Other·September 9, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for Facility Reported Incident CA00605932. Representing the Department of Public Health: 37553, HFEN 39723, HFEN The inspection was limited to the specific Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for Facility Reported Incident: CA00605932.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 07/08/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's 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: FV3W11 Facility ID: CA240000650 If continuation sheet 1 of 11 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 06/28/2019 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 medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical and sexual assault from Resident 2 when a lock station was unsecured, and there was a lack of supervision of the residents. These failures resulted in Resident 1 in being sexually assaulted by Resident 2. Resident 1 sustained physical injuries evidenced by scratches, bruises, abrasions, discomfort/pain, and suffered mental anguish manifested by frequent crying and fearfulness. Resident 1 experienced a decline in mental status, resulting in Resident 1 being transferred to a hospital for psychiatric evaluation. Findings: On October 1, 2019 at 11:06 AM, a standard abbreviated survey was conducted to investigate an allegation of sexual abuse involving Resident 1 (alleged victim) and Resident 2 (alleged perpetrator). During an interview with the Director of Operations (DO), on October 1, 2018, at 11:30 AM, the DO stated, on September 30, 2018, law enforcement had detained Resident 2 for outstanding DUI warrants (driving under the influence). The DO further stated she did not know if Law Enforcement had arrested Resident 2 for the sexual assault of Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 2 of 11 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 06/28/2019 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 1's "Face Sheet (demographic information)" indicated Resident 1 was readmitted to the facility on September 10, 2018, with diagnoses which included unspecified intellectual disability (an impairment of cognitive skills, adaptive life skills, and social skills) and schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves). During an observation on October 1, 2018, at 12:30 PM, in Resident 1's room, Resident 1 was sitting on the bed. Resident 1 was guarding (protecting) her stomach with both hands and rocking back and forth. Resident 1 cried out, "My tummy, tummy hurts." During an interview with Resident 1, on October 1, 2018, at 12:35 PM, Resident 1 stated Resident 2 had done "bad things" to her. Resident 1 pointed to the bruises on her right hand and right forearm and stated, "He fight me." Resident 1 further stated she had pain in the vaginal area. Resident 1 stated she had tried to scream for help, but Resident 2 covered her mouth with his hand. During an interview with Restorative Nurse Assistant 1 (RNA 1), on October 1, 2018 at 12:48 PM, RNA 1 stated Resident 1 had not been coping well, she had been very tearful and anxious since the "sexual abuse incident." RNA 1 stated Resident 1 had become extremely fearful and did not want to be alone. During an observation in Resident 1's room on October 1, 2018, at 2:40 PM, with RNA 1, RNA 1 opened the window above Resident 1's bed. Resident 1 started to scream and yelled out, "No, he come back, no, no." RNA 1 immediately closed the window. Resident 1 stopped yelling and held a teddy bear close to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 3 of 11 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 06/28/2019 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 her chest. Resident 1 cried out, "He hurt me." During an observation with the Director of Nursing (DON), on October 1, 2018, at 12:55 PM, Resident 1's room was located on the lower level of the facility in a "Locked Station (Station 2, back hall)." Resident 1's room was the farthest room from the nurses' station and the closest room to the door (Door 3) which had easy access to the north courtyard (also referred to as patio). Door 3 was unlocked with a non-functioning door alarm. During an interview with the DON, on October 1, 2018, at 1:03 PM, the DON stated Door 3's alarm had been manually turned off and Door 3 had been left unlocked. The DON stated she did not know how long Door 3 had been left unlocked or how long the alarm had been turned off. The DON stated Door 3 should have been locked and the alarm should have been functioning properly. During an interview with the Maintenance Supervisor (MS), on October 1, 2018, at 2:15 PM, the MS stated he was not aware the lock on Door 3 had been disabled. The MS further stated he did not know the alarm had been disarmed. The MS stated he had not routinely tested Door 3. The MS was not able to show documentation Door 3 had been tested to ensure proper functioning. During an interview and record review with the Director of Staff Development (DSD 1), on October 1, 2018, at 3:37 PM, DSD 1 stated Resident 1's "Brief Interview for Mental Status (BIMS)" dated July 30, 2018, score was three (3) which indicated severe intellectual impairment. DSD 1 further stated Resident 1's "History and Physical Assessment", dated September 14, 2018, indicated Resident 1 did not have the capacity to understand or make FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 4 of 11 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 06/28/2019 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 decisions. A review of Resident 1's emergency room notes, a document titled "Physician Progress Note" dated September 30, 2018, at 1:10 PM, indicated Resident 1 had evidence of sexual assault and was "uncomfortable with sitting." The progress note further indicated the physician prescribed pain medication to alleviate some of Resident 1's discomfort. During a telephone interview and record review with the Forensic Examiner (FE 1, a professional person who collects, analyzes,and report crime scene evidence), on October 3, 2018, at 4:15 PM, FE 1 stated she had examined Resident 1. Resident 1 was very anxious and uncomfortable during the examination. FE 1 stated Resident 1 exhibited "a child-like demeanor throughout the examination." FE 1 stated Resident 1's "Forensic Medical Report: Acute (less than 120 hours) Adult/Adolescent Sexual Assault Examination" dated September 30, 2018, at 12:16 PM, indicated the examination was consistent with vaginal penetration injury. FE 1 further stated Resident 1 was unable to tolerate an anal (opening for bowel movement) examination due to discomfort. The report indicated the following: 1. Abrasions to the labia minora (a moist layer of tissue and skin that lines the outer portion of the vagina); 2. Abrasions to the vestibule (the space between the labia minora into which the vagina opens); 3. Abrasions to the abdomen (stomach); 4. Bruised right hand; 5. Bruised right forearm. During a telephone interview with the Charge Nurse (CN 1), on October 3, 2018, at 8:12 AM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 5 of 11 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 06/28/2019 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 CN 1 stated she was the CN for Station 2's front and back hall on September 29, 2018 (11:00 AM-7:00 AM shift). CN 1 stated she had been employed with the facility for eight months. CN 1 further stated Door 3 had always been unlocked and the alarm to Door 3 did not work. CN 1 stated Door 1 and Door 2 have functioning alarms and key pad codes for entry and exit. She further stated Resident 2 did not go out of Door 1 or Door 2. CN 1 stated Resident 2 had gone out of the Slider located in Resident 2's room. She further stated the Slider gave Resident 2 access to the north courtyard and Door 3. CN 1 stated Resident 2's room Slider should have been safeguarded to minimize the risk for injury to Resident 2 and other residents. During an interview with the DON, on October 4, 2018, at 1:03 PM, the DON stated Resident 2 had entered the unlocked door (Door 3) from the courtyard and Door 3 is not visible from the dining room on Station 2's back hall. The DON stated Resident 2 should not have been able to access Station 2's back hall. She further stated Door 3 should have been locked or supervised at all times. The DON stated it is the facility's responsibility to ensure a safe and secured environment for all residents. During an interview and record review with the Social Services Director (SSD), on October 4, 2018, at 1:45 PM, the SSD stated, on September 30, 2018, the Licensed Nurse had conducted a physical and pain assessment on Resident 1. The SSD stated Resident 1 had reported pain in the vaginal area. The SSD further stated Resident 1 had scratches to the left hip, scratches to the right forearm and redness to the left labia (female genitalia). The SSD stated, on October 1, 2018, the Licensed Clinical Social Worker had performed a psychological evaluation and on October 2, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 6 of 11 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 06/28/2019 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 2018, the physician transferred Resident 1 to a Psychiatric Hospital, for a "follow-up and further evaluation related to incident and intermittent emotional distress." During a record review and concurrent interview with DSD 1, on October 4, 2018, at 2:19 PM, Station 2's "Daily Station Assignment" dated September 29, 2018 (11:00 PM-7:00 AM shift), indicated there were four CNA's assigned to Station 2, however he had reassigned one CNA to Station 4 leaving three CNA's to provide care for Station 2's front hall and back hall residents. DSD 1 stated he should have four CNA's constantly supervising the front and the back hall. During a telephone interview with the Certified Nurse Assistant (CNA 1), on October 4, 2018, at 6:30 AM, CNA 1 stated she had been employed with the facility for two years and Door 3 did not have a working alarm and Door 3 was never locked. CNA 1 stated, on September 30, 2018, at approximately 7:00 AM, she was in the dining room supervising 16 residents. She further stated she was the only employee on Station 2's back hall until CNA 2 had completed the split assignment on Station 2's front hall. CNA 1 stated after CNA 2 returned from Station 2's front hall, CNA 1 asked CNA 2 to supervise the 16 residents in the dining room until she had finished her assignment. CNA 1 stated after leaving the dining room, on September 30, 2018, at approximately 7:00 AM, she heard Resident 1 yelling out for help. CNA 1 stated she had hurried to Resident 1's room which was four doors from the dining room and observed Resident 2 on top of Resident 1. She stated she had yelled for help from CNA 2 and yelled for Resident 2 to get off of Resident 1. CNA 1 stated Resident 2 left the Station 2's back hall through Door 3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 7 of 11 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 06/28/2019 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 telephone interview with the Charge Nurse (CN 1), on October 4, 2018, at 6:44 AM, CN 1 stated, on September 30, 2018, at approximately 7:03 AM, she entered Station 2's back hall and heard Resident 1 crying out "it hurts." CN 1 stated Resident 2 was no longer in Station 2's back hall when she had arrived. CN 1 stated there should have been four CNA's assigned in Station 2 but there were three CNA's assigned on September 29, 2018 on the night shift (11:00 PM-7:00 AM). CN 1 stated, a safe assignment that would have met the care needs and minimized the possibility of sexual abuse for Station 2's residents required at least four CNAs. CN 1 stated, on September 29, 2018, there should have been two CNAs assigned to Station 2's front hall and two CNAs assigned to Station 2's back hall to meet the care and safety needs of the residents. During a review of Resident 1's "Nurse Progress Note" dated October 2, 2018, at 2:08 PM, indicated Resident 1 had become progressively agitated and had " ...episodes of emotional outburst (manifested by- exhibited by) M/B yelling out." During a review of Resident 1's "Progress Note" dated October 2, 2018, 4:32 PM, indicated Resident 1's mental status had declined and the facility transferred Resident 1 to the hospital for psychiatric care and "(Follow up) F/U for further evaluation (due to) d/t sexual behavior (BX) from peer resident." A review of Resident 2's "Face Sheet" indicated Resident 2 was readmitted on July 26, 2018, with a diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), schizoaffective disorder (a chronic condition characterized by psychotic symptoms such as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 8 of 11 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 06/28/2019 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 Hallucinations, which are seeing or hearing things that aren't there) and delusions, (false, fixed beliefs that are held regardless of conflicting evidence). During an interview with the DON, on October 1, 2018, at 2:55 PM, the DON stated Resident 2 had exhibited elopement attempts and aggressive behaviors over the past few months with staff and other residents. The DON stated the facility had implemented frequent visual checks for Resident 2 to ensure Resident 2's safety and location. The DON further stated there was no documentation indicating how often the visual checks had been done and she was not aware Resident 2 was able to access the courtyard without supervision. The DON stated there were no documented door checks completed on Resident 2's Slider. She further stated the Slider should have been locked at all times. The DON stated, on September 30, 2018, there were no interventions in place to alert the staff that Resident 2 had eloped through the Slider. Review of the History and Physical Examination for Resident 2, dated April 29, 2018, reflects Resident 2 does not have the capacity to understand and make decisions. A review of the "Plan of Care" for Resident 2, dated June 23, 2018, indicated "Focus: Agitation/aggressive behavior." Interventions included: "Keep resident from others when agitated ..." A review of the "Nurse Progress Note" for Resident 2, dated September 30, 2018, at 10:00 AM, indicated "(Resident 2) was escorted out of the building (on September 30, 2018, at 10:00 AM) by two officers for the alleged sexual assault that occurred this morning." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 9 of 11 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 06/28/2019 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 the "Nurse Progress Note" for Resident 2, dated July 28, 2018, at 2:25 PM, indicated "Resident continues to display aggressive behavior. Attempted to strike out at a fellow resident." A review of the "Nurse Progress Note" for Resident 2, dated July 29, 2018, at 1:39 PM, indicated "Resident was found with a metal knife A review of the "Plan of Care" for Resident 2, revised July 30, 2018, indicated "Focus: Resident has behaviors of having sharp objects at bedside. Goal: (Resident 2), staff, and residents will remain free of injury through review ... Interventions: Remove any sharp or hazardous objects from resident ...Sweep resident room for any sharp objects and in courtyard for environmental hazards ..." During a record review of Resident 2's care plan and concurrent interview with CN 1, on October 3, 2018, at 8:55 AM, Resident 2's care plan dated May 22, 2018, indicated, "Focus: (Resident 2) is an elopement risk/wanderer ... Resident wanders aimlessly, Resident often fully dressed with his jacket on and wanders at the time when he should be in bed asleep ... Goal: (Resident 2) will not leave facility unattended through the review date (target date: November 3, 2018) Interventions: ...Provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, pictures and memory boxes ...distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book." CN 1 stated, on September 30, 2018, at approximately 6:45 AM, she had observed Resident 2 awake, fully dressed and walking in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 10 of 11 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 06/28/2019 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 his room. CN 1 further stated an immediate structured intervention (activity) had not been provided. The facility policy and procedure titled, "Abuse and Neglect-Clinical Protocol", dated March 2018, indicated: "Definitions: ...3. Nonconsensual sexual contact of any type with a resident. Assessment and Recognition: 4. The physician and staff will help identify risk factors for abuse within the facility; for example, significant number of residents/patients with unmanaged problematic behaviors ...issues related to staff knowledge and skills. Treatment and Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FV3W11 Facility ID: CA240000650 If continuation sheet 11 of 11