Other·January 14, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the annual Recertification Survey conducted on November 26, 2018 through November 30, 2018. Representing the Department of Public Health: 39429, HFEN 36321, HFEN 32495, HFEN 39431, HFEN 39907, HFEN 40273, HFEN Total Resident Census: 228 Total Resident Sample: 42 There were three Immediate Jeopardy (IJ) identified during this recertification survey. One Facility Reported Incident (FRI) CA00614689 was investigated with no deficiencies. An Immediate Jeopardy (IJ) (a crisis situation in which the health and safety of individual(s) are at risk) was called called under §483.60 Food and Nutrition Services (refer to 812 Food Procurement, Store/Prepare/Serve - Sanitary) on November 26, 2018 at 6:36 PM, when potentially contaminated romaine lettuce was readily available for use in the facility's kitchen's walk- in refrigerator and was served to the residents on November 23, 2018 despite a food safety alert received on November 20, 2018, in the presence of the Administrator (ADMIN), the Director of Nursing (DON) and the Regional Director Clinical (RDC). A 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: 8RST11 Facility ID: CA240000650 If continuation sheet 1 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 Corrective Action Plan (CAP) was requested. A record review conducted on November 27, 2018 at 3:00 PM, the in-services training, interviews with the staffs and record review confirmed compliance with the Skilled Nursing Facility's (SNF) corrective action plan which included multiple posters with bold letters regarding the romaine lettuce alert in the kitchen, and dining area. An acceptable CAP was verified with the facility to be implemented through observation, interview and record review. The IJ was lifted on November 27, 2018 at 3:32 PM, in the presence of the ADMIN, DON and the RDC. A second IJ was called called under §483.80 Infection Control (refer to 880 Infection Prevention & Control) on November 28, 2018, at 3:58 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON were informed of the findings related to the glucometer. On November 28, 2018 at 5:16 PM, the facility provided a corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure the corrective action plan was implemented. The facility's corrective action plan included inservice training of all staffs on performing hand wash before and after the procedure, using clean technique while using glucometer to perform blood sugar check, and disinfecting glucometer before and after use with EPA approved disinfectant, replaced with new glucometers, and refilled EPA approved wipes [BRAND NAME] in all medication carts. The IJ was lifted on November 30, 2018, at 11:45 AM, in the presence of the ADMIN and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 2 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 DON after the survey team ensured the corrective action plan had been implemented. A third IJ was called under §483.45 Pharmacy Services (refer to 761 Label/Store Drugs and Biologicals) on November 28, 2018 at 3:58 PM under medication storage and labeling, in the presence of the Administrator (Admin), Director of Nurses (DON), and a Nurse Consultant (Consultant 3). The IJ was called when medication refrigerator containing temperature sensitive medications were found and kept inside an out of safe range (36 degrees Fahrenheit (F) to 46 degrees F) refrigerator. There was a temperature log sheet being kept on the outside of refrigerator with temperatures being checked twice a day. The staff were aware of the out of range temperatures below 36 degrees Fahrenheit but failed to report and fix the refrigerator. The temperature log indicated there were five days in October 2018 and 27 days out of 28 days in November of 2018 that the medication refrigerator temperature were out of range, below 36 degrees Fahrenheit. The staff verified the temperature sensitive medications being stored in the out of range refrigerator were administered to the residents. A corrective action plan was requested. The Corrective Action Plan (CAP) was provided and verified to be implemented. The CAP indicated all of the medications being stored inside the out of range refrigerator in Nursing Station 4 were disposed, a log sheet was posted on every refrigerator to remind staff to monitor the refrigerator temperature two times a day with the correct safe temperature range indicated on the log. Training of staff was provided on how to correctly take refrigerator temperatures and what to do if they are out of range. The old refrigerator was replaced, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 3 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 temperatures on all refrigerators were verified in a safe range, five of 57 residents will be revaccinated. The IJ situation was lifted on November 30, 2018 at 11:45 AM in the presence of the Admin, DON, and the Consultant 3.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 12/21/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 4 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include nephrostomy tube (a thin plastic tube inserted into the kidneys to drain urine) care and monitoring for one of two residents (Resident 126) with urinary catheters (various types of flexible tubes that allow urine to drain into a bag outside of the body). This failure had the potential to result in unmet needs and a delay in continuity of care. Findings: During an observation on November 26, 2018, at 8:15 AM, Resident 126 stated he just returned to the facility a few weeks ago after being hospitalized for "kidney issues." Resident 126 was observed with a drainage bag attached to a nephrostomy tube to his right lower back. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 5 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 126, the admission record (demographic information) indicated Resident 126 was initially admitted on December 06, 2013, discharged to the hospital on October 08, 2018, and was readmitted to the facility on October 17, 2018 with a diagnoses that included displaced nephrostomy tube and methicillin resistant staphylococcus aureus urinary tract infection (MRSA-UTI, a bladder infection caused by a bacteria that is resistant to some commonly used antibiotics and requires isolation precautions). During an interview with a Certified Nursing Assistant (CNA 1), on November 27, 2018, at 8:29 AM, CNA 1 stated she's not sure about the nephrostomy tube care plan regarding care and monitoring but receives instructions from the licensed nurse. CNA 1 confirmed that she is allowed to empty the nephrostomy tube drainage bag and will report to the licensed nurse if any changes are noted. During an interview with Licensed Vocational Nurse (LVN 5), on November 27, 2018, at 8:35 AM, LVN 5 confirmed Resident 126 was readmitted with a nephrostomy tube in place and a baseline care plan for nephrostomy tube care and monitoring was not initiated. During a review of the clinical record for Resident 126, the admission assessment dated October 17, 2018, at 7:15 PM indicated " ...8. Bladder Habits: Incontinent" and "8 a. Catheter Type: (if applicable) Urostomy". During an interview and record review with the Assistant Director of Nursing (ADON 1), on November 30, 2018, at 2:10 PM, ADON 1 confirmed Resident 126 was readmitted to the facility on 10/17/2018 with a nephrostomy tube in place. ADON 1 acknowledged the baseline FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 6 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan for nephrostomy tube care and monitoring was not initiated until November 26, 2018, resident baseline care plans should be done upon admission or readmission. The facility policy and procedure titled, "Admission Assessment", dated December 2016, indicated "Admission assessment, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions."

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

F658 12/17/2018 §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 the correct medication administration via G-Tube (gastrostomy tube, a tube used for feeding and medication administration) was performed for one of three residents on tube feeding (Resident 329). This failure can result in an occluded feeding tube, a reduced drug effect, or drug toxicity. These potential adverse (serious) outcomes can lead to patient harm or death. During a review of the clinical record for Resident 329's Admission Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 7 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 (demographic information) indicated Resident 329 was admitted on November 21, 2018 with a diagnoses that included muscle weakness, type 2 diabetes mellitus (elevated blood sugar levels), and essential hypertension (high blood pressure). During medication administration observation on November 28, 2018, at 8:53 AM, Licensed Vocational Nurse (LVN 4) crushed all medications and administered all together via G-Tube for Resident 329. During an interview with LVN 4 on November 28, 2018, at 9:18 AM, she stated, "I should not crush all tablets and administer all together via G-Tube", she further stated, "I know the standard procedure for medication administration should be crush and administered via G-Tube one at a time". During an interview with LVN 2 on November 28, 2018, at 9:39 AM, he stated, "I crush one medication at a time and administer separately." During an interview with LVN 17 on November 28, 2018, at 9:40 AM, she stated that every tablet should be crushed independently and administer one at a time. During an interview with LVN 7 on November 28, 2018, at 9:44 AM, she stated, "I will crush the tablets one at a time and mixed with water and administer one at a time". During an interview with Nurse Pharmacy Consultant (Consultant 1) on 11/28/18, at 3:45 PM, she stated, "All medications for G-Tube administration must be prepared, crushed and administered separately". The policy and procedure titled "Crushing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 8 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Medications" dated April 2018, indicated 3. In addition, the following guidelines shall be followed when crushing medications: ... d. Crushing each medication separately and administering each. During a review of the medication administration Licensed Nurse Skills Competency Worksheet dated November 16, 2018, indicated "Follows proper G-Tube protocol, prepare, crush, administer meds ALL SEPARATELY (do not cocktail)".

F691 SS=D Colostomy, Urostomy, or Ileostomy Care CFR(s): 483.25(f)

F691 12/21/2018 §483.25(f) Colostomy, urostomy,, or ileostomy care. The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the nephrostomy tube (a thin plastic tube inserted into the kidneys to drain urine) care and treatment orders were documented in the physician orders upon readmission to the facility for one of two residents (Resident 126) with urinary catheters (various types of flexible tubes that allow urine to drain into a bag outside of the body). This failure had the potential to result in an undetected need or delay in medical and/or nursing care and services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 9 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 an observation on November 26, 2018, at 8:15 AM, Resident 126 stated he just returned to the facility a few weeks ago after being hospitalized for "kidney issues". Resident 126 was observed with a drainage bag attached to a nephrostomy tube to his right lower back. During a review of the clinical record for Resident 126, the admission record form (demographic information) indicated Resident 126 was readmitted to the facility on 10/17/2018 with a diagnoses that included displaced nephrostomy tube and methicillin resistant staphylococcus aureus urinary tract infection (MRSA-UTI, a bladder infection caused by a bacteria that is resistant to some commonly used antibiotics and requires isolation precautions). During a continued review of the clinical record for Resident 126, the order summary report (a summary of medication orders) dated November 2, 2018, at 10:34 AM, indicated there was no order for nephrostomy tube care and monitoring. During an interview and record review with the Assistant Director of Nursing (ADON 1), on November 30, 2018, at 2:10 PM, the ADON 1 confirmed Resident 126 was readmitted to the facility on October 17, 2018 with a nephrostomy tube. The ADON 1 confirmed there was no order for care and monitoring on the order summary report dated November 2, 2018. The facility policy and procedure titled, "Admission Assessment", dated December 2016, indicated " ...b. Define current treatments and services ... (1) identify the current FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 10 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 interventions and treatments. c. Identify overall care goals and specific objectives of individual treatments; d. Make decisions about care and treatment."

F698 SS=E Dialysis CFR(s): 483.25(l)

F698 12/21/2018 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow the policy and procedure on care of a resident on renal dialysis (process of removing waste products and excess fluid from the body) when: 1. Staff did not accurately complete the pre and post dialysis assessment for eight of eight residents (Resident 22, 55, 102, 112, 630, 13, 60 and 76) receiving dialysis. 2. Staff was not provided training by the facility on how to meet the needs of a dialysis resident. This failure had the potential to result in an unidentified complication and/or worsening of condition. Findings: 1a. During an observation on November 29, 2018, at 8:48 AM, in Nurse's Station 3, Resident 22 was in wheelchair (w/c) with a transportation attendant preparing to leave for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 11 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 dialysis. During a review of the clinical record for Resident 22, the admission record (a document that includes resident identification and a brief medical history) indicated an admission date of November 06, 2015 and diagnoses that included end stage renal disease (ESRD, kidney disease resulting in loss of kidney function) and dependence on renal dialysis. During review of the clinical record for Resident 22, the order summary (a summary of medication orders) dated November 2018, indicated Resident 22 attends dialysis three times a week on Tuesday, Thursday, and Saturday and has an arteriovenous fistula (AV shunt, a surgically created connection between an artery [a blood vessel that carries blood away from the heart to the rest of the body] and vein [a blood vessel that carries blood to the heart from the rest of the body] used to remove and return blood during dialysis) to the right upper arm (RUA). During a continued review of the clinical record for Resident 22, the "Nurse's Dialysis Communication Record" (an assessment form used for dialysis residents) for the following dates were incomplete: a. September 15, 2018 on pre-assessment, time left and vital signs were not documented. On post-assessment, no assessment of access site and missing nurse's signature and date. b. September 29, 2018 on pre-assessment, time left was not documented. On postassessment, no assessment of access site. c. October 04, 2018 on pre-assessment, time left was not documented. On post-assessment, no assessment of access site and missing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 12 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 nurse's signature. d. October 06, 2018 on pre-assessment, time left was not documented. On post-assessment, no assessment of access site and missing nurse's signature. e. October 13, 2018 on post-assessment, signature time was not documented. f. October 16, 2018 on pre-assessment, time left and vital signs were not documented. On post-assessment, no assessment of access site. g. October 18, 2018 on pre-assessment, time left was not documented. On post-assessment, signature time was not documented. h. October 20, 2018 on pre-assessment, time left was not documented. On post-assessment, no assessment of access site. i. October 23, 2018 on post-assessment, signature time was not documented. j. October 25, 2018 on pre-assessment, time left was not documented. k. October 30, 2018 on pre-assessment, time left was not documented. On post-assessment, no assessment of access site. l. November 01, 2018 on pre-assessment, time left was not documented. On post-assessment, no assessment of access site. m. November 15, 2018 on pre-assessment, time left was not documented. On postassessment, no assessment of access site. n. November 17, 2018 on pre-assessment, time left was not documented. On postFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 13 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 assessment, no assessment of access site. During an interview with Licensed Vocational Nurse (LVN 6), on November 29, 2018, at 9:03 AM, LVN 6 stated the licensed nurses are responsible for completing the pre and post dialysis form for vital signs, assessment of site, documenting changes, and time resident left the facility. LVN 6 stated the dialysis form is sent with the resident to the dialysis center and upon return to the facility the post-assessment time of return, site assessment, and vital signs is to be completed by a licensed nurse. 1b. During an observation on November 29, 2018, at 12:30 PM in Nurse's Station 3, Resident 112 out of facility at dialysis. During a review of the clinical record for Resident 112, the admission record indicated an admission date of June 22, 2016 and diagnoses that included ESRD and dependence on renal dialysis. Further review indicated Resident 112 attends dialysis three times a week on Tuesday, Thursday, and Saturday and has a right internal jugular (IJ, a large vein that drains blood from important body organs) central venous catheter (CVC, a tube placed in a large vein for medical procedures). During a continued review of the clinical record for Resident 112, the "Nurse's Dialysis Communication Record" for the following dates were incomplete: a. September 29, 2018 on pre-assessment, time left and vital signs was not documented. b. October 04, 2018 on pre-assessment, time left was not documented. On post-assessment, nurse's signature, date, and time were not documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 14 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 c. October 30, 2018 on pre-assessment, time left was not documented. On post-assessment, nurse's signature, date, and time were not documented. d. November 15, 2018 on pre-assessment, time left was not documented. On postassessment, signature date and time was not documented. e. November 17, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. f. November 20, 2018 on pre-assessment, time left was not documented. On post-assessment, signature date and time was not documented. g. November 22, 2018 on pre -assessment, time left and vital signs was not documented. On post-assessment, signature date and time was not documented. h. November 24, 2018 on post-assessment, access site assessment has bruit (an audible sound heard over an AV shunt site with a stethoscope [a medical instrument for detecting sounds] associated with blood flow) and thrill (a vibration felt on the skin over an AV shunt) checked off. i. November 27, 2018 on pre-assessment, time left was not documented. On post-assessment, signature date and time was not documented. During an interview with LVN 6, on November 29, 2018, at 12:40 PM, LVN 6 stated Resident 112 has a CVC to the right IJ and this type of access site cannot be assessed for bruit or thrill. LVN 6 confirmed the "Nurse's Dialysis Communication Record" for Resident 112 was incomplete. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 15 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 1c. During an observation and interview with Resident 55 on November 29, 2018, at 12:42 PM, Resident 55 up in w/c and states, "I'm doing fine". During a review of the clinical record for Resident 55, the admission record indicated an admission date of June 27, 2017 and diagnoses that included ESRD and dependence on renal dialysis. Further review indicated Resident 55 attends dialysis three times a week on Monday, Wednesday, and Friday and has a left groin (area on the body between the abdomen and thigh) femoral (a vein located on the upper thigh) CVC. During a continued review of the clinical record for Resident 55, the "Nurse's Dialysis Communication Record" for the following dates were incomplete: a. September 19, 2018 on pre-assessment, time left and temperature was not documented. On post-assessment, no documentation of access site. b. October 05, 2018 on pre-assessment, time left, temperature, pulse, respiratory rate, and blood pressure is incomplete. On postassessment, no documentation of access site. c. October 10, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site and pain level was not documented. d. October 15, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. e. October 17, 2018 on pre -assessment, time left and vital signs, excluding pain level, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 16 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 not documented. On post-assessment, no documentation of access site. f. October 19, 2018 on pre-assessment, time left, pulse (a measurable beat due to the opening and closing of an artery that can be palpated at specific landmarks on the body), and blood pressure (a measurable output produced by the force of blood against the arteries) were not documented. g. October 22, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. h. October 26, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. i. October 29, 2018 on pre-assessment, time left was not documented. j. October 31, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. k. November 02, 2018 on pre-assessment, time left was not documented. l. November 07, 2018 on pre-assessment, time left was not documented. On post-assessment, access site assessment has bruit and thrill checked off. m. November 12, 2018 on pre-assessment, time left was not documented. n. November 14, 2018 on post-assessment, signature time was not documented. o. November 16, 2018 on pre -assessment, time left was not documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 17 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 p. November 19, 2018 on pre-assessment, time left was not documented. On postassessment, signature date was not documented. q. November 21, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. During an interview with LVN 6, on November 29, 2018, at 12:55 PM, LVN 6 stated Resident 55 has a CVC to the left groin and this type of access site cannot be assessed for bruit or thrill. LVN 6 confirmed the "Nurse's Dialysis Communication Record" for Resident 55 was incomplete. 1d. During an observation Resident 102 on November 29, 2018, at 12:47 PM, Resident 102 in her room eating lunch. During a review of the clinical record for Resident 102, the admission record indicated an admission date of October 03, 2018 and diagnoses that included ESRD and dependence on renal dialysis. Further review indicated Resident 102 attends dialysis three times a week on Monday, Wednesday, and Friday and has a right groin femoral CVC. During a continued review of the clinical record for Resident 102, the "Nurse's dialysis Communication Record" for the following dates where incomplete: a. September 12, 2018 on pre-assessment, time left was not documented. On postassessment, signature time was not documented and access site documented as "RUE [right upper extremity]" with "Bruit, Thrill" marked. b. September 14, 2018 on pre-assessment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 18 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 time left was not documented. On postassessment, no documentation of access site. c. September 19, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. d. September 24, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. e. September 27, 2018 on pre-assessment, time left was not documented. On postassessment, time returned was not documented and no documentation of access site. f. October 10, 2018 on pre-assessment, time left was not documented. On post-assessment, time returned was not documented and no documentation of access site. g. October 17, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. h. October 19, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. i. October 25, 2018 on post-assessment, no documentation of access site. j. October 26, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. k. October 30, 2018 on pre-assessment, time left was not documented. On post-assessment, no documentation of access site. l. October 31, 2018 on pre-assessment, time left was not documented. On post-assessment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 19 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 no documentation of access site and pain level was not documented. m. November 12, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. n. November 14, 2018 on post-assessment, signature time was not documented. o. November 16, 2018 on pre -assessment, time left was not documented. On postassessment, no signature date documented. p. November 19, 2018 on pre-assessment, time left was not documented. On postassessment, no signature time documented. q. November 21, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. r. Undated form on pre-assessment, time left was not documented and no documentation of access site. On post-assessment, no documentation of access site. During an interview with LVN 6, on November 29, 2018, at 12:55 PM, LVN 6 stated Resident 102 has always had a CVC to the right groin and this type of access site cannot be assessed for bruit or thrill. LVN 6 confirmed the "Nurse's Dialysis Communication Record" for Resident 102 was incomplete. 1e. During a review of the clinical record for Resident 630, the admission record indicated an admission date of November 21, 2018 and diagnoses that included ESRD. Further review indicated Resident 630 attends dialysis three times a week on Monday, Wednesday, and Friday and has a right IJ CVC. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 20 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 continued review of the clinical record for Resident 630, the "Nurse's Dialysis Communication Record" for the following dates where incomplete: a. November 27, 2018 post-assessment was not documented. b. November 28, 2018 form missing name, room number, and physician name. On preassessment, "Bruit/Thrill" documented for access site. On post-assessment was not documented. During an interview with LVN 8 on November 29, 2018 at 1:15 PM, LVN 8 stated documentation of pre and post dialysis assessment dialysis "vital signs and bruit" each time a resident goes to dialysis should be completed. During an interview with Assistant Director of Nursing (ADON 1) on November 30, 2018, at 2:10 PM, ADON 1 stated the licensed nurses are responsible for filling out the pre and post dialysis assessment which includes vital signs, assessment of site, pertinent information, times in/out. ADON 1 confirmed pre and post dialysis assessments should be filled out completely. 1f. During a clinical record review of Resident 13's clinical record indicated, the Resident 13 was admitted to the facility original on December 12, 2017 with diagnoses which included ESRD and dependence on renal dialysis. Currently Resident 13 is out of the facility on a bed hold. During a clinical record review of Resident 13's, the order summary dated November 2018, indicated Resident 13 receives dialysis three times a week on Monday, Wednesday, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 21 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 Friday and has a central line in his right subclavian (or peripherally inserted central catheters (PICC) surgically created connection between an artery and vein used to remove and return blood during dialysis). During a clinical record review of Resident 13's "Nurse's Dialysis Communication Record", to be completed pre and post dialysis treatments, the following dates were incomplete: a. November 5, 2018 on pre assessment, time left was not documented. Post assessment was not documented. b. November 7, 2018 on the position to be completed by dialysis center was left blank. Post assessment was not documented. c. November 9, 2018 on pre-assessment, time was not documented. On the position to be completed by dialysis center was left blank. Post assessment was not documented. d. November 12, 2018, post assessment was not documented. e. November 14, 2018 on pre-assessment, time left was not documented. f. November 18, 2018 on pre-assessment, undated and time left was not documented. g. November 2018-on pre-assessment undated and time left was not documented. Postassessment had no nurses signature, date or time documented. h. November 23, 2018 on pre-assessment, time was not documented. During an interview with LVN 11 on November 28, 2018, at 12:43 PM, LVN 11 confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 22 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 13 goes to dialysis on Monday, Wednesday, and Friday. The LVN 11 stated licensed nurses are responsible for filling out the resident's pre and post dialysis assessment form. The LVN 11 stated each resident has their own, "Nurses Dialysis Communication Record". 1g. During a clinical record review of Resident 60's clinical record indicated the Resident 60 was admitted to the facility originally on August 8, 2014 with diagnoses which included osteomyelitis (infection in the bone), type II diabetes (a chronic condition that affects the way the body processes blood sugar) and ESRD. During an observation of Resident 60, on November 26, 2018, at 10:30 AM, Resident 60 is lying in bed with a dialysis access port in her abdomen. During a clinical record review of Resident 60, the order summary dated November 2018, indicated Resident 60 receives dialysis treatment three times a week on Tuesday, Thursday, and Saturday and has a dialysis access port in her right groin. During a clinical record review of Resident 60's, the "Nurse's dialysis Communication Record," for the following dates were incomplete: a. November 15, 2018 post assessment was not documented. b. November 20, 2018 post assessment was not documented. c. November 21, 2018 post assessment was not documented. d. November 27, 2018 post assessment was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 23 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 not documented. e. November 29, 2018 on pre-assessment, date was not documented Post assessment was not documented. During an interview with LVN 15 on November 28, 2018, at 11: 52 AM, the LVN 15 confirmed Resident 60 goes to dialysis treatments on Tuesday, Thursday, and Saturday. The LVN 15 stated there is a form called pre and post assessment that has to be filled out by a licensed nurse for residents receiving dialysis services. The LVN 15 confirmed Resident 60's pre-assessment and post-assessments was incomplete. 1h. During a clinical record review of Resident 76, the clinical record indicated Resident 76 was admitted to the facility originally on February 5, 2016 with diagnoses which included ESRD, dependence of renal dialysis, and type 2 diabetes. During an observation of Resident 76 on November 28, 2018, at 12:34 PM, the Resident 76 was in the dining room for lunch. During a clinical record review of Resident 60, the "Nurse's Dialysis Communication Record," for the following dates were incomplete: a. October 2, 2018 on pre-assessment, date was not documented. Post assessment dialysis center only documented vital signs. b. October 27, 2018 on per-assessment, date was not documented. On post assessment, time was not documented. c. November 15, 2018 illegible writing on front and back of form. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 24 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 d. November 17, 2018 on pre and post assessment, time was not documented. There was illegible writing on front and back of form. e. November 22, 2018 on pre and post assessment, time was not documented. There was illegible writing on front and back of form. f. November 24, 2018 on pre and post assessment, time was not documented. There was illegible writing on front and back of form. g. November 27, 2018 on pre-assessment, time was not documented. During an interview with LVN 7, on November 28, 2018, at 12:34 PM, the LVN 7 confirmed Resident 76's pre and post assessment was incomplete. LVN 7 stated she does not remember the last time the facility provided training on ESRD and care of a dialysis resident. 2. During an interview with LVN 6, on November 29, 2018, at 9:03 AM, LVN 6 stated she doesn't recall when the facility last provided training on ESRD and care of a dialysis resident. During an interview with LVN 7, on November 29, 2018, at 12:35 PM, LVN 7 stated she does not remember the last time the facility provided training on ESRD and care of a dialysis resident. During an interview with Director of Staff Development (DSD 1), on November 29, 2018, at 12:50 PM, the DSD 1 stated the facility cannot provide a training sign-in record for training provided to staff on ESRD and care of a dialysis resident. A review of the facility policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 25 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 titled, "End-Stage Renal Disease, Care of a Resident with (Dialysis)", dated September 2010, indicated "1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training staff includes, specifically: b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift bases .f. the care of grafts and fistulas; check dialysis site before and after dialysis; h. communication with contracted Dialysis center.

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

F761 12/07/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 26 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 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: Based on observation, interview, and record review, the facility failed to ensure temperature sensitive medications were properly monitored and stored when medications were found to have been stored at or below 35 degrees Fahrenheit (F) and not within an acceptable temperature range between 36 degrees Fahrenheit (F) to 46 degrees F, according to the facility's policy and procedure and medication safe storage guidelines, affecting five of 57 sampled residents (Residents 329, 537, C, D, and E) in a universe of 228 residents. This failed practice could result in medication losing their potency (effectiveness) which could cause residents not getting the full benefits of their medications. Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a Resident) was called on November 28, 2018 at 3:58 PM, under medication storage and labeling, in the presence of the Administrator (Admin), Director of Nurses (DON), and a Nurse Consultant (Consultant 3). The IJ was called and the Administrator, Director of Nurses and Nurse Consultant were made aware of a medication refrigerator containing temperature sensitive medications FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 27 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 were found and kept inside an out of safe range (36 degrees Fahrenheit (F) to 46 degrees F) refrigerator. There was a temperature log sheet being kept on the outside of the refrigerator with temperatures being checked twice a day. The staff were aware of the out of range temperatures below 36 degrees Fahrenheit but failed to report and fix the refrigerator. The temperature log indicated, there were five days in October 2018 and 27 days out of 28 days in November of 2018 that the medication refrigerator temperature were out of range, below 36 degrees Fahrenheit. The staff verified the medications being stored in the out of temperature range refrigerator were administered to the residents. A corrective action plan was requested. The Corrective Action Plan (CAP) was provided and verified to be implemented. The CAP indicated all of the medications being stored inside the out of range refrigerator (the temperatures ranged from 30 degrees F to 35 degrees F) in Nursing Station 4 were disposed, a log sheet was posted on every refrigerator to remind staff to monitor the refrigerator temperature two times a day with the correct safe temperature range indicated on the log. Training of staff was provided on how to correctly take refrigerator temperatures and what to do if they are out of range. The old refrigerator was replaced, temperatures on all refrigerators were verified in a safe range, five of 57 residents will be revaccinated. The IJ situation was lifted on November 30, 2018 at 11:45 AM in the presence of the Admin, DON, and the Consultant 3. Findings: During an inspection of the medication room in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 28 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nursing Station 4, with Registered Nurse (RN 1) on November 28, 2018, at 8:25 AM, the refrigerator temperature was 35 degrees Fahrenheit (F) (normal range is 36 degrees F to 46 degrees F). RN 1 verified the refrigerator temperature was out of range. RN 1 stated she was aware that the refrigerator was out of temperature range but did not notify anyone. Review of the Refrigerator Log indicated out of range temperatures from October 13 to October 18, 2018 and for the month of November, 2018. The medication refrigerator contained the following medications. 1. Quadrivalent- (vaccine given in 2018-2019 to prevent getting the Influenza Flu) nine of 10 prefilled syringes, one dose was missing. 2. Flusaval Quadrivalent- (vaccine given in 2018-2019 to prevent getting the Influenza Flu) 14 of 16 (3 milliliters-ML Unit of measure) vials. One vial opened on November 22, 2018, one opened on November 22, 2018, Expired: May, 2019, Lot #5GBPRF2XGG. 3. Flucelvax Quadrivalent- (vaccine given in 2018-2019 to prevent getting the Influenza Flu) one of two, one vial opened on November 12, 2018, Expired: June 30, 2019, Lot# 253823. 4. Colistimethate- (antibiotic that fights bacteria)150 milligram (MG-unit of measure) vial-date Filled-November 26, 2018- Seven of seven {Quantity six}. 5. Colistimethate- (antibiotic that fights bacteria) dry vial 150 mg vial-date filled: November 26,2018, Unopened for {Quality six}. 6. Novolog- (hormone that works by lowering levels of sugar) 100-unit vial, date filled: November 19, 2018, Expired: June 2020, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 29 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 Unopened. 7. Levemir- (hormone that works by lowering levels of sugar) 100 units/ml vial, date filled: October 25, 2018, Expired: July 2020, unopened. 8. Humalog- (hormone that works by lowering levels of sugar) 100 units/ml, date filled: August 24, 2018, expired: September 2019, unopened. 9. Humulin- (hormone that works by lowering levels of sugar) 100 units/ml, dated filled: November 6, 2018, expired: July 2020, unopened. 10. Aplisol - (Tuberculin (TB) purified protein derivative PPD used in a skin test to diagnose TB [ infection in persons at increased risk of developing active disease])-five units/o,1 ml, date filled: November 26, 2018, expired: July 2020, unopened. House supply. 11. Lorazepam- (used to treat anxiety disorder)2 mg/ml vial, date filled: November 7, 2018, Expired: October 2020, Six of Six. 12. Humulin-R- (hormone that works by lowering levels of sugar) 100 units/ml vial, date filled: November 26, 2018, Expired: October 2020. 13. Pneumovax (vaccine indicated for active immunization for the prevention of pneumococcal disease) 23 vials, date filled: November 23, 2018, expired July 10 2020, unopened. 14. Lorazepam- (used to treat anxiety disorder)2 mg/ml vial, date filled: November 20, 2018, expired May 19, 2019, unopened one of one. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 30 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 15. Lorazepam- (used to treat anxiety disorder)2 mg/ml, date filled: September 21, 2021, expired: April 2021 unopened two of two. 16. Lorazepam- (used to treat anxiety disorder) 20 mg/10 ml, 18/18, date filled: IV February 1, 2018, Expired May 21, 2019, unopened. 17. Acetyzcyetine - (used for the treatment of Tylenol over dose) 20% vial, date filled: November 27, 2018, expire May 1, 2020. Box #1-1 unopened, 1 opened, 1 missing. 18, Acetylcysteine- (used for the treatment of Tylenol over dose) 20% vial, date filled: November 28, 2018, May 1, 2020. Box #1three bottles unopened-30 ml each. 19. Acetylcysteine- (used for the treatment of Tylenol over dose) (20% vial, date filled: November 17, 2018, expired: May 1, 2020. 20. E-Kit-Expired October 31, 2020, date filled: November 26, 2018 L4017131 for Station 4. a. Humulin R-(hormone that works by lowering levels of sugar) 3 ml 100 units/ML, expire: 10/2020- unopened. b. Lorazepam- (used to treat anxiety disorder) 2 mg/ml 100 units/ml, expired: August 2020, Lot # 088373, unopened. c. Lorazepam- (used to treat anxiety disorder) 2 mg/ml expired: April 2021, Lot # 048391, unopened. d. Humulin N- (insulin-a manmade form of a hormone produced in the body that lowers blood sugar) 3 ml 100 units/ml, Expired: October. 2020, unopened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 31 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 and record review with Registered Nurse (RN 2) on November 28, 2018, at 8:35 AM, the medication refrigerator's temperature log sheet from November 1 through 28, 2018 at Nursing Station 4 indicated, the medication refrigerator was out of temperature range between 30 degrees F to 35 degrees F. RN 2 verified temperature sensitive medications were kept inside the out of range refrigerator. There was a reminder note for the staff that indicated, "Acceptable temperatures should be between 36 degrees Fahrenheit (F) to 40 degrees." The temperature log did not reflect what to do if the medication refrigerator temperature was out of range. RN 2 stated she was aware the temperature log sheet and medication refrigerator in Nursing Station 4 was out of range but did not report it. RN 2 stated, "The refrigerator temperatures being out of range would change the potency of the medications administered to the residents and vaccines would not have been as effective." RN 2 verified all of the medications that were found in the refrigerator. RN 2 stated, "I did not notify maintenance regarding the refrigerator temperatures being out of range." During an interview and record review with RN 1 on November 28, 2018, at 8:53 AM, RN 1 stated the medication refrigerator temperatures get checked twice a day and the normal range should be between 36 degrees to 40 degrees F. The medication refrigerator log sheet for the month of November 2018 was reviewed with RN 1. RN 1 confirmed for 28 days the temperatures were out of range. RN 1 verified the medications found stored in the refrigerator with out of range temperatures and the potential of reduced potency of the medications. RN 1 verified the medications were administered to Residents 329, 537, C, D, and E, which could leave them susceptible to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 32 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 illnesses. RN 1 stated," I did not notify anyone regarding the refrigerators being out of range." During an interview with the Infection Control Prevention Nurse (ICP), on November 28, 2018, at 10:00 AM, the ICP verified the medication temperature log sheet for the medication room on Station 4 was out of range for 28 days in November 2018. The ICP verified there was temperature sensitive medications being stored in a refrigerator with out of range temperatures. The ICP also verified that would affect the potency of the vaccines that were being stored in that refrigerator that were administered to Resident 329, 537, C, D, and E. During a review of the October's Refrigerator Log sheet for the medication room on Nursing Station 4, it indicated temperatures were out of range and revealed: October 13, at 6 AM, the temperature is documented as 32 degrees F. October 15, at 8 AM, the temperature is documented as 34 degrees F. October 16, at 8 AM, the temperature is documented as 34 degrees F. October 17, at 8 AM, the temperature is documented as 33 degrees F. October 18, at 9 AM, the temperature is documented as 30 degrees F. October 18, at 6 PM, the temperature is documented as 30 degrees F. A review of the November's Refrigerator Log sheet for the medication room on Nursing Station 4, indicated temperatures were out of range and revealed: November 1, at 9 AM and at 3 PM, the temperature is documented as 32 degrees F. November 2, at 9 AM and at 8 PM, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 33 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 temperature is documented as 32 degrees F. November 3, at 9 AM and at 8 PM, the temperature is documented as 32 degrees F. November 4, at 9 AM and at 8 PM, the temperature is documented as 32 degrees F. November 5, at 9 AM and at 3 PM, the temperature is documented as 32 degrees F. November 6, at 8 AM and at 5 PM, the temperature is documented as 32 degrees F. November 7, at 8 AM and at 6 PM, the temperature is documented as 31 degrees F. November 8, at 9 AM and at 8 PM, the temperature is documented as 31 degrees F. November 9, at 9 AM and at 8 PM, the temperature is documented as 31 degrees F and 32 degrees F. November 10, at 9 AM and at 3 PM, the temperature is documented as 32 degrees F. November 11, at 9 AM and at 3 PM, the temperature is documented as 31 degrees F. November 12, at 9 AM and at 4 PM, the temperature is documented as 31 degrees F. November 13, at 9 AM and at 5 PM, the temperature is documented as 31 degrees F. November 14, at 9 AM and at 10 PM, the temperature is documented as 31 degrees F. November 15, at 7 AM and at 8 PM, the temperature is documented as 30 degrees F and 31 degrees F. November 16, at 6 AM and at 6 PM, the temperature is documented as 31 degrees F. November 17, at 8 AM and at 6 PM, the temperature is documented as 31 degrees F. November 18, at 9 AM and at 6 PM, the temperature is documented as 34 degrees F and 31 degrees F. November 19, at 10 AM and at 7 PM, the temperature is documented as 34 degrees F and 31 degrees F. November 20, at 6 AM and at 8 PM, the temperature is documented as 32 degrees F. November 21, at 6 AM and at 8 PM, the temperature is documented as 32 degrees F. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 34 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 November 22, at 8 AM and at 6 PM, the temperature is documented as 32 degrees F. November 23, at 8 AM and at 6 PM, the temperature is documented as 32 degrees F. November 24, at 11:10 AM and at 9 PM, the temperature is documented as 32 degrees F and 33 degrees F. November 25, at 8 AM and at 5 PM, the temperature is documented as 32 degrees F. November 26, at 8:15 AM and at 5 PM, the temperature is documented as 33 degrees F and 32 degrees F. November 27, at 8:15 AM and at 7 PM, the temperature is documented as 33 degrees F and 34 degrees F. November 28, at 8 AM and at 7 PM, the temperature is documented as 35 degrees F and 32 degrees F. During a review of maintenance log for the months of September, October, and November 2018, there were no entries from the staff indicating medication refrigerator in Station 4 was out temperature range. During an interview and a review of the refrigerator log with the DON, on November 28, 2018, at 12:30 PM, the DON confirmed there were five days in October 2018 and 28 days in November 2018 the medication refrigerator temperature in Station 4 was out of range. The DON verified the refrigerator contained temperature sensitive medications and medications were administered to the residents where the potency could have been affected. During a review of the clinical record Immunization report, dated September 1, 2018 to November 30, 2018, Type of Immunization: Influenza, it revealed five residents from Station 4 were vaccinated from vaccines that were stored in a refrigerator with documented temperatures out of range. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 35 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 phone call was made to the Pharmacy Consultant (PC), on November 28, 2018, at 2:18 PM. The PC stated he would have to call back. A review of the inserts of the medications that were being stored and were administered and available for use in the refrigerator indicated the following: 1. Quadrivalent, should be stored in a refrigerator with temperature ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 2. Flusaval Quadrivalent, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 3. Flucelvax Quadrivalent, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 4. Colistimethate, should be stored at room temperature (59 degrees F- 86 degrees F) for full potency of medication use when in seven days. 5. Novolog, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. Do not freeze. 6. Levemir, should be stored in a refrigerator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 36 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. 7. Humalog, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. 8. Humulin, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. 9. Aplisol, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. 10. Lorazepam, store in a refrigerator and protect from light. Lorazepam should be stored at 36 degrees F to 46 degrees F. 11. Pneumovax, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 12. Acetylcsteine, store unopened vials at room temperature 68 degrees F to 77 degrees F. Store at 36 degrees F to 46 degrees F after opening. During an interview with the Maintenance Director Of Operations (MDO), on November 28, 2018, at 2:55 PM, the MDO stated he is incharge of the facility maintenance for the building. The MDO confirmed no one had reported any refrigerator with temperatures out of range for the past two months. The MDO verified each nursing station had a log book to record any maintenance issues and it gets FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 37 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 checked twice a day. The MDO also verified he carries a radio and can be reached at all times when he is at the facility. When asked about the procedure for a refrigerator with temperatures that are out of range, the MDO stated," The staff should report it right away and I will check with my laser gun (a device used to check refrigerator temperatures)." The MDO stated the medication rooms are locked and only licensed nurses go in them and should report any problems to me." A phone call was made to the Pharmacy Consultant (PC), on November 28, 2018, at 3:01 PM, there was no answer. During a phone interview with the PC, on November 29, 2018, at 9:25 AM, the PC confirmed he is the Pharmacy Consultant for {Name of Facility}. The PC stated he comes to facility twice month and he does Drug Regimen Reviews, reviews any potential medication problem, and does a reconciliation on the cubex (automated medication and supply management). The PC stated he delegates the medication storage to the nurse consultant but everything is supposed to be reported to him. The PC confirmed medication refrigerator temperatures should be monitored by staff and maintained at a safe range for medications around 36 degrees F to 46 degrees F. The PC stated if a medication refrigerator temperatures were out of range and they contained temperature sensitive medications like vaccines and insulin, "I would not administer them because they would not be affective anymore." Review of the facility's Pharmacy Services Agreement For: {Name of Facility}, dated March 1, 2017, indicated " Handling, Storage and Distribution. Pharmacy will assist the Facility in complying with the federal and state FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 38 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 regulations regarding drug handling, storage, control and distribution." Review of the facility policy and procedure titled, "Medication Refrigerator Storage," Revised May 2017, indicated,"1. Temperature Control-Drugs requiring refrigeration shall be stored on a refrigerator between 36 degrees F and 46 degrees F. 2. A daily medication refrigerator temperature log will be kept to assure that the temperature is maintained. 3. Adjustments will be made to the thermostatic control as needed. 4. If the temperature is found to be outside acceptable range then monstrance will be alerted." Review of the facility policy and procedure titled," Maintenance Services, "revised December 2009, indicated, "Maintenance service shall be provided to all areas of the building, grounds, and equipment."

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

F812 11/30/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 39 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 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 safe and sanitary food preparation and storage practices were implemented when 16 heads of potentially contaminated romaine lettuce were found inside the facility's walk-in refrigerator readily available for resident consumption. The facility received a food safety alert notice from their food vendor not to consume romaine lettuce due to Escherichia coli (E. coli, a harmful bacteria usually found in the gut, if it is infectious cause severe abdominal cramps, nausea, diarrhea) infections. This failure had the potential to cause food borne illness (food poisoning caused by contaminated food consumption) for a medically compromised (residents with weak immune system) population of 174 residents who received food from the kitchen in the universe of 228. An Immediate Jeopardy (IJ, a crisis situation in which the health and safety of individual(s) are at risk) was called on November 26, 2018 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 40 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 6:36 PM, when romaine lettuce was available for use in the kitchen's walk- in refrigerator and was served to the residents on November 23, 2018, despite a food safety alert advisement received on November 20, 2018. The IJ was called in the presence of the Administrator (ADMIN), the Director of Nursing (DON) and the Regional Director Clinical (RDC). A Corrective Action Plan (CAP) was requested. A record review was conducted on November 27, 2018 at 3:00 PM, and indicated corrective action plan that included multiple posters with bold letters regarding the romaine lettuce alert in the kitchen's refrigerator door and dining area, monitoring the residents for signs and symptoms of E.coli infections, immediately throw out the recalled food, and any other foods stored with it and any instances of potential contamination will be reported immediately California Department of Public Health (CDPH) . An acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on November 27, 2018 at 3:32 PM, in the presence of the ADMIN, DON and the RDC. Findings: During an initial tour of the kitchen on November 26,2018, at 8:20 AM, with the facility's Dietary Service Supervisor (DSS), there were 16 heads of romaine lettuce observed stored inside a plastic tub in the bottom rack of the walk in refrigerator. During a concurrent interview with the DSS, he verified there were 16 heads of romaine lettuces in the kitchen's walk in refrigerator. He stated they purchased 24 heads of romaine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 41 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 lettuce on November 20, 2018, and eight heads of romaine lettuce were used and been served to the residents with their salad. The DSS stated he received a food safety alert from their food vendor and Centers for Disease Control and Prevention(CDC) on November 20, 2018. The DSS verified there were no other kind of lettuces stored inside facility's walk in refrigerator. During an interview with the DSS on November 26, 2018 at 10:10 AM, the DSS stated "It is my fault, I would have tossed it." The DSS stated romaine lettuces were used on November 23,2018, and served to the residents with their salad. The DSS provided a copy of the purchase order and the food safety alert issued by their food vendor, dated November 20, 2018. The DSS stated he received CDC food safety alert about a recall on romaine lettuce on for potential E. Coli contamination on November 20, 2018. During an interview with the DSS on November 26, 2018 at 4:45 PM, he stated although he received the romaine lettuce food safety alert on November 20, 2018, he did not notify the dietary staffs about the food safety alert until November 22, 2018. A review of the facility's menu titled, "GOOD FOR YOUR HEALTH MENUS", indicated the following: 1. November 21, 2018 Week 3 Lunch: Italian Green Salad 2. November 23, 2018 Week 3 Lunch: Tossed green salad 3. November 27,2018 Week 4 Lunch: Tossed Green Salad FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 42 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 4. November 30, 2018 Week 4 Lunch: Mixed Greens Salad 5. December 1, 2018 Week 4 Lunch: Italian Green Salad A review of the facility's recipe book by RD's for Healthcare, Inc. indicated the following: 1. TOSSED GREEN SALAD WITH DRESSING: Ingredients: Lettuce of choice: Romaine, ... 2. ITALIAN GREEN SALAD: Ingredients: Lettuce of choice: Strongly suggest portion of lettuce be romaine, ... 3. MIXED GREENS SALAD: Ingredients: Romaine, ... A review of the facility's purchase order invoice by (NAME OF THE COMPANY) dated November 20, 2018, indicated ... "LETTUCE RMN FRESH REF 24 EA ...". A review of the facility provided letter titled (NAME OF FOOD SUPPLIER) dated November 20, 2018 indicated the following: "...Effective immediately, (NAME) has put a national hold on ALL romaine lettuce products in response to the November 20, 2018 CDC FOOD SAFETY ALERT. The CDC and Food Drug administration (FDA) are investigating a multistate outbreak of Shiga toxin- producing E. coli infections linked to romaine lettuce ..." A review of the facility provided record titled, "Outbreak of E. coli infections Linked to romaine Lettuce", Food Safety Alert issued by CDC posted on November 20, 2018 at 2:30 PM indicated the following: Advice to Consumers, Restaurants, and Retailers; CDC is advising FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 43 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 U.S. customers not eat any romaine lettuce, and retailers and restaurants not serve or sell any, until we learn more about the outbreak ... Consumers who have any type of romaine lettuce in their home should not eat it and should throw it away, even if ... Restaurants and retailers should not serve or sell any romaine lettuce, including salad and salad mixes. The facility policy and procedure titled, "STORAGE OF FOOD AND SUPPLIES", by (Name of healthcare), Inc. 2017 indicated "POLICY: Food and supplies will be stored properly and in a safe manner".

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

F842 12/21/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 44 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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) 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; (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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 45 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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) 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 ensure residents medical records were complete and easily accessible as follows: 1. Staff did not properly document the Pre and Post assessments for Residents 22, 55, 102, 112, 630, 13, 60, and 76. This failure could potentially affect the health and well-being of eight of eight residents receiving dialysis services. 2. For Resident 30 there was no documentation of blood sugar on November 30, 2018 at 6:30 AM. This failure could potentially result in Resident 30 receiving inaccurate care. Findings: 1. During a clinical record review of, "Nurse's dialysis Communication Record" (an assessment form used for dialysis residents containing Pre and Post assessment which includes vital signs, assessment of site, documenting changes, and time resident left facility) for Residents 22, 55, 102, 112, 630, 13, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 46 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 60 and 76 were not documented. During an interview with Licensed Vocational Nurse (LVN 6), on November 29, 2018, at 9:03 AM, LVN 6 stated the licensed nurses are responsible for completing the pre and post dialysis form for vital signs, assessment of site, documenting changes, and time resident left the facility. LVN 6 stated the dialysis form is sent with the resident to the dialysis center and upon return to the facility the post-assessment time of return, site assessment, and vital signs is to be completed by a licensed nurse. For Resident 22: a. November 2017, 18 on pre-assessment, time was not documented. Post-assessment, no assessment of access site was documented. b. November 15, 2018 on pre -assessment, time was not documented. Post-assessment, no assessment of access site was documented. c. November 1, 2018 on pre-assessment, time was not documented. Post-assessment, no assessment of access site was documented. d. October 30, 2018 on pre-assessment, time was not documented. Post-assessment, no assessment of access site was documented. e. October 25, 2018 on pre-assessment, time was not documented. f. October 23, 208 on post-assessment, signature time was not documented. g. October 20, 2018 on pre-assessment, time was not documented. Post-assessment, no assessment of access site was documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 47 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 h. October 18, 2018 on pre-assessment, time was not documented. Post-assessment, signature time was not documented. i. October 16, 2018 on pre-assessment, time and no vital signs were not documented. Postassessment, no assessment of access site was documented. j. October 13, 2018 on post-assessment, signature time was not documented. k. October 6, 2018 on pre-assessment, time was not documented. Post-assessment, no assessment of access site and missing nurse's signature. l. October 4, 2018 on pre-assessment, time was documented. Post-assessment, no assessment of access site and missing nurse's signature. m. September 29, 2018 on pre-assessment, time was not documented. Post-assessment, no assessment of access site was documented. n. September 15, 2018 on pre-assessment, time and no vital signs were not documented. Post-assessment, no assessment of access site and missing nurse's signature and date For Resident 55: a. November 21, 2018 on pre-assessment, was documented. Post-assessment, no documentation of access site. b. November 19, 2018 on pre-assessment, time was not documented. Post-assessment, no signature date was documented. c. November 16, 2018 on pre -assessment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 48 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 time was not documented. d. November 14, 2018 on post-assessment, signature time was not documented. e. November 12, 2018 on pre-assessment, time was not documented. f. November 7, 2018 on pre-assessment, time was not documented. Post-assessment, access site assessment has bruit and thrill checked off. g. November 2, 2018 on pre-assessment, time was not documented. h. October 31, 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site. i. October 29, 2018 on pre-assessment, time was not documented. j. October 26, 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site. k. October 22, 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site. l. October 19, 2018 on pre-assessment, time was documented, pulse (a measurable beat due to the opening and closing of an artery that can be palpated at specific landmarks on the body), and blood pressure (a measurable output produced by the force of blood against the arteries) are not documented. m. October 17, 2018 on pre -assessment, time left and vital signs are not documented except for pain level. Post-assessment, no documentation of access site. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 49 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 n. October 15, 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site. o. October 10. 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site and pain level. p. October 5, 2018 on pre-assessment, time was not documented and no documentation of temperature, pulse, respiratory rate, and blood pressure is incomplete. Post-assessment, no documentation of access site. For Resident 102: a. November 21, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site. b. November 19, 2018 on pre-assessment, time left not documented. Post-assessment, no signature time documented. c. November 16, 2018 on pre -assessment, time left not documented. Post-assessment, no signature date documented. d. November 14, 2018 on post-assessment, signature time was not documented. e. November 12, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site. f. October 31, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site and pain level not documented. g. October 30, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 50 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 h. October 26, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site. i. October 25, 2018 on post-assessment, no documentation of access site. j. October 19, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site. k. October 17, 2018 on pre-assessment, time left not documented. Post-assessment, no documentation of access site. l. October 10, 2018 on pre-assessment, time left was not documented. Post-assessment, time returned and access site had no documentation. m. September 27, 2018 on pre-assessment, time was not documented. Post-assessment, time returned and access site was not documented. n. September 24, 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site. o. September 19, 2018 on pre-assessment, time was not documented. Post-assessment, no documentation of access site. p. September 14, 2018 on pre-assessment, time not documented. Post-assessment, no documentation of access site. q. September 12, 2018 on pre-assessment, time not documented. Post-assessment, no signature time documented and access site documented as "RUE [right upper extremity]" with "Bruit, Thrill" marked. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 51 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 r. Undated form shows on pre-assessment, time left is blank and no documentation of access site. On post-assessment, no documentation of access site. For Resident 112: a. September 29, 2018 on pre-assessment, time left and vital signs was not documented. b. October 04, 2018 on pre-assessment, time left was not documented. On post-assessment, nurse's signature, date, and time were not documented. c. October 30, 2018 on pre-assessment, time left was not documented. On post-assessment, nurse's signature, date, and time were not documented. d. November 15, 2018 on pre-assessment, time left was not documented. On postassessment, signature date and time was not documented. e. November 17, 2018 on pre-assessment, time left was not documented. On postassessment, no documentation of access site. f. November 20, 2018 on pre-assessment, time left was not documented. On post-assessment, signature date and time was not documented. g. November 22, 2018 on pre -assessment, time left and vital signs was not documented. On post-assessment, signature date and time was not documented. h. November 24, 2018 on post-assessment, access site assessment has bruit (an audible sound heard over an AV shunt site with a stethoscope [a medical instrument for detecting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 52 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 sounds] associated with blood flow) and thrill (a vibration felt on the skin over an AV shunt) checked off. i. November 27, 2018 on pre-assessment, time left was not documented. On post-assessment, signature date and time was not documented. For Resident 630: a. November 28, 2018 form missing name, room number, and physician name. On preassessment, "Bruit/Thrill" documented for access site. On post-assessment, time returned, assessment of access site, vital signs, nurse's signature, date and time were not documented. b. November 27, 2018 on post-assessment, time returned, assessment of access site, vital signs, nurse's signature, date and time were not documented. During an interview with LVN 8 on November 29, 2018 at 1:15 PM, LVN 8 stated documentation of pre and post dialysis assessment dialysis "vital signs and bruit" each time a resident goes to dialysis should be completed. During an interview with Assistant Director of Nursing (ADON 1) on November 30, 2018, at 2:10 PM, ADON 1 stated the licensed nurses are responsible for filling out the pre and post dialysis assessment which includes vital signs, assessment of site, pertinent information, times in/out. ADON 1 confirmed pre and post dialysis assessments should be filled out completely. For Resident 13: a. November 5, 2018 on pre assessment, time FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 53 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 left was not documented. Post assessment was not documented. b. November 7, 2018 on the position to be completed by dialysis center was left blank. Post assessment was not documented. c. November 9, 2018 on pre-assessment, time was not documented. On the position to be completed by dialysis center was left blank. Post assessment was not documented. d. November 12, 2018, post assessment was not documented. e. November 14, 2018 on pre-assessment, time left was not documented. f. November 18, 2018 on pre-assessment, undated and time left was not documented. g. November 2018-on pre-assessment undated and time left was not documented. Postassessment had no nurses signature, date or time documented. h. November 23, 2018 on pre-assessment, time was not documented. During an interview with LVN 15 on November 28, 2018, at 11: 52 AM, LVN 15 confirmed residents have a form called pre and post assessment that has to be filled out by a licensed nurse for residents receiving dialysis services. For Resident 60: a. November 15, 2018 post assessment was not documented. b. November 20, 2018 post assessment was not documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 54 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 c. November 21, 2018 post assessment was not documented. d. November 27, 2018 post assessment was not documented. e. November 29, 2018 On pre-assessment, date was not documented Post assessment was not documented. During an interview with LVN 11 on November 28, 2018, at 12:43 PM, LVN 11 confirmed each resident should have a pre and post dialysis assessment completed. For Resident 76: a. October 2, 2018 on pre-assessment, date was not documented. Post assessment dialysis center only documented vital signs. b. October 27, 2018 on per-assessment, date was not documented. On post assessment, time was not documented. C. November 15, 2018 illegible writing on front and back of form. d. November 17, 2018 on pre and post assessment, time was not documented. There was illegible writing on front and back of form. e. November 22, 2018 on pre and post assessment, time was not documented. There was illegible writing on front and back of form. f. November 24, 2018 on pre and post assessment, time was not documented. There was illegible writing on front and back of form. g. November 27, 2018 on pre-assessment, time was not documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 55 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 facility policy and procedure titled, "Charting and Documentation," revised date July 2017, indicated ..." Documentation of Procedures and Treatments will include CareSpecific Details, including: a. The date and time the procedure/treatment was provided, the name and title of individual who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, How the resident tolerated the procedure/treatment, whether the resident refused it, Notification of family, physician or other staff, if indicated; and The signature and title of the individual documenting." 2. For Resident 30, there was no documentation of blood sugar (BS) on November 26, 2018. At 6:30 AM. A review of Resident 30's admission record indicated he was admitted on October 12, 2018 with diagnoses that included diabetes mellitus (high blood sugar), diabetic neuropathy (due to prolonged problem of diabetes with loss of sensation, numbness and pain in feet), and hypertension (high blood pressure). During an interview with Resident 30 on November 26, 2018 at 3:50 PM, resident stated, "The night nurse did not take my blood sugar. I was asleep. Nobody woke me up." During a review of Resident B's e-MAR (electronic medication administration record) with Licensed Vocational Nurse (LVN 5), she confirmed that there was no record of blood sugar (BS) on November 26, 2018 scheduled at 6:30 AM. Further review of Resident 30's clinical record indicated no documentation of any reason why there was no BS documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 56 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 30's clinical record indicated a physician order on October 12, 2018 as, "Humalog Solution (insulin drug that lowers the amount of sugar in the blood) 100 Unit/ ML (milliliter), Inject per sliding scale (chart of insulin dosages) subcutaneously (a shot given into the fat layer between the skin and muscle) before meals." A review of Resident 30's e-MAR on November 29, 2018 indicated the missing documentation on November 26, 2018 at 6:30 AM was entered with a code 1 and nurse initial. The number 1 code in chart record is defined as, "Away from home with meds." During an interview with Medical Record Designee (MRD) on November 29, 2018 at 12:45 PM, she stated that she audited the eMAR through (name of program) the next day (morning of last shift) and will inform licensed nurse of any missing documentation to follow up for correction. During a phone interview with LVN 12 on November 29, 2018 at 1:55 PM, LVN 12 stated he corrected the missing documentation on November 26, 2018 at 6:30 AM by putting the number 1 code in the e-MAR on November 27, 2018 when he reported to work on the night shift. During an interview with Director of Nursing (DON) on November 29, 2018 at 2:30 PM, she stated that LVN 12 was not working on the night shift of November 25, 2018 and LVN 12 made an error of correcting the e-MAR for Resident 30's missing documentation of BS. A phone call to Licensed Vocational Nurse (LVN 15) on November 30, 2018 at 11:30 AM and at 3:30 PM was of not available due to no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 57 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 mail box set up to leave messages. A review of the facility policy and procedure titled, "Charting and Documentation," revised July 2017 indicated, "Policy Interpretation and Implementation: 1. Documentation in the medical record may be electronic, manual, and combination. 2. The following information is to be documented in the resident medical record: . . . b. Medication administered; c. Treatment or services performed. . . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. . . 6. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviation and symbols may be used when recording entries in the resident's clinical records."

F867 SS=D QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 12/21/2018 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to identify systemic issues that includes potentially contaminated romaine lettuce available for use to the residents, non-disinfected multi-use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 58 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 glucometers, and temperature sensitive medications stored in the refrigerators with out of range temperatures. These failures may increase the risk for transmission of infection linked to use of romaine lettuce on high alert for E.Coli, transmission of blood borne infection for nondisinfected multi-use glucometers, and medication with the potential for decreased potency administered to residents. Findings: During an initial tour of the kitchen on November 26, 2018, at 8:20 AM, with the facility's Dietary Service Supervisor (DSS), there were 16 heads of romaine lettuce stored inside a plastic tub in the bottom rack of the walk in refrigerator. Twenty four (24) heads of romaine lettuce were purchased and 8 heads had been served for resident consumption. The DSS received a food safety alert from US Foods and Centers for Disease Control and Prevention (CDC) on November 20, 2018. During the medication pass observation on November 28, 2018, at 6:11 AM, it was noted LVN 12 wiped the glucometer with alcohol wipes. After LVN 12 completed the blood sugar test for Resident B he placed the glucometer on top of the medication cart without disinfecting the machine. During an observation on November 28, 2018 at 11:24 AM, the team identified temperature sensitive medications stored in the refrigerators with out of range temperatures from October 2018 to November 2018, ranging from 30 to 33 Degree Fahrenheit. During a meeting for the (Quality Assurance and Performance Improvement) QAPI review FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 59 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on November 30, 2018 at 2:33 PM, attended by the Administrator (ADMIN), Director of Nursing (DON), Nurse Consultant (Consultant 3), Director Staffing Services (DSD), Infection Control Preventionist Nurse (ICP Nurse), Assistant Director of Nursing (ADON), Maintenance Director (MDO) and Social Worker Director (SW), the ADMIN discussed the current Quality Assessment and Assurance (QAA) issues which they identified prior to the recertification survey. During an interview with ADMIN the Quality Assurance (QA) consists of the following members: the Medical Director, and all department heads, Laboratory staff and Pharmacy staff. They (QA) meet at least quarterly and monthly meeting with department heads and Medical director. All issues were communicated to all staff during the morning huddle and monthly all staff meetings. During an interview with the ADMIN he stated that he was not aware that the dietary department did not discard the romaine lettuce when they were aware the lettuce was on a high alert for possible E. Coli, that the nurses were not disinfecting the glucometers before and after use with Environmental Protection Agency (EPA) approved disinfectant (a chemical agent that destroy bacteria, virus, and fungi) and that the temperature sensitive medications stored in the refrigerator with an out of range temperatures from October 2018 to November 2018 ranging from 30 to 33 Degree Fahrenheit was not reported to the maintenance. During a review of facility document indicated QA Monthly with Department Heads and Medical Director, QA Quarterly with Department Heads, laboratory Staff, Pharmacy Staff and Medical Director. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 60 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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=K PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/21/2018 §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 precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 61 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 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 follow their policy and procedure to implement their infection control and prevention program as evidenced by the following: 1. A Glucometer (device used to check blood sugar) was not disinfected according to the manufacturer's guidelines and adhere to facility's policy and procedure to use specified Environmental Protection Agency (EPA) approved disinfectant (a chemical agent that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 62 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 destroy bacteria, virus, and fungi) before and after residents' use for four of 39 sampled residents (Residents B, 170, 45, and 57) in a universe of 228 residents. A. For Resident B, the Licensed Vocational Nurse (LVN 12) used alcohol wipes instead of facility approved disinfectant. B. For Resident 170, LVN 3 used the glucometer without disinfecting the glucometer before and after use. C. For Residents 45 and 57, LVN 9 did not disinfect the glucometer before and after obtaining the blood sugar checks between these two residents. 2. A Biohazard waste container was found in the conference room with a sharps container filled with used syringes, trash, and a towel. 3. LVN 3 did not perform hand washing before and after medication administration for Residents 170 and 199. 4. LVN 3 used tap water from the bathroom faucet for Gastrostomy tube (a feeding plastic tube used to administer medication and liquid nutrition through a surgical opening in the stomach) medication administration for Resident 199. 5. The Respiratory Therapist (RT) did not label the incentive spirometer (breathing machine to help the lungs) for Resident 153. 6. Three oxygen tubings and concentrators were found unlabeled for Residents 9, 28, and 31. 7. The Cubex (automated drug dispensing machine) was inside the storage room with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 63 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 piles of residents' personal clothing, water bottles, dry food, radios, and staff personal belongings. 8. Resident 176's wheelchair was found with multiple white spots, dry food, and dust at the foot board and arm rests. 9. Multiple plastic food warming lids and food warming bases were stacked and stored wet in the kitchen. These failures created an overall danger of transmission of infection to vulnerable residents and had the potential for all residents who shared the potentially contaminated glucometer to develop blood borne infection (disease that can be spread through contaminated blood and other body fluids). The failure to follow the manufacturer's guidelines and adhere to the facility's policy and procedure to disinfect their glucometer with EPA approved disinfectant in between resident' use resulted in an Immediate Jeopardy (IJ, immediate danger of harm). An IJ was called on November 28, 2018, at 3:58 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON were informed of the findings related to the glucometer and were asked to provide a corrective action plan. On November 28, 2018 at 5:16 PM, a corrective action plan was provided by the facility. Observation, staff interviews, and record reviews were conducted to ensure the corrective action plan was implemented. The facility's corrective action plan included, providing in-service training of all staffs to perform hand hygiene before and after resident's care, using clean technique while FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 64 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 performing blood sugar checks, and disinfecting glucometer properly before and after use with EPA approved disinfectant, new glucometers were provided, and EPA approved wipes [BRAND NAME] were made available for disinfecting on all medication carts. The IJ was lifted on November 30, 2018, at 11:45 AM, in the presence of the ADMIN and DON after the survey team ensured the corrective action plan had been implemented. Findings: 1. A review of Resident B's clinical records indicated she was admitted on November 15, 2018 with diagnoses that included diabetes mellitus type 2 (high blood sugar) and chronic kidney disease Stage 4 (advanced kidney damage). During a medication pass observation on November 28, 2018, at 6:11 AM, LVN 12 wiped the glucometer with alcohol wipes after performing blood sugar testing for Resident B. During a concurrent interview with LVN 12, he stated he used one glucometer machine to check for blood sugar test on multiple residents in his unit and used alcohol wipes to disinfect the glucometer in between residents use. LVN 12 stated he normally uses [BRAND NAME] wipes to disinfect the glucometer machine at midnight and at the end of the shift, otherwise, he used alcohol wipes to disinfect the glucometer before and after resident's use. LVN 12 stated he never received in service training on disinfecting the glucometer machine. A review of the in-service training record sign-in log for the glucometer machine dated June 28, 2018, July 6, 2018, and July 26, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 65 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 LVN 12 did not attend the in service provided by the facility. B. A review of Resident 170's clinical records indicated Resident 170 was admitted on October 4, 2018 with diagnoses that included acute respiratory failure (a breathing problem, where there is an inadequate amount oxygen in the lungs and blood), and gastrostomy tube (gastrostomy tube, a tube used for feeding and medication administration) placement. During an observation on November 28, 2018, at 6:11 AM, LVN 3 used the glucometer without disinfecting the glucometer prior to and after use during the blood sugar check for Resident 170. During an interview with LVN 3 on November 28, 2018, at 6:22 AM, she stated, "I forgot to clean the glucometer before and after checking the blood sugar" for Resident 170. During an interview with LVN 1 on November 28, 2018, at 6:43 AM, LVN 1 stated, "The night shift nurses will disinfect with [BRAND NAME] wipes and I use alcohol wipes before and after use of glucometer, right now I don't have any disinfectant wipes [BAND NAME] in my medication cart". During an interview with the Director Staff Development (DSD 1) on November 28, 2018, at 6:58 AM, the DSD 1 stated it (the glucometer) should be disinfected before and after use with disinfectant wipes [BRAND NAME]. During an interview with the Infection Control Preventionist Nurse (ICP Nurse) on November 28, 2018 at 7:00 AM, he stated, "We have to clean our glucometer with certain wipe's [BRAND NAME] that should be available on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 66 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 every medication cart and our glucometer must be disinfected before, after, and in between resident use." During an interview with the Assistant Director of Nursing (ADON 1) on November 28, 2018 at 7:04 AM, the ADON stated that the glucometer machine should be cleansed with disinfectant wipes [BRAND NAME] before and after checking the blood sugar of the residents. During an interview with the Director of nursing (DON) on November 28, 2018 at 7:21 AM, the DON stated that the nurse must disinfect the glucometer before and after using our approved disinfectant wipes [BRAND NAME] for disinfecting our equipment's used for resident care. C. A review of Resident 45's clinical record, indicated Resident 45 was admitted on June 24, 2018 with diagnoses that included dementia (chronic mental disorder caused by brain disease), osteoarthritis (causes pain & stiffness of the joints), Type 2 diabetes mellitus (increased blood sugar), and anemia (decreased red blood cells in the blood, resulting in body weakness). During an observation on November 28, 2018, at 6:41 AM, LVN 9 was observe not to disinfect the glucometer before use on Resident 45. LVN 9 left the glucometer on Resident 45's bed and performed the blood sugar check on the resident. LVN 9 did not perform hand hygiene nor did he disinfected the glucometer after the blood sugar test on Resident 45. LVN 9 proceeded to perform another blood sugar test on Resident 57 without disinfecting the glucometer. A review of Resident 57's clinical record, indicated Resident 57 was admitted on August FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 67 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 16, 2018 with diagnoses that included dementia (chronic mental disorder caused by brain disease), type 2 diabetic mellitus (increased blood sugar), and long term use of insulin (drug to control blood sugar level). During an observation on November 28, 2018, at 6:42 AM, LVN 9 continued to check the blood sugar for Resident 57 without performing hand hygiene nor disinfecting the glucometer before and after use for Resident 57. During a concurrent interview with LVN 9, he verified he did not disinfect the glucometer or perform hand hygiene. He stated, "I forgot." LVN 9 stated he usually uses alcohol wipes to disinfect the glucometer before and after residents' use. During an interview with the DON on November 28, 2018, at 8:30 AM, the DON stated the glucometer should be disinfected between residents use with facility approved disinfectant [BRAND NAME] wipes to prevent the transmission of infection. The DON further stated alcohol wipes should not be used to disinfect the glucometer. During an interview with the Pharmacy Nurse Consultant (Consultant) on November 28, 2018, at 3:46 PM, she stated the glucometer should be disinfected with EPA approved disinfectant in between resident use and alcohol wipes are never to be used as a disinfectant for glucometer. A review of facility's policy and procedure titled, "Blood Sampling and DisinfectantGlucometer", dated September 2014, indicated wash hands before and after the procedure and "Equipment and supplies; 6. Approved EPA registered disinfectant for cleaning of sampling device such as [BRAND NAME], General FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 68 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 Guidelines; 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses with disinfectant such as [BRAND NAME] disinfecting." A review of facility's form titled, "Medication Administration Licensed Nurse Skills Competency Worksheet", dated 2016, indicated the glucose machine should be disinfected. 2. During an observation on November 26, 2018 at 8:36 PM, a red plastic container labeled with a "Biohazard Wastes" (any waste contaminated with potentially with infectious agents or materials) was found inside the conference room/chapel room. The biohazard waste container had a plastic sharps container with used syringes, trash, and a towel. During an interview with the Director of Nursing (DON) on November 26, 2018 at 8:45 PM, she stated the biohazard wastes should be stored inside the biohazard wastes storage located in Unit 1, on the first floor of the facility. During a concurrent observation and interview with the DON, she verified the biohazard waste was in the conference room /chapel room. She opened the biohazard waste container and confirmed it contained a sharps container filled with used syringes, trash, and towel. The DON stated the biohazard wastes container should have been stored in the bio hazard wastes storage room in Unit 1, on the first floor. During an interview with Infection Control Preventionist Nurse (ICP Nurse) on November 27, 2018 at 9:50 AM, he stated that the RN (Registered Nurse) Supervisor and himself had the key to the biohazard storage room. The ICP Nurse stated he was responsible for leaving the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 69 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 biohazard wastes container in the conference room. He stated it should have been removed and stored in the biohazard storage room. A review of the facility policy and procedure titled, "Biohazard Waste Storage," revised May 2012, indicated, "Policy Interpretation and Implementation: 3. Containers of medical waste will be stored in the following location (s): Station I - Labeled Biohazard room. 8. Medical wastes storage room will be locked and access to medical waste will be to the limited to the following personnel: ADON, RN Supervisor, Charge Nurse, Infectious Control Preventionist, and Maintenance Supervisor." 3. A review of Resident 170's clinical record, indicated Resident 170 was admitted on 10/4/18 with diagnoses of acute respiratory failure, (breathing problems), muscle weakness, and gastrostomy tube (gastrostomy tube, a plastic tube used for feeding and medication administration) placement. A review of Residents 199 's clinical record indicated, Resident 199 was admitted on October 12, 2018 with a diagnoses that included respiratory failure, muscle weakness, and gastrostomy tube placement. During a medication pass observation on November 28, 2018, at 6:11 AM, LVN 3 did not wash her hands before and after medication administration. During a concurrent interview with LVN 3, she verified and stated, "I forgot to wash my hands before and after medication administration." During an interview with the Director Staff Development (DSD 1) on November 28, 2018 at 6:58 AM, he stated that the staff should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 70 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 always perform hand hygiene before and after resident care and during medication administration. During an interview with Director of Nursing (DON) on November 28, 2018 at 7:21 AM, she stated staff should follow and implement their policy and procedure to observe hand hygiene practices to prevent transmission of infection. The facility policy and procedure titled, "Handwashing/Hand Hygiene", indicated, "This facility considers hand hygiene the primary means to prevent the spread of infections; ... 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situation b. before and after contact with residents, before preparing or handling medications ... l. after contact with objects (e.g., medical equipment. Applying and Removing Gloves; ... 1. Perform hand hygiene before applying non-sterile gloves". The facility policy and procedure titled, "Medication Administration Licensed Nurse Skills Competency Worksheet", dated September 27, 2018, indicated, "Procedure steps: wash hands prior to passing medication, invasive procedures, before and after gloves, after touching resident or their items". 4. During a review of Resident 199's clinical record indicated, Resident 199 was admitted on October 12, 2018 with diagnoses that included respiratory failure, muscle weakness, and gastrostomy placement. During a medication pass observation on November 28, 2018, at 6:16 AM, LVN 3 used tap water from the bathroom faucet for medication administration via G-Tube for Resident 199. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 71 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 LVN 3 on November 28, 2018, at 6:22 AM, she stated, "I think I'm allowed to get water from the bathroom faucet but usually our water pitcher was always filled from the kitchen". During an interview with the DSD 1 on November 28, 2018, at 6:58 AM, he stated the drinking water for the residents and G-Tube medication administration and GT flushes should come from the kitchen. During an interview with Infection Control Preventionist Nurse (ICP Nurse) on November 28, 2018 at 7:00 AM, he stated that they use water from the kitchen for medication administration. During an interview with (ADON 1) on November 28, 2018 at 7:04 AM, she stated, "We don't get water from the resident bathroom water faucet for medication administration." During an interview with the Director of Nursing (DON) on November 28, 2018 at 7:21 AM, she stated that the water from the bathroom faucet cannot be use for medication administration. The policy and procedure was requested from Medical Records Director (MRD) for water to use for medication administration but a policy and procedure was not provided during the survey. 5. A review the clinical record for Resident 153 indicated the resident was admitted on September 20, 2018 with a diagnoses that included acute and chronic respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood). During an observation on November 26, 2018 at 10:40 AM, Resident 153 was in his bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 72 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 watching TV. On top of the bedside table were a water pitcher, a drinking glass and an incentive spirometer (a medical device used to help patients improve the functioning of their lungs) with no label. During an interview with Resident 153 on November 26, 2018 at 10:48 AM, Resident 153 stated, "This thing is mine, I use it sometimes and yes the Respiratory Therapist forget to put my name I guess". During an interview on November 26, 2018 at 10:55 AM, LVN 19 stated, "All equipment's used by residents were usually labeled with their names". During an interview on November 26, 2018 at 10:58 AM, with the Respiratory Therapist (RT), the RT stated, "I haven't noticed that there was no name on it." During an interview on November 26, 2018 at 11:08 AM, the Director of Staff Development (DSD 1) stated that they have instructed all staff to write the name of the resident on the items belonging to each resident such as their incentive spirometer, oxygen tubing, water pitcher, drinking glass and more. The policy and procedure titled, "Standard Precautions", dated December 2007, indicated "standard precautions include the following practices: 5. Resident-Care-Equipment; Ensure that reusable equipment is not used for the care of another resident after it has been appropriately cleaned". 6a. A review of Resident 9's clinical record indicated, the resident was admitted to the facility on January 22, 2018 with diagnoses that included acute respiratory failure (impaired lung FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 73 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 function with inadequate delivery of oxygen to body's tissues), pressure ulcer of sacral region stage four (pressure injury that is deep, reaching into muscle, bone and causing extensive damage) and dependence on supplemental oxygen. During a review of Resident 9's physicians orders dated November 30, 2018, an order for oxygen at 2 L/ Minute continuously for chronic obstructive pulmonary disease (COPD, lung disease that block airflow and make it difficult to breathe). During an observation on November 26, 2018 at 9:46 AM, Resident 9 was observed with oxygen (O2-a gas essential to life) at 2 Liter (Lunit of measure)/minute via nasal cannula (N/C- used to deliver oxygen when low to medium concentration is required) via a concentrator (a medical device used to deliver oxygen) that was unlabeled, without a date and time of when it was last changed. During a concurrent interview with LVN 13, LVN 13 verified the oxygen tubing and concentrator were not labeled with the date and time of when it was last changed and acknowledged it should be labeled. 6b. A review of Resident 31's clinical record indicated, the resident was admitted to the facility on November 10, 2017 with diagnoses which included COPD and dependence on supplemental oxygen. During a review of Resident 31's physician's orders dated November 29, 2018, indicated a physician order for O 2 at 2 L/ minute per MN/NC by nasal cannula continuously for COPD. During an observation on November 26, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 74 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 at 10:17 AM, Resident 31 was observed with O 2 at 2L/minute per N/C via a concentrator, which was found unlabeled with no date and time of when it was last changed. During a concurrent interview with LVN 13, LVN 13 confirmed oxygen tubing and concentrator were not labeled and should be labeled. 6c. A review of Resident 28's clinical record indicated, Resident 28 was admitted to the facility on August 3, 2015, with diagnoses that included COPD and dependence on supplemental oxygen. A review of Resident 28's physician's orders dated November 30, 2018, indicated the physicians order for O 2 at 2/minute continuously for shortness of breath. During an observation on November 26, 2018, at 10:48 AM, Resident 28 was observed to have O 2 in-place at 2 L/ minute per N/C via concentrator was found unlabeled. Resident 28 stated the O 2 does help her breathe. During a concurrent interview with LVN 13, LVN 13 confirmed oxygen tubing and concentrator were not labeled and should be labeled with date and time when it was last changed. The facility schedule titled," Terracina Respiratory Equipment Change Schedule," Undated, indicated' ..." Sunday Night ShiftOxygen tubing, tubing mask, and yankauer. Change as needed." 7. During an observation of the facility's Cubex (automated drug dispensing machine) located inside the medication room on November 28, 2018, at 7:17 AM, with the Licensed Vocational FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 75 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 Nurse (LVN 10), there were piles of residents' personnel clothes, water bottles, dry food, radios, and staffs' personnel belongings. During a concurrent interview with LVN 10, she stated she was not sure why the residents and staff belongings were stored inside the Cubex medication dispenser area. During an interview with the Social Worker (SW) on November 28, 2018, at 7:20 AM, she stated these clothes belonged to transferred residents. During an interview with the RN 1, on November 28, 2018, at 7:30 AM, she stated, "Only licensed staff had the access to Cubex medication room and should not be used as a storage." During an interview with the Activity Assistant (AA), on November 28, 2018, at 7:30 AM, she verified the radios belonged to the activity department". During an interview with Director of Nursing (DON), on November 28, 2018, at 2:19 PM, she stated the Cubex medication room should not be used for storage of personal belongings and etc. but for medication storage. A review of facility's policy and procedure titled, "Storage of Medication", dated Revised April 2007, indicated "2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner." 8. During an observation on November 26, 2018 at 10:56 AM, Resident 176 was sitting in a wheel chair (WC) with multiple white spots, dried food and dust at the foot board, and both arm rests. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 76 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 a Certified Nursing Assistant (CNA 4) on November 26, 2018 at 11:07 AM, CNA 4 stated. "It looks dirty". During an observation on November 27, 2018 at 9:30 AM, Resident 176 was observed sitting in a wheel chair with multiple white spots, dried food particles at the foot board and the both arm rests. During an observation on November 28, 2018 at 2:00 PM, Resident 176 was sitting in the same wheel chair with multiple white spots and dried food particles on the foot board and the both arm rests. During an interview with the House Keeping Supervisor (HK Sup) on November 28, 2018 at 2:25 PM, he stated morning housekeepers usually clean the wheelchairs in the unit. The HK Sup stated the facility had a wheelchair cleaning schedule, however the HK Sup can not provide the cleaning schedule log for wheelchair. During an observation on November 29, 2018 at 9:00 AM, Resident 176 was sitting in a same wheelchair with multiple white spots and dried food particles at the arm rests and foot board, in the activity room. During a concurrent observation and interview on November 30, 2018 at 8:44 AM, along with the Housekeeping 1 (HK 1) he verified and stated, "It is a dirty wheelchair". During an interview with CNA 3, on November 30, 2018 at 8:50 AM, she stated, "It looks dirty to me". CNA 3 stated housekeeping/maintenance usually cleaned the wheel chair once a week. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 77 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 facility policy and procedure titled, "Standard Precautions", revised December 2007, indicated the following: Standard precautions include the following practices: 6. Environmental Control a. "Ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned." 9. During a kitchen observation on November 26, 2018 at 3:15 PM, multiple plastic food warming lids were found stacked and stored wet in the kitchen rack readily available for resident's use. During an interview with the Dietary Aide/Dishwasher (DA) on November 26, 2018 at 3:15 PM, the DA verified the lids were stored and stacked wet. He further stated, "It takes more time to dry, there is no time to dry it". During an interview with the Dietary Service Supervisor (DSS) on November 26, 2018, at 3:17 PM, the DSS verified the food warming lids were stacked and stored wet in the kitchen rack and were ready for resident's use. The DSS stated all food warming lids should be completely air dry before stacking and storing. During a tray line observation on November 28, 2018 at 7:00 AM, 13 plastic food warming bases were stacked and stored wet and ready to use in the kitchen. During a concurrent interview with the DSS, he confirmed that there were 13 counts of plastic food warming bases that were stacked and stored wet and was readily available for resident's use. A review of the facility policy and procedure titled, "DISH WASHING" (NAME OF THE HEALTHCARE GROUP), Inc. 2018, indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 78 of 79 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 11/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 Procedure 5. "Dishes are to be air dried in racks before stacking and storing". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8RST11 Facility ID: CA240000650 If continuation sheet 79 of 79