Health inspection·November 21, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and facility policy review, the facility failed to update their abuse policy and procedure related to 1 of the 7 components of abuse prohibition. Specifically, the facility policy did not reflect the reporting of all allegations of abuse within the mandated timeframe of immediately, but not later than 2 hours after the allegation was made. Residents Affected - Few Findings included: A facility policy titled, Policy and Procedure on Patient Abuse and Prevention, with an effective date of 10/2014, indicated, VII. Reporting, Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. a) Facility administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. b) Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. c) The Administrator and Director of Nurses, in the order written shall report incidents of suspected abuse to the following agencies within twenty-four (24) hours of occurrence: - Department of Health-Licensing and Certification - LTC [long-term care] Ombudsman or designee or - Local enforcement agency or Police Department - Managing Physician for treatment orders as required - Family Members/Responsible Parties or Guardians. During an interview on 11/21/2024 at 3:36 PM, the Administrator stated the abuse policy was the one the facility had when he became the administrator in 07/2023. The Administrator stated that according to the facility abuse policy, the facility had 24 hours to report any allegation of abuse unless it involved serious bodily injury. Page 1 of 9 055076 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, record review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #27) of 1 sampled resident reviewed for abuse. Residents Affected - Few Findings included: A facility policy titled, Policy and Procedure on Patient Abuse and Prevention, with an effective date of 10/2014, indicated, 2. Verbal Abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy specified, VII. Reporting, Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. a) Facility administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. b) Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. c) The Administrator and Director of Nurses, in the order written shall report incidents of suspected abuse to the following agencies within twenty-four (24) hours of occurrence: - Department of Health-Licensing and Certification - LTC [long-term care] Ombudsman or designee or - Local enforcement agency or Police Department - Managing Physician for treatment orders as required - Family Members/Responsible Parties or Guardians. According to the policy, VII. Abuse Prevention Coordinator. The facility Administrator is the duly appointed Abuse Prevention Coordinator. In the absence of the Administrator, the designated alternate or Assistance Administrator, if any, will take over the responsibilities. An admission Record indicated the facility admitted Resident #27 on 12/07/2018. According to the admission Record, the resident had a medical history that included diagnoses of morbid obesity, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, muscle weakness, and chronic combined systolic and diastolic heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 11/18/2024 at 9:20 AM, Resident #27 stated the certified nursing assistants (CNAs) did not provider them a shower because of their weight. According to Resident #27, CNA #8 told them that staff could not do their shower because the staff had lives and homes to get back to, that their weight placed the staff in danger, and if the staff gave them a shower and got hurt, the CNAs could sue them Resident #27 reported CNA #8 had not worked with them lately and they had been getting their showers recently. On 11/18/2024 at 9:40 AM, the surveyor reported the allegation of abuse to the Administrator and the Director of Nursing Services. During an interview on 11/21/2024 at 3:03 PM, the Administrator stated he reported the allegation 055076 Page 2 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0609 of abuse to the state agency on 11/18/2024 at 4:00 PM. The Administrator stated since there was no physical harm, the allegation only needed to be reported within 24 hours and not 2 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055076 Page 3 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm 2. An admission Record revealed the facility admitted Resident #34 on 09/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of mood disorder and psychosis not due to a substance or known physiological condition. Residents Affected - Some The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include psychotic disorder. Resident #34's Resident Care Plan titled Psychosis included a problem/concern area, dated 09/22/2024, that indicated the resident was at risk for increasing confusion and disordered thoughts secondary to a diagnosis of psychosis. Resident #34's Order Summary Report, which contained active orders as of 11/20/2024, revealed an order dated 09/11/2024, for Seroquel oral tablet 100 milligrams, give one tablet by mouth one time a day for psychosis. Resident #34's Preadmission Screening and Resident Review Level I Screening dated 09/11/2024, revealed the resident did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. During an interview on 11/20/2024 at 10:50 AM, the MDS/Resident Coordinator stated she was not responsible for ensuring the accuracy of a resident's PASARR. The MDS/Resident Coordinator stated she did not know why Resident #34's diagnosis of psychosis was not captured on the PASARR Level I Screening dated 09/11/2024. Based on record review, interview, and facility policy review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 2 (Resident #34 and Resident #74) of 3 sampled residents reviewed for PASARRs. Findings included: A facility policy titled, Pre-admission Screening and Resident Review (PASARR), revised 12/2006, indicated All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process. Policy Interpretation and Implementation 1. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD, unless the individual was admitted directly to the facility from a hospital where he or she received acute impatient care and a Level I PASARR had already been completed and submitted. 1. An admission Record indicated the facility admitted Resident #74 on 11/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, unspecified psychosis due to a known substance or physiological condition, impulse disorder, mood disorder due to known physiological condition, depressive episodes, and anxiety disorder 055076 Page 4 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #74's Resident Care Plan, titled Psychosis revealed the resident had behavioral episodes of verbal outburst and a long history of psychosis and dementia with psychotic features. Resident #74's Preadmission Screening and Resident Review Level I Screening dated 11/04/2024, revealed the resident did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. During an interview on 11/20/2024 at 10:49 AM, the Minimum Data Set/Resident Coordinator stated the Director of Nursing Services (DNS) reviewed a resident's PASARR for accuracy. During an interview on 11/21/2024 at 8:51 AM, the DNS stated Resident #74 had a diagnosis of schizophrenia and the resident's diagnosis should have been listed on the PASARR. During an interview on 11/21/2024 at 11:18 AM, the Administrator stated Resident #74's PASARR should have been checked for accuracy. 055076 Page 5 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, record review, facility policy review, the facility failed to develop a care plan to address a resident's right hand contracture for 1 (Resident #185) of 1 sampled resident reviewed for limited range of motion. Findings included: A facility policy titled Care Plan with the effective date of 10/2014 revealed, Policy. Consistent with the facility's policy of providing appropriate care & services to residents admitted to the facility, the facility shall ensure development of a comprehensive care plan for each resident to meet his/her medical, nursing, and mental and psychological needs as identified in the comprehensive assessment. 2. Goals for plan of care should be measurable, achievable/attainable and resident centered. The policy specified, 7. Care Plan should be oriented to prevention of avoidable declines in functioning or functioning levels. An admission Record revealed the facility admitted Resident #185 on 10/21/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominate side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #185 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS revealed the resident had a range of motion limitation on side in both their upper and lower extremities. Resident #185's medical record revealed no evidence to indicate a care plan had been developed to address the resident's right hand contracture. During an observation on 11/18/2024 at 11:21 AM, Resident #185 was noted to have a right hand contracture. During an observation on 11/19/2024 at 12:37 PM, Resident #185 was noted to have a right hand contracture. During an interview on 11/20/2024 at 10:52 AM, Licensed Vocational Nurse #25 stated Resident #185 had a contracture of their right hand. During an interview on 11/21/2024 at 3:03 PM, the MDS/Resident Coordinator stated she completed residents' care plans with Director of Nursing Services. The MDS/Resident Coordinator confirmed Resident #185 did not have a care plan to address their right hand contracture. During an interview on 11/21/2024 at 3:11 PM, the Administrator stated a resident's care plan should include the resident's limited range of motion. 055076 Page 6 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

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 implement services for the treatment of a right hand contracture for 1 (Resident #185) of 1 sampled resident reviewed for limited range of motion. Findings included: A facility policy titled, Range of Motion, dated 10/2015, revealed, Residents need movement in order to prevent decreased functioning. Hence, it is vital that nursing assistances recognize the role they play in aiding the resident to maintain an or achieve as much movement as is possible relative to physical & medical conditions. An admission Record revealed the facility admitted Resident #185 on 10/21/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominate side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #185 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS revealed the resident had a range of motion limitation on side in both their upper and lower extremities. Resident #185's medical record revealed no evidence to indicate a care plan had been developed to address the resident's right hand contracture. During an observation on 11/18/2024 at 11:21 AM, Resident #185 was noted to have a right hand contracture and no use of a splint or hand towel was present. During an observation on 11/19/2024 at 12:37 PM, Resident #185 was noted to have a right hand contracture. During an observation on 11/20/2024 at 7:51 AM, Resident #185 was observed in bed. The resident was noted to have a right hand contracture and no splint or hand towel was present. During an interview on 11/20/2024 at 10:42 AM, Registered Nurse #24 stated there was a not a splint or hand roll in place that she knew of for Resident #185. During an interview on 11/02/2024 at 11:01 AM, Certified Nursing Assistant (CNA) #26 stated Resident #185's right hand was contracted and usually there was towel placed between the resident's fingers and hand. CNA #26 confirmed the hand roll or towel was not in place for the resident on 11/02/2024. During an interview on 11/21/2024 at 11:48 AM, the Administrator stated the expectation was that range of motion be provided based on the resident's assessment. Per the Administrator, a hand roll would be a measure to prevent infection and contractures. 055076 Page 7 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) before they entered the room of a resident who was on contact isolation and failed to ensure staff cleaned a multi-use glucometer after use before it was placed back on the medication cart for 1 (Resident #75) of 3 sampled residents reviewed for infection control. Residents Affected - Few Findings included: A facility policy titled, Infection Control- Transmission- Based Precautions, revised 10/2019, indicated Contact precautions are intended to prevent transmission of infections that are spread by direct (person-to-person) or indirect contact with the resident, or environment, and require the use of appropriate PPE including a gown and gloves upon entering the resident's room or cubicle. The PPE should be removed, and hand hygiene performed before leaving the residents room or cubicle. A facility policy titled, Blood Glucose Meter Calibration and Care, effective 10/2014, indicated Glucometer shall be sanitized in between patient use with any sterilizer per manufacturer's recommendation. The User Instruction Manual for the blood glucose monitoring system (glucometer) revealed, We suggest cleaning and disinfecting the meter between patient [resident] use. The manual specified, Cleaning and disinfecting can be completed by using a commercially available EPA [Environmental Protection Agency]-registered disinfectant detergent or germicide wipe. An admission Record indicated the facility admitted Resident #75 on 07/07/2021. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with foot ulcer and acute osteomyelitis of the right ankle and foot. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had a surgical wound and received insulin injections. On 11/19/2024 at 11;35 AM, Licensed Vocational Nurse (LVN) #6 entered the room of Resident #75 to check the resident's blood sugar. A sign posted on the resident's door indicated the resident was on contact isolation and those who entered the room must wear a gown and gloves. LVN #6 entered the room without application of a gown or gloves. LVN #6 stated he did not need to wear PPE because he was not going to touch the resident. Once LVN #6 pricked the finger of Resident #75 to obtain blood with a multi-use glucometer, LVN #6 placed the glucometer in the top drawer of the medication cart, without sanitizing the glucometer. During an interview on 11/19/2024 at 11:51 AM, LVN #6 stated he was taught to sanitize the glucometer after use. LVN #6 acknowledged the glucometer used was a multi-use glucometer. LVN #6 stated he did not clean the glucometer after it was used because he did not have any disinfectant wipes on the medication cart. LVN #6 commented that if he was at a safe distance from the resident and did not provide physical contact, he did not need to apply PPE to enter the resident's room, even if the resident was on contact isolation. 055076 Page 8 of 9 055076 11/21/2024 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/19/2024 at 1:36 PM, the Infection Preventionist (IP) stated staff were to always wear a gown and gloves when they entered a room of resident on contact precautions. During a follow-up interview on 11/21/2024 at 8:18 AM, the IP stated Resident #75 was on contact precautions for methicillin resistant staphylococcus aureus (MRSA), and all staff were to wear a gown and gloves when they entered the resident's room, regardless of the activity to be completed. The IP stated glucometers were to be cleaned after each use. During an interview on 11/21/2024 at 8:51 AM, the Director of Nursing Services (DNS) stated Resident #75 was on contact precautions for MRSA in a wound, and staff were to put on a gown and gloves when they entered the resident's room. The DNS stated LVN #6 should clean the glucometer after use. During an interview on 11/21/2024 at 11:18 AM, the Administrator staff were expected staff to wear a gown and gloves when they entered Resident #75's side of the room, and blood glucose meters were to be cleaned after each use. 055076 Page 9 of 9