Health inspection·May 23, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) user's manual, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 4 (Residents #14, #55, #62, and #80) of 6 sampled residents reviewed for MDS accuracy. Residents Affected - Some Findings included: During an interview on 05/22/2024 at 9:00 AM, the Director of Nursing (DON) revealed that the facility did not have a policy on MDS accuracy and stated they followed the RAI manual. 3.0 User's Manual, dated 10/2023, revealed All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions. The manual revealed Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. The manual revealed Coding Instructions for section A1500 included Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. 1. An admission Record revealed the facility admitted Resident #14 on 04/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified psychosis not due to a substance or known physiological condition and vascular dementia. An admission MDS, with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. MDS section A1500 indicated Resident #14 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had an active diagnosis of psychotic disorder and had taken an antipsychotic medication during the seven-day look-back period. Resident #14's care plan revealed a focus area, initiated 04/11/2024, that revealed the resident was prescribed psychotropic medication for behavior management related to a diagnosis of psychosis. Page 1 of 14 055042 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #14's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 04/06/2024, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 04/05/2024. During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed that Resident #14 had a PASRR Level II evaluation completed and was receiving psychiatrist services. The SS Supervisor indicated the MDS staff were responsible for coding section A of the MDS. 2. An admission Record revealed the facility admitted Resident #62 on 10/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder (bipolar type), anxiety disorder, bipolar disorder, and major depressive disorder. A significant change MDS, with an Assessment Reference Date (ARD) of 03/11/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. MDS section A1500 indicated Resident #62 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of anxiety disorder, depression, bipolar disorder, and schizophrenia and had taken an antipsychotic, antianxiety, and antidepressant medications during the seven-day look-back period. Resident #62's care plan included a focus area initiated 01/31/2023, that indicated the resident was prescribed psychotropic medications related to bipolar disorder, anxiety disorder, and schizoaffective disorder. Resident #62's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 11/18/2023, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 11/15/2023. During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed Resident #62 had a PASRR Level II and was receiving psychiatric and psychology services. The SS Supervisor further revealed that the MDS staff were responsible for coding section A of the MDS. 3. An admission Record revealed the facility admitted Resident #80 on 01/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder, other recurrent depressive disorders, and post-traumatic stress disorder (PTSD). An admission MDS, with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. MDS section A1500 indicated Resident #80 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of anxiety disorder, depression, and post-traumatic stress disorder and had taken an antidepressant medication during the seven-day look-back period. 055042 Page 2 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #80's care plan included a focus area, initiated 02/07/2024, that indicated the resident was prescribed psychotropic medications related to behavior management. Resident #80's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 01/28/2024 revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 01/25/2024. During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed Resident #80 had a PASRR Level II and was receiving psychiatrist services. The SS Supervisor revealed the resident refused the psychiatric services and preferred to talk it out with the resident's family and children. The SS Supervisor further revealed the MDS staff were responsible for coding section A of the MDS. During an interview on 05/23/2024 at 11:04 AM, the Director of Nursing (DON) revealed that a resident's PASRR was checked upon admission. The DON revealed it was hers and the MDS Coordinator's responsibility to check the PASRR portal daily. The DON indicated PASRR Level II evaluations were discussed in the daily morning meetings. The DON indicated she was aware the PASRR Level IIs should be coded in section A on the MDS assessments. She indicated it was the responsibility of the MDS coordinators to code section A of the MDS. The DON further indicated it was important that the MDS was coded accurately to ensure the resident received the appropriate care. The DON indicated it was her expectation that the MDS was coded accurately, and she was the registered nurse (RN) who signed off on them. The DON revealed going forward the facility planned to check the PASRR portal website a couple times a day for PASRR Level II evaluations. The DON revealed he MDS coordinators did not have access to the PASRR portal until April 2024 . During an interview on 05/23/2024 at 12:28 PM, the Administrator revealed that a Corporate MDS RN provided one-on-one training on coding section A of the MDS accurately on 05/22/2024. The Administrator revealed it was important that residents' MDS assessments were coded accurately so that the residents were in the proper setting and were receiving appropriate care. The Administrator indicated the DON and the Corporate MDS RN would be reviewing the assessments for accuracy going forward. The Administrator indicated it was his expectation that MDS assessments were accurate . 4. An admission Record indicated the facility originally admitted Resident #55 on 05/25/2022 and re-admitted the resident on 04/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar disorder, and major depressive disorder. An admission MDS, with an Assessment Reference Date (ARD) of 04/29/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses that included anxiety disorder, depression, bipolar disorder, and schizophrenia, and the resident received antipsychotic and antidepressant medications during the seven-day look back period. Further review of the MDS indicated Resident #55 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Resident #55's care plan included a focus area, initiated 04/27/2024 and revised 05/22/2024, that 055042 Page 3 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0641 Level of Harm - Minimal harm or potential for actual harm indicated the resident had a positive Level I PASRR screening, indicating diagnoses of anxiety, depression, schizoaffective disorder, and bipolar disorder, and indicated that the resident was taking psychoactive medications. Interventions directed staff to coordinate provisions of special needs with the state Medical/Medicaid Agency (initiated 04/27/2024) and to provide psychiatric evaluation and treatment as needed (revised 05/22/2024). Residents Affected - Some Resident #55's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 04/27/2024, indicated there were recommended specialized services to supplement the nursing facility's care to address the resident's mental health needs. The document indicated that the report was based on a review of the resident's medical and social history which revealed a significant medical condition with mental stressors that required nursing services. The report indicated a Level II evaluation was completed on 04/26/2024. During an interview on 05/22/2024 at 3:33 PM, MDS Coordinator #1 stated PASRR information was included on comprehensive MDS assessments, which included admission, annual, and significant change assessments. She stated she had access to the PASRR information from their system and she was able to see if a Level II was in place. She stated the admission Coordinator provided the Level I and Level II PASRR information to the Director of Nursing (DON). She stated the MDS staff were responsible for completing section A of the MDS, which included the Level II PASRR information. She stated the DON was responsible for checking to see if the PASRR had been completed and reviewed the determination letter, then the DON notified the MDS staff if a Level II was in place. She stated the MDS staff were responsible to ensure the MDS information was accurate. After review of Resident #55's MDS, MDS Coordinator #1 confirmed that it was not accurate. During an interview on 05/23/2024 at 11:05 AM, the DON stated the MDS staff were responsible for the accuracy of the MDS assessments and since she signed the completed MDS assessment, she was also responsible. She stated the accuracy of the MDS assessments was important to provide quality care. The DON stated that going forward they would log into the online portal a couple of times a day to see if there was any PASRRs available to code on the MDS assessments. The DON stated that Resident #55's MDS was not accurate. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he expected the MDS assessments to be accurate. He stated they had a consultant at the facility to compete one-on-one training with the MDS staff the previous day. The Administrator stated the DON would be reviewing the PASRRs to ensure that the MDS was coded correctly. He stated he received PASRR portal access for more users in the facility and they were going to be doing ongoing education. The Administrator stated the accuracy of the MDS was important so they could provide the proper services for the resident that was specific to their needs. 055042 Page 4 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure care of a peripheral intravenous (IV) access site was provided and documented in accordance with accepted standards of nursing practice and facility policy for 1 (Resident #55) of 1 sampled resident reviewed for IV site care. Specifically, the facility failed to obtain physician's orders for IV flushes and dressing changes, failed to conduct and document assessments of the IV site, and failed to ensure the IV site was discontinued promptly when not needed for IV therapy. Residents Affected - Few Findings included: A facility policy titled, Organizational Aspects of IV Therapy, effective 07/2013, specified, General Rules of IV Documentation 1. Document per facility policy - usually every shift if resident has an infusion catheter in place, or whenever and infusion treatment is given and 5. The shift note should include the following information: a. Date, time; signature and title of Nurse. b. Location and objective description of insertion site. The policy also indicated Nursing Responsibilities in Infusion Therapy included the following: - 8. Performing functions and procedures that are consistent with current standard of care, facility policy and procedure and that are within the scope of the State Nurse Practice Act. - 11. Clarifying an illegible, incomplete, or incorrect order. The policy also indicated, Scope of Practice for Specific Infusion Therapy Nursing Functions included, 5. Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, site rotation (for short peripheral catheters only), changing IV tubing and needleless connection devices. An admission Record indicated the facility re-admitted Resident #55 on 04/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of pneumonia and severe sepsis with septic shock. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS did not indicate the resident had IV access on admission or while a resident. An observation on 05/20/2024 at 9:43 AM revealed Resident #55 lying in bed with a peripheral IV access to the right foot. The dressing on the site was dated 04/29/2024, indicating the dressing had been in place for over 20 days. A Clinical Admission progress note, dated 04/22/2024, revealed Resident #55 had the peripheral IV access on the right foot on the date of the resident's readmission to the facility. A review of Resident #55's Order Summary Report revealed no orders for the care or maintenance of the IV access to the resident's right foot. Resident #55's care plan included a focus statement, dated as initiated 04/24/2024, which indicated the resident had impaired immunity and was on immunosuppressive therapy. The planned interventions 055042 Page 5 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few directed staff to monitor/document/report any signs or symptoms of infection, including fever, redness, or drainage/swelling around wounds or catheter sites. As of 05/20/2024, Resident #55's care plan did not address that the resident had a peripheral IV access site in place. The care plan included no interventions that addressed the care and monitoring of the IV site. During an interview on 05/21/2024 at 12:38 PM, Registered Nurse (RN) Supervisor #4 stated Resident #55 returned from the hospital with the IV access to the right foot. RN Supervisor #4 stated she contacted the dialysis center to make sure they were not using it then discontinued it since it was no longer needed. She stated she discontinued it the morning of 05/21/2024. She stated she was not able to find any reason for the IV site or any care orders for the IV site, including flushes or dressing changes. During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated if a resident had IV access, the nurse should assess the site for infection and infiltration. She stated there should be orders for care that included flushing the IV and assessing the site. She indicated the site should be monitored every shift and this should be documented in the nurses' notes. She stated a peripheral IV could stay in place for up to seven days and that the dressing over the insertion site should be changed every three days. She stated Resident #55's IV access should have been removed since they were not using the access. She stated she did not know why the IV access was not discontinued. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated the admitting nurse should do a full body assessment and document any IV access. She stated the facility would need orders to monitor the site and flush the IV catheter. She stated the IV access should be assessed throughout any treatment being provided, and if the resident was not receiving treatment, the access should be removed. She stated a peripheral IV line could stay in until it infiltrated and then would need to be changed out. She was not sure how often the dressing over the access site should be changed. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated if a resident had IV access, there should be physician's orders that included flushes, monitoring every shift, and dressing changes. She stated she thought the dressing should be changed once a week but was unsure how long a peripheral IV line could stay in place. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated that upon admission, the nurse should do a skin assessment. If there was IV access and it was not needed, then the nurse should get an order and the IV should be removed. She stated that sometimes, they would keep the access for a few days in case it was needed. In that case, they should have orders for flushing of the IV catheter and for care of the site. She stated a peripheral IV access could stay in as long as it was intact and patent. She stated the dressing to the site should be changed every seven days. The DON stated she was not sure if Resident #55's IV access was used and stated the resident did not have orders for IV access and care. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated if a resident was admitted with IV access, then the nurse should find out if it was needed and only keep it in place for the length of time it was needed. He stated they should have physician orders to care for the IV site. 055042 Page 6 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, record review, and facility policy review, the facility failed to ensure splints were applied as ordered for 2 (Resident #18 and Resident #46) of 3 sampled residents reviewed for positioning and mobility. Findings included: A facility policy titled, Restorative Nursing Program Guidelines, revised 09/19/2019, indicated the restorative nursing program may include, G. Splinting and brace application. The policy also indicated, VII. The RNA [restorative nurse aide] carries out the restorative program according on [sic] the Care Plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress note. 1. An admission Record indicated the facility most recently admitted Resident #18 on 02/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy (shrinkage of muscles) to multiple sites and cachexia (a metabolic syndrome characterized by muscle mass loss). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2024, revealed Resident #18 had short-term and long-term memory problems per a staff assessment of mental status (SAMS). The MDS indicated the resident had functional limitations in range of motion with impairment to the upper and lower extremities on both sides and was dependent for all activities of daily living (ADLs). According to the MDS, the resident received no or less than 15 minutes a day of restorative nursing program services, including splint or brace assistance, during the seven-day assessment look-back period. Resident #18's Order Summary Report, which listed active orders as of 05/22/2024, revealed the following RNA program orders: - An order started on 12/18/2023 directed an RNA to apply the resident's right elbow extension splint for two to five hours, as safely tolerated to prevent further development of contractures every day shift. - An order started on 12/18/2023 directed an RNA to apply the resident's right resting comfy hand splint for two to five hours as safely tolerated to prevent further development of contractures every day shift. Resident #18's care plan included a focus area, initiated on 03/17/2022, that indicated the resident had an ADL self-care performance deficit related to dementia and musculoskeletal impairment. Interventions initiated on 07/27/2023 indicated as part of the RNA program, the RNA was to apply an elbow extension splint to the resident's right upper extremity and a resting hand splint to the resident's right upper extremity for four hours five times per week or as tolerated. Another intervention, initiated on 05/23/2024 (during the survey), indicated a RA was to don and doff a left knee extension to prevent further development of contractures. The intervention did not specify the frequency or duration the knee extension was to be applied. 055042 Page 7 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0688 Level of Harm - Minimal harm or potential for actual harm During observations on 05/20/2024 at 12:58 PM, Resident #18 had contractures of all four extremities with no splints or hand rolls in place. Observations on 05/21/2024 at 10:43 AM and 2:12 PM revealed Resident #18 did not have any splints in place. Residents Affected - Few Observations on 05/22/2024 at 9:35 AM and 12:32 PM revealed Resident #18 did not have any splints in place. A review of Resident #18's Restorative Program forms revealed the resident's splint/brace care was not documented as provided for one or more of the resident's ordered splints/braces on 11 of 22 days between 05/01/2024 and 05/22/2024. During an interview on 05/22/2024 at 12:15 PM, Restorative Nursing Assistant (RNA) #10 stated there were three RNAs, and two worked every day. She stated the RNAs did weights on Monday and Tuesday, and if they had time at the end of the shift, then they would do range-of-motion exercises with some of the residents, but they did not apply the splints. She stated Sunday 05/19/2024 would have been the last time the resident had the splints on. She stated she did not work, but her partner would have done it. She stated she had not had a chance to apply the splints that day. During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated she did not apply the splints for the residents but did monitor to ensure that the splints were being put on as ordered. She stated she did not realize Resident #18's splints had not been applied the previous three days. During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) Supervisor #4 stated if a resident had orders for splints to be applied seven days a week, then the resident should have them on daily, and if they were not being applied, then the reason should be documented. She stated splints were important to prevent contractures. She stated she did not know why Resident #18's splints had not been applied. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated RNA services should be provided seven days a week if that was what was ordered. She stated if it was not being done, then the reason should be documented. She stated the use of splints was important to prevent further contractures. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated she was also the restorative nurse. She stated the proper use of splints was important for contracture management and needed to be followed because it was an order from the physician. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated if RNA services were ordered seven days a week, then it should be provided seven days a week, and if not, then the reason should be documented. She stated splints were important to use for contracture management. She stated the RNA should have provided the treatment as ordered and should document why the splints were not on Resident #18. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he thought the RNA services were being provided. He stated they were assessing all the RNA residents to see if there had been any decline related to the services not being provided and they were doing one-on-one in-services with the RNAs. He stated they did not direct the staff to only do weights on Monday and Tuesday and 055042 Page 8 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0688 were planning to revamp the Restorative system. Level of Harm - Minimal harm or potential for actual harm 2. An admission Record indicated the facility re-admitted Resident #46 on 03/13/2023. According to the admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy (shrinkage of muscles) to multiple sites and poly-osteoarthritis (joint pain that involves five or more joints). Residents Affected - Few An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had functional limitation in range of motion with impairment to the upper and lower extremities on both sides. The MDS indicated Resident #46 was dependent for all activities of daily living (ADLs). According to the MDS, restorative services were provided for eating and/or swallowing during the assessment period and splint and brace assistance was not provided. Resident #46's care plan included a focus area initiated 08/17/2023 that indicated the resident had an ADL self-care performance deficit related to limited mobility and weakness. Interventions included an RNA program for the left resting hand splint, right elbow extension, and left elbow extension to be applied seven days a week up to five hours a day as safely tolerated. Observation on 05/20/2024 at 9:32 AM revealed Resident #46 had contractures of bilateral hands with no hand rolls or splints in place. Observations on 05/21/2024 at 10:32 AM and 2:10 PM revealed Resident #46 did not have any hand rolls or splints in place. Observations on 05/22/2024 at 7:40 AM, 9:15 AM, 11:32 AM, and 12:02 PM revealed Resident #46 did not have any hand rolls/splints in place. A review of Resident #46's Order Summary Report, revealed the following active orders: - An order dated 12/31/2023 indicated the RNA was to apply the resident's left upper extremity elbow extension splint every day shift as safely tolerated for contracture prevention. - An order dated 12/31/2023 indicated the RNA was to apply the resident's right upper extremity elbow extension splint every day shift as safely tolerated for contracture prevention. A review of Resident #46's Restorative Program form revealed no documentation to indicate sling/brace care was provided for one or more of the resident's ordered splints on 12 of 22 days between 05/01/2024 and 05/22/2024. During an interview on 05/22/2024 at 12:15 PM, Restorative Nursing Assistant (RNA) #10 stated there were three RNAs, and two worked every day. She stated the RNAs did weights on Monday and Tuesday, and if they had time at the end of the shift, then they would do range-of-motion exercises with some of the residents, but they did not apply the splints. She stated Sunday 05/19/2024 would have been the last time the resident had the splints on. She stated she did not work, but her partner would have done it. She stated she had not had a chance to apply the splints that day. During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated she did not 055042 Page 9 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apply the splints for the residents but did monitor to ensure that the splints were being put on as ordered. She stated she did not realize Resident #46's splints had not been applied the previous three days. During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) Supervisor #4 stated if a resident had orders for splints to be applied seven days a week, then the resident should have them on daily, and it they were not being applied, then the reason should be documented. She stated splints were important to prevent contractures. She stated she did not know why Resident #46's splints had not been applied. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated RNA services should be provided seven days a week if that was what was ordered. She stated if it was not being done, then the reason should be documented. She stated the use of splints was important to prevent further contractures. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated she was also the restorative nurse. She stated the proper use of splints was important for contracture management and it was an order from the physician. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated if RNA services were ordered seven days a week, then it should be provided seven days a week, and if not, then the reason should be documented. She stated splints were important to use for contracture management. She stated the RNA should have provided the treatment as ordered and should document why the splints were not on Resident #46. The DON stated they were doing a full sweep of all the RNA residents and revamping the program to make sure there was not anything that had been missed and involving the Director of Rehabilitation (DOR). She stated they started in-servicing with the RNAs and put it on their Quality Assurance Performance Improvement (QAPI) to monitor. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he thought that the RNA services were being provided. He stated they were assessing all the RNA residents to see if there had been any decline related to the services not being provided and they were doing one-on-one in-services with the RNAs. He stated they did not direct the staff to only do weights on Monday and Tuesday and were planning to revamp the Restorative system. 055042 Page 10 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication order was limited to 14 days unless there was documented rationale for the extended use and a specific duration of the order. This affected 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Resident #27 had a PRN order for Ativan (a benzodiazepine) with no stop date or documented rationale for the continued use. Findings included: A facility policy titled, Behavior/Psychoactive Drug Management, revised 11/2018, specified, Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed the 14-day time frame. An admission Record indicated the facility admitted Resident #27 on 05/01/2021. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had taken antianxiety medications during the last seven days of the assessment period. Resident #27's care plan included a focus area, revised 02/07/2024, that indicated the resident used anti-anxiety medication that included Ativan related to anxiety disorder manifested by verbal agitation and verbal outbursts. Interventions directed staff to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness every shift. The care plan indicated the resident used Ativan 0.5 milligrams (mg) with instructions to give one tablet by mouth every six hours as needed for anxiety manifested by verbal agitation and verbal outbursts. A review of Resident #27's physician orders revealed the resident received an order on 04/12/2024 for Ativan 0.5 mg with instructions to give one tablet by mouth every six hours as needed (PRN) for anxiety manifested by verbal agitation and verbal outbursts. There was no stop date to the order. A review of Resident #27's April 2024 Medication Administration Record (MAR) revealed the resident received the PRN Ativan on 04/21/2024 at 8:00 PM. A review of Resident #27's May 2024 MAR revealed the resident received the PRN Ativan twice on 05/10/2024 at 5:00 PM and 11:00 PM; and again on 05/13/2024 at 6:26 AM. A review of Resident #27's progress notes revealed no documentation of the resident being reassessed for the rationale of the ongoing use of the PRN Ativan. During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) #4 stated psychotropic medications included anxiety medications, and the resident could have a PRN order but should have a stop date of 14 days. She stated after 14 days, the resident should be reassessed to determine the ongoing 055042 Page 11 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few need for the medication. She stated she was not sure why Resident #27 did not have a stop date on their Ativan. During an interview on 05/23/2024 at 9:08 AM, Licensed Vocational Nurse (LVN) #5 stated she was the desk nurse and did admissions. She stated a resident could have a PRN order for an anti-anxiety medication with a 14-day stop date until the resident was reassessed. She stated she was unsure why Resident #27's Ativan did not have a stop date. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated a resident could have a PRN order for a psychotropic medication, but it should have a stop date. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated a resident on a PRN psychotropic medication would need to have the order renewed after 14 days, and they would need to be assessed prior to the reordering of the medication to determine the ongoing need. She stated Resident #27 did have the behaviors to warrant the use of the medication. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated there needed to be a 14-day stop date for psychotropic medications but deferred to the DON for the specifics. He stated Resident #27 may have just slipped through the cracks. 055042 Page 12 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a glucometer (device used to check blood glucose levels) was cleaned and disinfected between use to prevent the potential spread of infection for 2 (Resident #7 and Resident #26) of 4 residents observed receiving blood glucose checks. Residents Affected - Few Findings included: A facility policy titled, Cleaning & [and] Disinfection of Resident Care Equipment, revised 01/01/2012, specified, Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. The policy also indicated the following: - II. Reusable items are cleaned and disinfected or sterilized between residents. - VI. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions. Observations on 05/22/2024 at 4:12 PM revealed Licensed Vocational Nurse (LVN) #3 performed a blood glucose test on Resident #7. The LVN performed a fingerstick using a lancet and applied a droplet of Resident #7's blood to the test strip which was inserted into the glucometer. After completing the test, LVN #3 took the glucometer out of Resident #7's room and placed it on top of the medication cart without cleaning or disinfecting it. LVN #3 continued to administer medications to other residents and then at 4:19 PM, entered Resident #26's room with the same uncleaned glucometer and performed a blood glucose test on Resident #26. LVN #3 then took the machine out to the medication cart and set the machine on top of the cart without cleaning or disinfecting it. During an interview on 05/22/2024 at 4:25 PM, LVN #3 stated the glucometer should be cleaned with the germicidal wipes between each use. He stated he was nervous trying to remember everything and forgot to disinfect the glucometer after using it. During an interview on 05/23/2024 at 11:46 AM, the Infection Preventionist stated glucometers should be cleaned before and after each use with a chemical approved by the Environmental Protection Agency (EPA) and they were currently using the purple-top wipes (Sani-wipe germicidal cloths). She stated it was important to do this to prevent the possible spread of bloodborne infections. During an interview on 05/23/2024 at 8:52 PM, Registered Nurse (RN) Supervisor #4 stated the glucometer should be cleaned before and after each use with the purple-top germicidal wipes to prevent the spread of infection. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated the glucometer should be cleaned with germicidal Sani-wipes after each use. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated the glucometer should be cleaned before and after use with an EPA-approved disinfectant. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated glucometers 055042 Page 13 of 14 055042 05/23/2024 Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be cleaned before and after each use with an EPA-approved chemical that was based on the manufacturer's recommendations. She stated it was important to do this for infection control and to prevent the transmission of infections. During an interview of 05/23/2024 at 12:36 PM, the Administrator stated the glucometer should be cleaned before and after use with an EPA-approved solution or chemical. 055042 Page 14 of 14