Health inspection·September 26, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its own policy and procedure concerning the use of physical restraints when three of three Justice-Involved Residents (residents under the care of law enforcement, community supervision, in custody, held involuntarily through operation of law enforcement authorities [Residents 1, 2, and 3]) did not receive respectful and dignified treatment. This includes the right to be free from physical restraints, which was not necessary to address residents' medical conditions. The facility, instead, placed sole responsibility on the correctional officers for the application, removal, and monitoring of potential complications associated with the use of restraints.These failures had the potential to place clinically compromised residents (Resident 1, 2, and 3) at risk of serious physical injuries, including skin damage, pressure ulcers, nerve damage, and prolonged immobility. Additionally, it can also lead to serious psychological effects, such as loss of dignity, which may lead to anxiety, depression, and suicidal thoughts resulting from lack of monitoring by a trained staff, physician order, care plan, nursing assessments, and proper documentation related to the use of restraints.Findings:During an observation in Resident 1's room on September 24, 2025, at 12:10 PM, Resident 1 was observed lying on bed, restrained with metal shackles on both ankles, which were attached to the end of the bed frame. Resident 1 appeared alert and calm during the observation. The skin around the shackles was assessed and found to be intact, with no evidence of redness, blistering, discoloration, or any other skin issues that possibly are associated with the use of shackles. During this observation, two correctional officers were present at the bedside, monitoring Resident 1. During a review of Resident 1's admission Record (general demographics) on September 24, 2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis ( partial paralysis on one side of the body), heart failure (heart is not pumping blood as well as it should), and hypotension ( low blood pressure).During an observation in Resident 2's room on September 24, 2025, at 12:15 PM, Resident 2 was observed on bed in the same room as Resident 1. Resident 2 was restrained with metal shackles on both ankles, which were attached to the end of the bed frame. Additionally, a metal shackle was observed on his left wrist and was attached to one of the side rails of the bed, while two correctional officers were on bedside monitoring Resident 1 and 2.During a review of Resident 2's admission Record (general demographics) on September 24, 2025, the admission Record indicated Resident 2 was admitted on [DATE], with a diagnoses that included peripheral autonomic neuropathy (condition that affects the nerves that control involuntary body functions, such as heart rate, blood pressure, and sweating), acute kidney failure ( kidney suddenly stops working properly), and fracture of the left hand (break in one or more bones in the left hand).During an observation in Resident 3's room on September 24, 2025, at 12:26 PM, Resident 3 was observed on bed, restrained with metal shackles on both ankles that were attached to the end of the bed Residents Affected - Some Page 1 of 4 055076 055076 09/26/2025 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some frame. Additionally, a metal shackle was also observed on his left wrist and was attached to one of the side rails of the bed, while two correctional officers were watching him.During a review of Resident 3's admission Record (general demographics) on September 24, 2025, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with a diagnoses that included cellulitis ( bacterial infection that gets into the deeper layer of the skin) of the right lower limb, neuropathy (damaged nerves), and hypertension (high blood pressure).During an interview on September 24, 2025, at 1:20 PM, with a Certified Nursing Assistant (CNA 1), CNA 1 stated, the shackles were removed when the patients [residents] are taken to the restrooms and receive a bath. When asked how she repositions the residents while they are in shackles, she stated, I request the correctional officer to remove the shackles. however, she noted the shackles are not usually removed because there is enough slack for the residents to move their legs around.During an interview on September 24, 2025, at 1: 31 PM, with Certified Nursing Assistant (CNA) 2. CNA 2 confirmed that she is assigned to the three residents who are in shackles. CNA 2 stated she requested the correctional officers to remove the shackles for Resident 1 and Resident 2 when they went to the toilet and when they took a shower. For Resident 3, CNA 2 stated she did not release the shackles throughout her shift, as he had not gone to the bathroom yet. When CNA 2 was asked if she had checked the wrists and ankles of Resident 1, Resident 2, and Resident 3 for bruises, CNA 2 mentioned she only observed briefly while she performed activities of daily living (ADL - basic tasks that residents perform to maintain their personal care).During an interview on September 24, 2025, at 1:50 PM, with the Activity Director (Director), Director stated, .The inmates do not participate with the activities of other residents, they are only given magazines, reading materials about people, nature or any topics they are interested in. The director confirmed the residents never leave their rooms except for showers and physical therapy sessions.During an interview on September 24, 2025, at 1:59 PM, with Licensed Vocational Nurse (LVN), LVN stated, the only time these shackles are removed is when the inmates go to the toilet or bathroom. The facility is a non- restraint facility, and the staff are not trained in the use of restraints. Furthermore, the staff indicated he does not visually check the resident's wrists and ankles. He also stated that the facility does not classify shackles as a means of restraint, and there is no official order for restraint as it is not part of the physician's orders.During a concurrent interview and record review on September 24, 2025, at 2:15 PM, with the Registered Nurse supervisor (RN supervisor), the medical records for Residents 1, 2, and 3 have no documentation of the following:a. no physician's order for the use of restraints.b. no care plan in place for restraints.c. no assessment conducted regarding the use of restraints; nor restraint was coded on Minimum Data Set (MDS-a standardized assessment tool used collect information about residents' health, functional abilities, and psychosocial status).d. no nursing progress notes documenting the placement and removal of the restraint; ande. no assessment of skin integrity associated with the use of restraints.These findings were verified by the RN supervisor, who stated that the facility is a no-restraint facility. The three residents, under the supervision of correctional officers admitted to the facility in shackles; however, the facility does not consider those shackles to be restraints.During an interview on September 24, 2025, at 2:59 PM, with the Director of Staff Developer (DSD), the DSD stated, This is a no restraint facility, we don't have residents on restraints, federal guards are the ones releasing the shackles when the staff requested during patient [resident] care like when they go to shower. The DSD further stated the staff are not trained in the use of restraints.During an interview on September 24, 2025, at 3:10 PM, with Resident 3, he stated, I do not go out, they only give me magazines to read. The resident stated his shackles are only released when he goes to the bathroom and toilet and when he does 055076 Page 2 of 4 055076 09/26/2025 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some physical therapy training in the evening at least once a day.During an interview on September 24, 2025, at 3:39 PM, Resident 1 confirmed he does not participate in any activity, and his shackles are only released during toileting, showers, and physical therapy training. Resident 1 also stated that PT training is conducted in his room in the evening at least once a day.During an interview on September 24, 2025, at 3:44 PM, Resident 2 confirmed his shackles are only released when he goes to the bathroom, showers and does physical therapy training at least once a day, for a few minutes in the evening. Resident 2 also stated he does not participate in any activities. During a concurrent interview and record review on September 24, 2025, at 4:45 PM, with the administrator and the DSD, the facility's policy and procedure (P&P) titled, Use of Restraints, dated October 2022, was reviewed. The P&P defined physical restraints, . as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The P&P also states, Prior to placing a resident in restraints, there shall be a pre-restraining assessment, . The P&P further states, Restraints shall only be used upon the written order of a physician. Also, the P&P mandates, A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel, When asked if this P&P was being followed, the administrator responded, The residents came with restraints, citing that they are inmates under the custody of correctional officers.During an interview on September 24, 2025, at 3:48 PM, with the Correction Officer (Officer), the Officer stated, inmates does not go out from their rooms, and the staff does not released shackles. Officer confirmed that they are with the residents twenty-four (24) hours a day, and they have to be on shackles per their policy.On September 24, 2025, at 5:00 PM, an immediate jeopardy (IJ- a situation that has threatened or was likely to threaten the health and safety of a resident) situation was called in the presence of the Administrator and the DSD for noncompliance related to the use of physical restraints, resulting in Residents 1, 2, and 3 being denied the right to be treated with respect and dignity. The Administrator and the DSD were verbally notified of the IJ situation.A corrective action plan (CAP) was requested following the implementation of IJ.On September 26, 2025, at 1:30 PM, an IJ Removal Plan was provided by the facility, which included:Upon notification, the facility initiated the following actions:1. What corrective action will be accomplished for those patients found to have been affected by the deficient practice?- Residents identified as affected by the deficient practice involving the use of physical restraints were discharged in coordination with the Federal Correctional Complex (FCC) Victorville and attending physician and transferred to [NAME] Valley Global Medical Center. The attending physician declined to issue orders for the continued use of restraints.Residents affected by the deficient practice will be discharged in coordination with FCC as follows:o. Room # 9A Resident 1 on 9/25/25 to [Name of the hospital].o. Room # 9C Resident 2 on 9/25/25 to [Name of the hospital].o. Room # 16C Resident 3 on 9/25/25 to [Name of the hospital]. 2. How will the facility identify other patients having the potential to be affected by the same deficient practice?- A comprehensive review of records for 107 residents was completed. In addition, direct observations were conducted across all shifts by charge nurses and Registered Nurses. Alert residents were interviewed by staff. No additional residents were found to be affected by the deficient practice.- On 09/24/25 around 5:00 PM on-going in-service training was provided by Director of Staff Development with an emphasis on the distinction between medical and correctional restraints.3. What measures will be put into place or what systemic changes will be made to ensure the deficient practice does not recur?- To prevent recurrence of the deficient practice related to physical restraints, the facility has implemented the following systemic changes:o Resident's requiring physical restraints will be 055076 Page 3 of 4 055076 09/26/2025 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some observed for 72 hours, during which non-pharmacological interventions will be attempted in collaboration with Activities, Social Services, Nursing, and Rehab.o Physicians and family members will be notified, and nursing staff will follow up on all physician orders.o Social Services, in coordination with the interdisciplinary team (IDT), will provide information regarding the resident's behavior and the effectiveness of the treatment plan to the resident and, as appropriate, to the family or responsible party.o Licensed nurses will conduct weekly skin integrity checks and document daily progress notes. Any concerns will be escalated to the Primary Care Provider (PCP) and family.o Residents will be repositioned per facility protocol. 9/26/2026? Monthly psychosocial-emotional assessments will be conducted by Social Services, with documentation of observations, interviews, and reviews involving residents, families, and staff.4. How will the facility monitor its corrective actions to ensure ongoing compliance?Recapitulation of findings will be presented and reported by the Director of Nursing (DON) or designee to the Quality Assessment and Assurance Committee on a monthly basis for three months, or until 100% compliance has been sustained. The Committee will review the findings and take action as indicated.The facility will not admit justice-involved individuals until it has confirmed substantial compliance with all applicable statutes and regulations governing the care of justice-involved individuals. This includes alignment with the authorities outlined in

F604.The safety and security of all residents remain the facility's highest priority. This corrective action plan directly addresses the Immediate Jeopardy finding by implementing the immediate measures outlined above.The IJ was removed on September 26, 2025, at 3:44 PM, in the presence of the Administrator and Meridian Management Representative after onsite observation, interview, and record review verified the facility's implementation of the corrective action plan. 055076 Page 4 of 4