Other·May 8, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during a Standard Abbreviated Survey for investigation of an entity self-reported incident (ERI). ERI: CA00505742-Substantiated Representing the Department: HFEN-36826 The inspection was limited to the investigation of the ERI does not reflect the findings of a full investigation of the facility.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 04/28/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive 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: UVP011 Facility ID: CA050000069 If continuation sheet 1 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 2 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 facility failed to ensure: 1. Hip precautions (important guidelines for those who have recently had a hip surgery to replace a hip joint. Hip precautions are ways of moving around that help prevent hip dislocation or separation of the new joint until the joint has time to heal) care plan was in place for one of two sampled residents (Resident 2) between 10/7/16 and 10/13/16. 2. Care plan for the use and monitoring of Seroquel (an antipsychotic - mind altering medication) was initiated for one of two sampled residents (Resident 2) from the moment Seroquel was first administered on 8/25/16 until 10/12/16. This failure resulted in licensed and direct care staff not having specific instructions needed to keep Resident 2 safe and to provide care after a hip surgery. This failure also resulted in Resident 2 receiving an antipsychotic medication without required monitoring. Findings: 1. The facility policy and procedure titled "Care Plans-Comprehensive" revised 10/10, indicated "Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain...Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: when there has been a significant change in the resident's condition...When the resident has been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 3 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 readmitted to the facility from a hospital stay..." During a record review of the clinical record for Resident 2 on 12/14/16, the Admission Progress Note dated 10/7/16, indicated Resident 2 was readmitted to the facility after a left hip surgery following a fall on 10/4/16. The Interfacility Transfer After Visit Summary dated 10/7/16, under Interfacility Transfer Notes section, indicated Resident 2 had hip precautions after left hip surgery performed on 10/5/16. During a record review of the clinical record from the general acute care hospital for Resident 2 on 12/15/16, the Emergency Department Provider physician's note dated 10/13/16, indicated Resident 2 was admitted to the general acute care hospital on 10/13/16 and was found to have a left hip dislocation. During an interview with a clinical supervisor nurse (LN 1), on 12/14/16, at 10:06 a.m., LN 1 confirmed a hip precautions care plan should have been in place. During a record review and a concurrent interview with a licensed nurse (LN 2) and the administrator (ADMIN) on 12/14/16, at 2:15 p.m., both confirmed Resident 2's clinical record did not have a hip precautions care plan in place between the dates of 10/7/16 and 10/13/16. 2. The facility policy and procedure titled "Care Plans-Comprehensive" revised 10/10, indicated "Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 4 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 attain...Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: when there has been a significant change in the resident's condition...When the resident has been readmitted to the facility from a hospital stay..." During a record review of physician's orders for Resident 2 on 12/8/16, the Order Recap Report indicated Resident 2 to receive Seroquel 12.5 mg (milligrams) one time a day starting 8/25/16 to 10/7/16. The Medication Administration Records for the time period from 8/25/16 to 10/7/16, indicated Resident 2 received Seroquel as it was ordered. During a record review and a concurrent interview with a licensed nurse (LN 2) and a social worker (SW), on 12/9/16, at 9:45 a.m., both confirmed Resident 2' clinical record had no care plan in place for the use and monitoring of Seroquel prior to 10/12/16.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 04/28/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 5 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (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 record review and interview, the facility failed to: a. Ensure staff were present at all times during toileting for one of two sampled residents (Resident 2), which led to Resident 2 sustaining a fall on 8/10/16. b. Ensure one of two sampled residents (Resident 2) was not left alone in her room, which led to Resident 2 sustaining another fall on 10/4/16 resulting in a fracture (broken bone) of the left hip. c. Ensure certified nursing assistants (CNAs) followed hip precautions (important guidelines FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 6 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 for those who have recently had a hip surgery to replace a hip joint; hip precautions are ways of moving around that help prevent hip dislocation or separation of the new joint until the joint has time to heal) and ensure a physician's order and care plan for hip precautions were in place for one of two sampled residents (Resident 2), which resulted in Resident 2's left hip being dislocated sometime between 10/7/16 and 10/13/16. d. Ensure CNAs followed hip precautions for one of two sampled residents (Resident 2) after Resident 2's first dislocation and another surgical procedure of the left hip, which resulted in Resident 2's left hip being redislocated sometime between 10/17/16 and 11/23/16. These failures resulted in Resident 2 suffering from two falls, one fracture of the left hip, two dislocations of the left hip, undergoing two surgical procedures under general anesthesia (anesthesia that affects the whole body and induces a loss of consciousness), and resulted in Resident 2 becoming disabled and no longer being able to walk. Findings: a. During a record review of the clinical record for Resident 2 starting on 12/14/16, the Admission Record undated, indicated Resident 2 was admitted to the facility on 2/15/16, with the following diagnoses: traumatic subdural hemorrhage without loss of consciousness (bleeding in the brain), dementia with Lewy bodies (progressive memory loss that leads to a decline in thinking, reasoning and independent function), and fracture of unspecified parts of lumbosacral (lower spinal region) spine and pelvis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 7 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 Review of Physical Therapy Discharge Summary dated 4/28/16, indicated Resident 2 was receiving physical therapy from 3/23/16 to 4/26/16. Upon physical therapy discharge on 4/26/16, Resident 2 was able to walk 200 feet using a front wheel walker (device to help with balance) and with contact guard assist (staff need to have one or two hands on the body of a resident, but provide no other assistance to perform a functional task; the contact is made to help steady the body or help with balance) of one person. Review of Nursing Admission Assessment dated 2/15/16, indicated Resident 2's fall risk score was 23. A total score of ten or above represents the resident is at high risk for falls. Review of a Minimum Data Set (MDS), a comprehensive assessment, dated 5/21/16, indicated Resident 2 had severely impaired cognition and required one person physical assist with toileting. Review of Assistance with Activities of Daily Living care plan initiated 2/15/16, indicated the facility staff to provide assistance to Resident 2 with toileting at least before meals, after meals, at bedtime, and as needed. Review of Committee Review Progress Note dated 8/10/16, indicated Resident 2 was found on the floor in the bathroom and sustained a "raised area on the top part of her forehead." During an interview with Resident 2's responsible party (RP), on 12/9/16, at 10:35 a.m., RP indicated on a couple of occasions witnessing the facility staff leaving Resident 2 on the toilet unsupervised. During an interview with a certified nursing assistant (CNA 2), on 12/9/16, at 2:18 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 8 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 CNA stated "Sometimes I make her (Resident 2's) bed while she is there (on the toilet)...To me, as long as I stay in the room with her means I'm not leaving her (Resident 2) alone..." During an interview with a clinical supervisor nurse (LN 1), on 12/9/16, at 2:30 p.m., LN 1 confirmed Resident 2 required supervision at all times while toileting, stated "...she cannot be left alone in the bathroom..." During an interview with a licensed nurse (LN 2), on 12/9/16, at 2:45 p.m., LN 2 stated "...those people (residents) that need assistance with toileting need continuous assistance at all times and cannot be left alone." b. During a record review of the clinical record for Resident 2 on 12/9/16, the High Risk for Falls care plan initiated 5/20/16, indicated Resident 2 needed activities that minimize the potential for falls while providing diversion and distraction such as "putting charge stickers on, folding linens, offer use of year book, bring to activities of choice." Progress Notes dated 10/4 and 10/5/16, indicated Resident 2 sustained a fall in her room on 10/4/16. "Resident was found lying on the floor on her left side with the wheelchair in front of her. Resident stated that she wants to go to the bathroom...Resident c/o (complained of) left hip pain...Resident was transferred to (name of the hospital) ER (emergency room) for evaluation and management." During an interview with a certified nursing assistant (CNA 1), on 10/20/16, at 10:20 a.m., CNA 1 described the fall incident Resident 2 sustained on 10/4/16 and stated "...she (Resident 2) was in the room (where Resident 2 resides), but she (Resident 2) wasn't FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 9 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 supposed to be in the room...She (Resident 2) said she was trying to go to the bathroom. We try to keep her (Resident 2) in front of the nursing station..." During a record review of the clinical record for Resident 2 from a general acute care hospital on 12/15/16, the physician's Consultation Report dated 10/5/16, indicated Resident 2 sustained a left hip fracture (broken bone). The Discharge Summary Details of Hospital Stay report dated 10/7/16, indicated Resident 2 underwent left hip arthroplasty (surgical reconstruction or replacement of a joint) on 10/5/16 without surgical or post-surgical complications. c. The Admission Progress Note dated 10/7/16, indicated Resident 2 was readmitted to the facility. During a record review of the clinical record for Resident 2 on 12/14/16, the "Interfacility Transfer After Visit Summary" dated 10/7/16, under Interfacility Transfer Note, indicated Resident 2 had hip precautions (important guidelines for those who have recently had a hip surgery to replace a hip joint; hip precautions are ways of moving around that help prevent hip dislocation or separation of the new joint until the joint has time to heal) after left hip surgery performed on 10/5/16. During a record review and a concurrent interview with a licensed nurse (LN 2), on 12/14/16, at 2:15 p.m., LN 2 confirmed the facility did not initiate a hip precautions care plan after Resident 2 was readmitted to the facility and did not have one in place between 10/7/16 and 10/13/16. During an interview with the physician (MD 2) and LN 2, on 12/14/16, at 1:58 p.m., MD 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 10 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 explained when a resident is discharged from a general acute care hospital with new orders, MD 2 would either write them as new orders on a prescription (an instruction written by a medical practitioner that authorizes a patient to be provided a medicine or treatment) or sign new hospital orders electronically. LN 2 reviewed Resident 2's clinical record and confirmed there was no prescription or electronically signed orders signed by MD 2 for Resident 2's hip precautions between 10/7/16 and 10/13/16. The Health Status Progress Note dated 10/13/16, indicated Resident 2 was not able to bear weight upon standing and was noted to have the left hip to be shortened, internally rotated and moved toward the midline of the body. Emergency 911 was called, ambulance arrived and Resident 2 was sent to the emergency room for an evaluation. During a record review of the clinical record from the general acute care hospital for Resident 2 on 12/15/16, the Emergency Department Provider physician's note dated 10/13/16, indicated Resident 2 was admitted to the general acute care hospital on 10/13/16 and was found to have a left hip dislocation. The Discharge Summary dated 10/14/16, indicated Resident 2 underwent a closed reduction (procedure to set or reduce a broken bone without surgery; this allows the bone to grow back together) of the left hip under general anesthesia (anesthesia that affects the whole body and induces a loss of consciousness) on 10/14/16. The facility policy and procedure titled "Reporting Abuse to Facility Management" revised 4/10, indicated "It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc. to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 11 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source...'Injury of unknown source' is defines as an injury that meets both the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of the extend of the injury..." During a record review and a concurrent interview with LN 2 on 12/9/16, at 2:55 p.m., LN 2 confirmed an incident report was not filled out and an investigation was not done after the incident on 10/13/16 when Resident 2 was found to have a dislocated left hip. During an interview with MD 2 and the administrator (ADMIN), on 12/14/16, at 1:58 p.m., MD 2 confirmed Resident 2's left hip dislocation on 10/13/16 would be considered an incident with an injury of an unknown source. ADMIN confirmed the facility must investigate and file a report with the state of California in case of an incident with an injury of an unknown source. ADMIN indicated it is the facility's practice to report injuries of an unknown source within 24 hours. d. During a record review of the clinical record for Resident 2 on 12/9/16, the Admission Progress Note dated 10/17/16, indicated Resident 2 was readmitted back to the facility with a left immobilizer (device to prevent left extremity from moving) and an abduction pillow (a pillow or cushioned wedge placed between the legs of a patient to maintain proper positioning and prevent dislocation of the hip joint). During an interview with the director of rehabilitation department (OT), on 12/9/16, at 3:50 p.m., OT indicated he educated certified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 12 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 assistants (CNAs) about hip precautions on 10/26/16. OT explained the inservice he provided about Resident 2's hip precautions and indicated CNAs were instructed to do the following when transferring Resident 2 from a wheel chair to the toilet and back: *Transferring Resident 2 requires two CNAs. *CNAs are supposed to space the wheel chair so that Resident 2 can grab the bar (supportive device in the bathroom) without leaning forward. *CNAs are to use verbal cues to initiate the transfer and have Resident 2 stand up. *CNAs are supposed to have a gait belt on Resident 2 (special belt used to assist with transfers which is placed around the resident's waist) which they need to hold on to when having Resident 2 rise from the wheel chair. *One CNA is supposed to support Resident 2's back by placing hands on her back and the other CNA is to move the wheel chair away and wheel a commode (device which could be placed over the toilet) closer to Resident 2. *Once in place, CNAs are supposed to cue Resident 2 to lower her buttocks onto the commode. *Once Resident 2 is in the sitting position, a trash can is placed under the foot with an immobilizer. *The abduction wedge is removed during transfers and is put back on when Resident 2 is back in the wheel chair after toileting. *No other supportive devices or regular pillows FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 13 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 are to be used, only the abduction wedge. During an interview with a certified nursing assistant (CNA 2) who helps to take care of Resident 2, on 12/09/16, at 2:18 p.m., CNA 2 explained how she transfers Resident 2 from the wheel chair to the toilet and back. CNA 2 stated "...I help her (Resident 2) to get to the bathroom. She (Resident 2) reaches for the bar. I help her (Resident 2) stand and put her (Resident 2) on the commode. When she (Resident 2) is done, we (CNAs) have her (Resident 2) stand and sit back in the wheel chair..." When asked for more details, CNA 2 stated "We (CNAs) hold her (Resident 2) by her arms. I tell her (Resident 2) to make the leg straight, put the wedge, then we (CNAs) put her (Resident 2) in the wheel chair with the wedge in the middle and put a pillow underneath the wedge and second pillow above the wedge. This was in October after her (Resident 2's) surgery..." During an interview with a certified nursing assistant (CNA 3) who helps to take care of Resident 2, on 12/14/16, at 9:44 a.m., CNA 3 indicated when she and another CNA transfer Resident 2 from the wheel chair to the toilet and back, they hold Resident 2 "underneath armpits." CNA 3 also indicated once Resident 2 finished with toileting and assisted back into the wheel chair, CNA 3 places the abduction wedge and then places one pillow above the wedge and another pillow behind Resident 2's calves (back part of the human leg between the knee and ankle). CNA 3 indicated she was not aware of a hip precautions care plan or any other written instructions for hip precautions. During an interview with a certified nursing assistant (CNA 4), on 12/14/16, at 9:21 a.m., CNA 4 stated "(Resident 2) doesn't have any hip precautions at the moment. I just try to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 14 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 follow them on my own anyway..." When asked about transferring Resident 2 after the surgery back in 10/16, CNA 4 indicated two people were required to transfer Resident 2 and stated "She (Resident 2) will hold on to bars. Each of us (CNAs) would be on each side of her (Resident 2). She (Resident 2) would stand on her own. We would hold her (Resident 2) on her lower back..." CNA 4 explained when Resident 2 was finished with toileting and was sitting back in her wheel chair, CNA 4 would place the wedge and then place one pillow under the wedge. CNA 4 indicated the names of two other CNAs who usually assist her with transferring Resident 2. Those two other CNAs are CNA 2 and CNA 3. During a record review of the clinical record for Resident 2 on 12/14/16, the Order Summary Report indicated there is an active physician's order initiated on 10/17/16 for hip precautions "No hyperextension (excessive joint movement in which the angle formed by the bones of a particular joint is opened or straightened beyond its normal, healthy range of motion) or external rotation (rotation away from the center of the body). The Health Status Progress Note dated 11/23/16, indicated Resident 2 came back to the facility from a doctor's follow up appointment with new written orders from the physician indicating Resident 2 "has redislocated her left hip..." During a record review of the clinical record for Resident 2 on 12/14/16, the surgeon's Progress Note dated 11/23/16, indicated Resident 2 had a "Recurrent dislocation left hip hemiarthroplasty (surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact). (Resident 2's responsible party) does not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 15 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 desire further surgical intervention at this time." During an interview with Resident 2's RP on 12/9/16, at 10:35 a.m., RP indicated Resident 2's second dislocation of the left hip was identified by the physician during a follow up appointment on 11/23/16. RP explained both the physician and the RP decided not to proceed with another surgical intervention due to high risks associated with exposing Resident 2 to general anesthesia. During an interview with a licensed nurse (LN 2), on 12/14/16, at 11:32 a.m., confirmed Resident 2's second dislocation on 11/23/16 was not investigated and no incident report was filled out. During an interview with a licensed nurse (LN 1), on 12/14/16, at 11:50 a.m., LN 1 indicated injury of an unknown source needs to be reported to a physician and the facility needs to investigate. LN 1 confirmed dislocation is considered a serious injury and needs to be reported to the State of California. During a record review of the clinical record for Resident 2 on 12/15/16, the Minimum Data Set (MDS), a comprehensive assessment, dated 10/24/16, indicated Resident 2 was no longer able to walk. A record review of the Order Summary Report, the physician's order dated 11/30/16, indicated "Non-ambulatory (not able to walk), transfer only WBAT (weight bearing as tolerated) every shift."

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 04/28/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 16 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure a drug regimen was free of unnecessary drugs for one of two sampled residents (Resident 2). Resident 2 received Seroquel (an antipsychotic - mind altering FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 17 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 medication): 1. Without adequate indication for its use. 2. Without adequate monitoring. This failure placed Resident 2 for an increased risk of death. Findings: 1. During a record review of the clinical record for Resident 2 on 12/8/16, the Admission Record dated 2/15/16, indicated Resident 2 was admitted to the facility with the diagnosis of dementia with behavioral disturbance (memory loss), dementia with Lewy bodies (memory loss causing progressive decline in mental abilities) and major depression. The facility drug reference book titled "PharMerica" dated 2015-2016, indicated quetiapine (generic name for Seroquel) is not approved for the treatment of dementia-related psychosis (depression, hallucinations, delusions, aggression, agitation, wandering, and late day confusion are hallmark behavioral and psychotic symptoms of dementia, commonly manifested in moderate to severe stages of the disease). Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death. During a record review of physician's orders for Resident 2 on 12/8/16, the Order Recap Report indicated Resident 2 to receive Seroquel 12.5 mg (milligrams) one time a day "For inability to sleep at night related to dementia" starting 8/25/16 to 10/7/16. The Order Report also indicated Resident 2 to receive Seroquel 25 mg half a tablet at bedtime "Related to dementia in other disease classified elsewhere with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 18 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 behavioral disturbance" starting 10/17/16. The Medication Administration Record (MAR) for the month of August, dated 8/25/16 to 8/31/16, indicated Resident 2 received Seroquel daily. The September MAR, dated 9/1/16 to 9/30/16 indicated Resident 2 received Seroquel daily. The October MAR, dated 10/1/16 to 10/4/16 and 10/17/16 to 10/31/16, indicated Resident 2 received Seroquel daily. The November MAR, dated 11/1/16 to 11/29/16, indicated Resident 2 received Seroquel daily. The December MAR, dated 12/1/16 to 12/15/16, indicated Resident 2 received Seroquel daily. During an interview with the clinical supervisor nurse (LN 1), on 12/8/19, at 2:13 p.m., LN 1 reviewed the US boxed warning (a warning to alert healthcare providers and individuals taking/receiving a medication about important safety concerns or life-threatening risks) for Seroquel in the facility's drug reference book and confirmed there is a problem with the indication for the use of Seroquel for Resident 2. During an interview with the pharmacist (PHARM), on 12/9/16, at 2:05 p.m., PHARM confirmed Seroquel is not used for residents diagnosed with dementia without having behavioral symptoms that present danger to self or others. During an interview with the medical director (MD 1), on 12/9/16, at 3:26 p.m., MD 1 confirmed using Seroquel solely for dementia is not appropriate. 2. The facility policy and procedure titled "Antipsychotic Medication Use" revised 4/07, indicated antipsychotic medications will not be used if the only symptoms are one or more of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 19 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 following: poor self-care, restlessness, impaired memory, mild anxiety, insomnia (difficulty sleeping), uncooperativeness or verbal expressions of behavior that do not represent a danger to the resident or others. The facility policy and procedure titled "Problematic Behavior Management - Clinical Protocol" revised 10/10, indicated "If the resident is being treated for problematic behavior or mood, the staff and physician will seek and document objective reassessment of positive or negative changes in the individual's behavior, mood, and function." During an interview with clinical supervisor nurse (LN 1), on 12/8/16, at 2:13 p.m., LN 1 confirmed behaviors have to be monitored and documented in the MAR and nurses' progress notes. During a record review of the clinical record for Resident 2 on 12/8/16, indicated the facility did not monitor Resident 2's behaviors while administering Seroquel. The MAR for the month of August, dated 8/25/16 to 8/31/16, indicated no monitoring of behaviors. The September MAR, dated 9/1/16 to 9/30/16 indicated no monitoring of behaviors. The October MAR, dated 10/1/16 to 10/31/16, indicated the behaviors were monitored only for seven days from 10/7/16 to 10/13/16. The November MAR, dated 11/1/16 to 11/30/16, indicated no monitoring of behaviors. The December MAR, dated 12/1/16 to 12/15/16, indicated behaviors were monitored only for eight days from 12/8/16 to 12/15/16. During a record review and a concurrent interview with a licensed nurse (LN 2), on 12/8/16, at 2:19 p.m., LN 2 confirmed Resident 2's clinical record had no monitoring and no documentation of Resident 2's behaviors, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 20 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 except for one week documented monitoring in the October MAR. During a record review of the clinical record for Resident 2 on 12/8/16, the October MAR dated 10/7/16 to 10/17/16, indicated to "Monitor for agitation/continuous calling out, cannot focus on eating or participation in care, repetitive sentences or questions (use of Seroquel)." The December MAR dated 12/1/16 to 12/15/16, indicated "Monitor behavior (Seroquel) use for repetitive questions looking for son." During an interview with LN 2, on 12/9/16, at 9:10 a.m., LN 2 confirmed "calling out for son" is not a behavior. During an interview with LN 1, on 12/8/16, at 2:19 p.m., LN 1 confirmed agitation is a subjective term and could mean different things to different people and verbalized examples such as "restlessness, continuously moving, yelling." During an interview with a licensed nurse (LN 3), on 12/8/16, at 3 p.m., LN 3 verbalized examples of agitation "anxious, could look like a lot of different things, calling out, moving." During an interview with a licensed nurse (LN 4), on 12/8/16, at 3:03 p.m., LN 4 verbalized examples of agitation "someone is getting upset, angry, not being cooperative." During an interview with the medical director (MD 1), on 12/9/16, at 3:26 p.m., MD 1 stated "Yelling out, agitation, repeating sentences are not psychotic behaviors. Hallucinations, paranoia would be." During a record review and a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 21 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 interview with a licensed nurse (LN 2), on 12/9/16, at 3:28 p.m., LN 2 confirmed Resident 2's clinical record had no documentation about Resident 2 having hallucinations.

F428 SS=D DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON CFR(s): 483.45(c)(1)(3)-(5)

F428 04/28/2017 c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 22 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 (iii) The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure irregularities of Seroquel (antipsychotic medication) were identified and addressed for one of two sampled residents (Resident 2). This failure placed Resident 2 at risk for receiving an unnecessary medication and at an increased risk of death. Findings: The facility Pharmaceutical Consulting Agreement made effective as of 3/31/00, indicated "Pharmacy shall provide pharmacist services under the general supervision of a qualified licensed pharmacist who shall be responsible for developing, coordinating, supervising and reviewing all Pharmaceutical Services delivered to residents in the Facility. Such pharmacist services shall include: as consulting pharmacist services, reviewing the drug regimen of each Facility resident at the skilled level of care monthly and reporting in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 23 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 writing any irregularities to Facility's Administrator, Medical Director, Director of Nursing Services and, where appropriate, the individual resident's physician." The facility policy and procedure titled "Medication Therapy" revised 4/07, indicated "Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: there is a clear indication for treating that individual with the medication..." The facility policy and procedure titled "Medication Management" dated 2007, indicated "In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use...The consultant pharmacist complies, analyzes, and presents findings regarding the proper monitoring of medication therapy to appropriate healthcare disciplines." During a record review of physician's orders for Resident 2 on 12/8/16, the Order Recap Report indicated Resident 2 to receive Seroquel 12.5 mg (milligrams) one time a day "For inability to sleep at night related to dementia", starting 8/25/16 to 10/7/16. The Order Report also indicated Resident 2 to receive Seroquel 25 mg half a tablet at bedtime "Related to dementia in other disease classified elsewhere with behavioral disturbance", starting 10/17/16. The facility drug reference book titled "PharMerica" dated 2015-2016, indicated quetiapine (generic name for Seroquel) is not approved for the treatment of dementia-related FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 24 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 psychosis (depression, hallucinations, delusions, aggression, agitation, wandering, and late day confusion are hallmark behavioral and psychotic symptoms of dementia, commonly manifested in moderate to severe stages of the disease). Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death. During a record review of the clinical record for Resident 2 on 12/9/16, The Consultant Pharmacist's Medication Regimen Review for 9/16, indicated there were no recommendations made for Resident 2's drug regimen. The Consultant Pharmacist's Medication Regimen Review for 10/16 indicated no recommendations about inadequate indication for Seroquel or behaviors monitoring inconsistency. The Note to Attending Physician/Prescriber, electronically verified by Resident 2's physician on 11/10/16, indicated no recommendations about inadequate indication for Seroquel or behaviors monitoring inconsistency. The Executive Summary of Consultant Pharmacist's Medication Regimen Review for 12/16, indicated there were no recommendations made for Resident 2's drug regimen. During an interview with a licensed nurse (LN 2), on 12/9/16, at 10:25 a.m., LN 2 confirmed Resident 2's clinical record had no other pharmacist's recommendations. During an interview with the pharmacist (PHARM), on 12/9/16, at 2:05 p.m., PHARM confirmed one of her responsibilities during residents' drug regimen review is to verify the indication for use for antipsychotic medications. PHARM also confirmed Seroquel is not used for residents diagnosed with dementia without having behavioral symptoms that present FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 25 of 26 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: _______________ 055733 (X3) DATE SURVEY COMPLETED 04/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLE VERDE HEALTH FACILITY 900 Calle De Los Amigos Santa Barbara, CA 93105 (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 danger to self or others. When asked about the rationale why Seroquel is not used for residents with dementia without having behavioral symptoms, PHARM stated "I do not know." During an interview with the medical director (MD 1), on 12/9/16, at 3:26 p.m., MD 1 confirmed using Seroquel solely for dementia is not appropriate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UVP011 Facility ID: CA050000069 If continuation sheet 26 of 26