camera 5 views the right side corner of the lot FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 16 of 33 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 01/11/2019 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 from the kitchen; - Camera 6 views the Medication Storage 1; - Camera 7 views the Medication Storage 2; and - Camera 8 views the back door of the facility. During an interview with the Maintenance Supervisor (MS), on January 9, 2019, at 2:30 PM, the MS stated, "There was no facility camera focusing toward the street." During an interview with the Director of Staff Development (DSD 1), on January 9, 2019, at 2:48 PM, the DSD 1 stated, "No one is monitoring the camera, unless something came up, then we [facility staff] can review it [recorded videos]." During an interview with the MDS nurse, on January 10, 2019, at 8:10 AM, the MDS nurse stated, "The residents [Resident 15, 22, 43] has a BIMS [Brief Interview for Mental Status a test given by medical professionals that helps determine a patient's cognitive understanding] score of 15 [15 as the highest]. [Resident 15] is dependent on wheelchair and can wheel himself in a short distance only. [Resident 22] is ambulatory, with left leg wound: shin area. [Resident 43] is on motorized chair needs, has psychosis (mental disorder)." During an environmental observation with the MDS nurse, on January 10, 2019, at 8:37 AM, the MDS nurse was made aware that Resident 15, 22, and 43 were found on East [name of the street] street. The MDS nurse stated, "That [pointing to east street] is considered as a main road. They [Residents 15, 22, and 45] are prone to accidents." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 17 of 33 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 01/11/2019 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 During an observation of the facility, on January 10, 2019, at 9 AM, Resident 15 was not in the facility for a scheduled removal of cataract [opacity of the eye] surgery. During an interview with Resident 43, on January 10, 2019, at 9:16 AM, Resident 43 stated, "We goes to the street [name of the street] to meet [name of the resident] fiancé and we smoke. His [referring to Resident 15] fiancé is a troublemaker. I wished marijuana could be legal. I do not want to be in trouble so it is better for me to shut my mouth." The Resident 43 also stated, "I love socialization while smoking. I, sometimes, go to the bus stop station in [name of the street] just to socialize." A review of facility policy and procedures entitled, "Signing Residents Out", indicated "Policy Statement: All residents leaving the premises must be signed out." "Policy Interpretation and Implementation: 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return... 6. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once... 9. Residents must be signed in upon return to the facility. 10. Inquiries concerning the signing out of residents should be referred to the Director of Nursing Services or to the Administrator." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 18 of 33 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 01/11/2019 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

F755 Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/10/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 19 of 33 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 01/11/2019 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 drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure Dilantin (medication for convulsion) was administered as ordered for one resident (Resident 38). This failure had the potential to cause the resident to have seizure activities. Findings: During a medication pass observation with Licensed Vocational Nurse (LVN 4), on 01/09/19 at 07:55 AM, Dilantin 100 mg P.O. (given by mouth) was not available at the time of scheduled medication administration for Resident 38. During an interview with LVN 4, on 1/9/19 7:55 AM, LVN 4 stated, "The medication was not available at this time, will call pharmacy to get it stat (as soon as possible)." LVN 4 further stated, "The Dilantin medication is not in the Ekit (emergency kit)." During a review of the clinical record for Resident 38, the "Physician's Orders", dated January 2019 indicated, an order for Dilantin 100 mg capsule by mouth (PO) every day (QD) for seizure, and not hold Dilantin unless Dilantin levels reaches above 30. The "Medication Administration Record" (MAR-a record to administer medication) dated January 2019 indicated, Dilantin 100 mg by mouth was administered once daily at 9 AM. The MAR further indicated Dilantin was not administered on January 7, 2019 and January 8, 2019. Further review of Resident 38's clinical record, the laboratory results dated August 27, 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 20 of 33 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 01/11/2019 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 indicated a Dilantin level (blood test to measure levels of drug in the blood) of 11.8 microgram per milliliters (mcg/ml). During an interview and concurrent record review with the Director of Nursing (DON) on January 9, 2019 at 1:44 PM, the DON confirmed the Dilantin was not administered as ordered on 1/7/19 and 1/8/19. The DON stated, "They [LVNs] should have notified the MD and documented the reason why the medication was not given on 1/7 and 1/8/19. The DON confirmed no physician notification was located in the resident's clinical record. During an interview with LVN 4 on January 9, 2019 at 2:06 PM, the LVN stated "Our process for ordering medications we [the facility] fax the order and call the pharmacy, they [pharmacy] normally send over medications the same day." The LVN also indicated that when the medication is not available she calls the MD and get a new order or recommendation and, it gets documented in the nursing notes. The LVN stated, "I did not give the medication on January 7 and 8 the medication was not here, pharmacy has not yet delivered the medication." I believed I did not document." No documentation was found in the record. The undated facility policy and procedure titled, "Physician Medication Orders" indicated, "Drugs and biologicals that are required to be refilled must be reordered from the issue pharmacy not less than three days (3) days prior to the last dosage being administered to ensure the refills are readily available." The undated facility policy and procedure titled, "Ordering and Receiving Medications from Senior Care Pharmacy Services" indicated, "Refills of medications should be called to the pharmacy 3 to 4 days in advance of need to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 21 of 33 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 01/11/2019 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 assure an adequate supply in on hand." The undated policy and procedure titled, "Documentation of Medication Administration" indicated, "Document must include, as a minimum: 3: e ...Reason why a medication was withheld, not administered, or refuse (as applicable)."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 01/10/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 22 of 33 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 01/11/2019 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 Based on observation, interview, and record review the facility failed to ensure safe storage of medication when an outdated Fluticasone Propionate (nasal spray for allergy relief) 50 mcg (micrograms - unit of measure) per spray found in medication room 1. This failure had the potential for the residents to use outdated medication that may lead to severe allergic response and life-threatening shortness of breath. Findings: During an observation of medication room 1 with Licensed Vocational Nurse (LVN 1), on January 8, 2019, at 1239 PM, found a nasal spray medication, Fluticasone Propionate 50 mcg per spray, with November 2018 expiration date. During an interview with the LVN 1, on January 8, 2019, at 1240 PM, LVN 1 stated "This [Fluticasone Propionate 50 mcg nasal spray] was expired. It must be thrown away." A review of facility policy and procedures titled, "Storage of Medications", indicated "Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner." "Policy Interpretation and Implementation: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

F800 SS=D Provided Diet Meets Needs of Each Resident CFR(s): 483.60

F800 01/10/2019 §483.60 Food and nutrition services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 23 of 33 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 01/11/2019 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 dietary needs, taking into consideration the preferences of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that meat products were not on the plate of one of 97 residents (Resident 36), whose dietary preference was vegetarian. This failure had the potential for Resident 36 to consume non-vegetarian foods against her wishes. Findings: During a tray line observation, on January 8, 2019, at 12:06 PM, the plate for Resident 36 contained steamed spinach, mashed potatoes, and chopped roast beef. The Head Cook (HC) remade the plate after the Dietary Aide (DA) informed her that Resident 36 had a vegetarian diet. The HC made a new plate for Resident 36 that contained steamed spinach, mashed potatoes, and gravy. The DA covered the plate, put it on Resident 36's tray, and placed the tray on the tray cart. During an interview with the Dietary Supervisor (DS), on January 8, 2019, at 12:08 PM, the DS stated the gravy was not vegetarian, and a new plate needed to be made for Resident 36. During an interview with the DS, on January 10, 2019, at 2:52 PM, the DS stated that the expectation is that the facility would honor the dietary preferences of the residents to the best of their ability. A review of the tray card for Resident 36 indicated, "Vegetarian Diet." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 24 of 33 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 01/11/2019 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 review of the Dietary Notes, indicated that the DS spoke with the sister of Resident 36 and reviewed the preference of her diet. According to the note, "states her sister is a vegetarian and wants the diet to be vegetarian." A review of the policy and procedure titled "Resident Food Preferences", indicated "Whenever possible, the staff and physician will strive to minimize dietary restrictions in order to accommodate those preferences."

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

F812 01/10/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food safety when the Head Cook (HC) touched a piece of meat on a resident's plate with bare hands. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 25 of 33 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 01/11/2019 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 This failed practice had the potential to cause foodborne illness (illness caused by contaminated food) for one resident (Resident 72). Findings: During a Kitchen observation with the HS and the Dietary Supervisor (DS) on January 8, 2019, at 11:42 AM, the HC checked the temperature of a salad plate with bare hands. The HC removed the thermometer from the plate and a piece of ham was stuck on the tip of the thermometer. The HC used her index finger to slide the ham back on to the plate. The DS covered the plate and placed it in the refrigerator. During a tray line observation on January 8, 2019, at 12:07 PM, the HC took the salad from the refrigerator and placed it on Resident 72's tray. Resident 72's tray was then placed in the cart and was sent out to the dining room. During an interview with the HC and DS on January 8, 2019, at 12:15 PM, the DS and HC were asked if they served the same salad during temperature check. HC verified the salad placed in the cart was the same salad used during temperature check. During an interview with the DS on January 8, 2019, at 12:16 PM, the DS verified the finding and stated, "We need to make a new one (salad for Resident 72)." The facility's undated policy and procedure titled, "Preventing Food borne Illness Employee Hygiene and Sanitary Practices," indicated, "Contact between food and bare FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 26 of 33 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 01/11/2019 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 (ungloved) hands is prohibited." The facility's undated policy and procedure titled, "Food Preparation and Service," indicated, "Bare hand contact with food is prohibited. Gloves must be worn when handling food directly."

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 01/10/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 27 of 33 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 01/11/2019 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 (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to accurately document the dietary preferences for one of 14 sampled residents (Resident 36). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 28 of 33 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 01/11/2019 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 This failure had the potential for Resident 36 to not have her food preferences honored. Findings: A review of the tray card for Resident 36, indicated "Vegetarian Diet." A review of the Kardex for Resident 36, indicated "Vegetarian Diet." During an interview with the DS, on January 9, 2019, at 7:45 AM, the DS stated that she went back through her dietary notes and could not find a note for Resident 36 that recorded her dietary preference as vegetarian. During an interview with the DS, on January 10, 2019, at 9:39 AM, the DS stated that when she found out about a new dietary preference, the expectation would be to document it in the resident's medical record and to notify the nurse of the resident. She stated that the nurse of the resident should call the doctor to obtain a new diet order, and the DS should update the Kardex and tray card. The DS further stated that she should make a dietary note indicating the change. A review of the "Physician's Orders January 2019", indicated that on February 9, 2017 there was an order for "Mech soft ground fortified diet small portions." The order did not indicate Resident 36 had a vegetarian diet. A review of the policy and procedure titled "Resident Food Preferences", indicated "The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 29 of 33 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 01/11/2019 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

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

F880 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/10/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 30 of 33 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 01/11/2019 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 precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that resident care was performed with properly sanitized hands during medication pass for one of 10 sampled residents (Resident 244). This failure had the potential to result in the spread of infection to residents, staff, and visitors to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 31 of 33 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 01/11/2019 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 Findings: During a medication pass observation on January 9, 2019, at 6:35 AM, with Licensed Vocational Nurse (LVN) 3, LVN 3 performed resident care and administered medications, but was not observed washing her hands or using hand sanitizer afterward. During an observation on January 9, 2019, at 7:23 AM, LVN 3 re-entered the room of Resident 244, put on gloves and performed a blood sugar check on her right ring finger. LVN 3 was not observed washing her hands or using hand sanitizer before giving care to Resident 244. During an observation on January 9, 2019, at 7:28 AM, LVN 3 was not observed washing her hands or using hand sanitizer after giving care to Resident 244. During an interview with LVN 3, on January 9, 2019, at 7:30 AM, LVN 3 stated she washed her hands before giving care to Resident 244. She stated she could not recall washing her hands or using hand sanitizer since then. She stated, "I made a booboo." LVN 3 stated that the expectation for proper hand hygiene would be for her to wash her hands before and after contact with a resident or to use hand sanitizer. During an interview with the Director of Nursing (DON), on January 10, 2019, at 3:26 PM, the DON stated the expectation is that licensed staff would practice hand hygiene before and after giving care to residents, including administering medications, as well as before and after putting on gloves. The facility policy and procedure titled "Infection Control Guidelines For All Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 32 of 33 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 01/11/2019 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 Procedures", indicated "Employees must wash their hands for twenty to thirty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents. d. After removing gloves." Additionally, the same policy indicated "If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents. d. Before preparing or handling medications. J. After removing gloves." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GJ4O11 Facility ID: CA240000152 If continuation sheet 33 of 33