Health inspection·January 16, 2025

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Significant Change of Status Assessments (SCSA- comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline) Minimum Data Set (MDS- a computerized assessment instrument) were completed within 14 days for one of two residents (Resident 5) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.). Residents Affected - Few This failure resulted on Resident 5's care plan not being updated and revised to reflect her current status, and had the potential to delay identification and implementation of the resident's care and support needs. Findings: During a review of Resident 5's admission Record (a document that contains demographic and clinical data), it indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease (condition that affects the blood vessels in the brain, lead to stroke) and atherosclerosis heart disease (condition where the blood vessels clogged, and lead to heart attacks or strokes). During a concurrent interview and record review, on January 16, 2025, at 10:10 AM, with the Minimum Data Set Nurse 1 (MDS Nurse 1), the MDS Nurse 1 reviewed and acknowledged Resident 5's physician's order, dated May 24, 2024, which indicated . Admit to [Name of the Hospice Company] Hospice on routine level of care . During a follow-up concurrent interview and record review, on January 16, 2025, at 10:15 AM, with the MDS Nurse 1, the MDS Nurse 1 reviewed Resident 5's clinical record, which indicated the SCSA assessment was not completed 14 days after hospice admission. The MDS Nurse 1 stated, The SCSA MDS assessment should have been completed on June 6, 2024, and we missed it. (Six months and 11 days past due). During a concurrent interview and record review, on January 16, 2025, at 10:15 AM, with the MDS Nurse 1, the MDS Nurse 1 reviewed the facility's policy and procedure titled Change in Resident's Condition or Status revised May 20, 2017, which indicated .2. A significant assessment is major decline or improvement in resident status that will: a. Will not normally resolve itself without intervention . c. requires interdisciplinary review and/or revision of the care plan .9. If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of the resident's Page 1 of 16 055183 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition will be conducted as required by current OBRA [is a federal law that establishes regulations for nursing facilities] regulation governing resident assessment and as MDS RAI [Resident Assessment Instrument] instruction manual . The MDS Nurse 1 stated the facility did not follow the policy. Instrument, this manual provides guidelines and definitions for completing MDS assessment) manual, dated October 2024, it indicated .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing . 055183 Page 2 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on January 13, 2025, at 2:48 PM, in Resident 19's room, Resident 19 was lying in bed, watching television. Resident 19 stated she had no concerns with her care. Residents Affected - Few During a review of Resident 19's admission Record, it indicated Resident 19 was admitted to the facility with the diagnoses of other mechanical complication of other internal orthopedic devices, implants, and grafts (issues that arise due to complications on an internal orthopedic implant), generalized muscle weakness (decreased strength or weakness in most of muscles), and osteomyelitis (OM- bone infection). During a review of Resident 19's Physician's Order, dated October 16, 2024, it indicated Bactrim (antibiotic medication) DS (Double Strenght) Oral Tablet 800 - 160 MG (milligram-unit of measurement) Give 1 tablet by mouth in the morning for Chronic LLE (left lower leg) hardware/OM infection for 52 weeks. During a review of Resident 19's Infection Note, dated December 18, 2024, it indicated .per dr (doctor) . resident is to continue current antibiotic regime and continue to follow infectious disease MD's (Medical Doctor) directives without a time out (scheduled review of the patient antibiotic treatment) at this time . During a review of Resident 19's MDS - Section N: Medications, dated January 1, 2025, it indicated Resident 19 did not receive any antibiotics. During a review of Resident 19's MAR for the month of December 2024, it indicated Resident 19 received her antibiotic medications everyday for the whole month. During a concurrent interview and record review, on January 15, 2025, at 2:12 PM, with the MDS Nurse 1, the MDS Nurse 1 reviewed Resident 19's MAR for the month of December 2024 and MDS- Section N dated January 1, 2025, and stated Resident 19's MDS was not coded correctly. The MDS Nurse 1 further it was her mistake. During a concurrent interview and record review, on January 16, 2025, at 2:26 PM, with the DON, the DON reviewed the facility's P&P titled, Certifying Accuracy of the Resident Assessment revised on November 2019, which indicated . Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion . 3. The information captured on the assessment reflects the status of the resident during the observation (look back) period for that assessment . The DON stated the P&P was not followed. During a review of the CMS RAI manual, dated October 2024, it indicated, .The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for two of two 055183 Page 3 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0641 Level of Harm - Minimal harm or potential for actual harm residents (Residents 9 and 19) reviewed for insulin (hormone that helps the body use sugar and starches for energy or store them for later use) and antibiotic (medication used to treat bacterial infections) use when: 1. Resident 9's insulin injections were not coded on the MDS assessment. Residents Affected - Few 2. Resident 19's antibiotic therapy was not coded on the MDS assessment. These failures had the potential to cause inaccuracy in identifying Residents 9 and 19's care and support needs. Findings: 1. During a review of Resident 9's admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses of Type 2 diabetes mellitus (when the body has trouble using insulin properly, causing high blood sugar levels.), and long term use of insulin. During a review of Resident 9's Physician's Orders, dated July 12, 2023, it indicated . Humalog injection solution (insulin Lispro- type of insulin) 100 unit/mL (units of insulin in each milliliter of the liquid) inject as per sliding scale (: if 70 - 150 = 0 UNITS;151 - 200 = 2 UNITS; 201 - 250 = 4 UNITS; 251 - 300 = 6 UNITS; 301 - 350 = 8 UNITS; 351 - 400 = 10 UNITS; 401 - 450 = 12 UNITS, subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus without complications .IF OVER 400 GIVE 12 UNITS AND CALL MD .-Start Date 08/01/2024 (August 1, 2024) 0600 (6 AM) . During a concurrent interview and record review, on January 14, 2025, at 10:12 AM, with the MDS Nurse 2, the MDS Nurse 2 reviewed and acknowledged Resident 9's Medication Administration Record (MAR) for the month of October 2024, which indicated Resident 9 has received insulin injections on October 1, 2024, October 3, 2024, October 4, 2024, October 5, 2024, October 6, 2024, and October 7, 2024. (A total of 6 days from October 1, 2024 through October 7, 2024.) During further interview and record review, on January 14, 2025, at 10:18 AM, with the MDS Nurse 2, the MDS Nurse 2 reviewed and acknowledged Resident 9's MDS Section N - Medications dated October 7, 2024, which indicated Resident 9 did not receive any insulin injection from the seven day look back period (October 1, 2024 through October 7, 2024). The MDS Nurse 2 stated the MDS Assessment was inaccurately coded and further stated it should have reflected the six days of insulin use. During a concurrent interview and record review on January 16, 2025, at 8:20 AM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment dated November 2019, which indicated 2. Any person who completes any portion of the MDS assessment, tracking form or correction request form is required to sign the assessment certifying the accuracy of the portion of that assessment . The DON stated the policy was not followed. During a concurrent interview and record review, on January 16, 2025, at 9:38 AM, with the MDS Nurse 2, Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2024, which indicated, .The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) 055183 Page 4 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0641 Level of Harm - Minimal harm or potential for actual harm that any type of injection, insulin, and/or select medications were received by the resident . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . The MDS Nurse 2 stated that the RAI Manual guidelines were not followed. Residents Affected - Few 055183 Page 5 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

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, and record review, the facility failed to ensure a physician's order was carried out timely for one of two residents (Resident 62) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care) when Resident 62's order for a Speech Therapy (STassessment and treatment of communication problems and speech disorders) evaluation was not communicated with the hospice provider. Residents Affected - Few This failure had the potential to place Resident 62 at risk for aspiration (when food, liquid, or other material is accidentally inhaled into the lungs), weight loss and further nutritional decline. Findings: During an observation on January 13, 2025, at 8:29 AM, outside of Resident 62's room, Resident 62 was yelling out nonsensically. During a review of Resident 62's admission Record (contains demographic and medical information), it indicated Resident 62 was admitted to the facility with the diagnoses of cerebral atherosclerosis (disease that occurs when fatty plaque builds up in the arteries of the brain), unspecified dementia (group of brain diseases that cause a decline in thinking, memory, and reasoning skills), and encounter for palliative care (specialized care aimed at improving the quality of life for patients with serious illnesses). During a review of Resident 62's Minimum Data Set [MDS- a computerized assessment instrument] Section C - Cognitive Patterns, dated October 30, 2024, it indicated a Brief Interview for Mental Status (BIMS - test used to screen cognitive impairment in long term care facilities) score of 6, indicating severe cognitive impairment (medical term referring to problems with thinking, learning, remembering, and making decisions). During a review of Resident 62's Nutrition/Dietary Note dated November 22, 2024, it indicated .per IDT (Interdisciplinary Team- a team mixed of different professions who come together to make recommendations for patient care), pt (patient) had difficulty chewing meats, however pt reported being able to chew normally. Will refer to ST for precaution . RECS: (recommendations) . 3) ST eval d/t [due to] difficulty chewing. During a review of Resident 62's Physician's Order dated November 23, 2024, it indicated ST eval (evaluation) d/t difficulty chewing. During a review of Resident 62's Nurses Note dated November 23, 2024, it indicated Carried out RD (Registered Dietician) recommendations as follows: . 2. ST eval d/t difficulty chewing. Orders noted and carried out . MD (Medical Doctor) and resident made aware. During a concurrent interview and record review, on January 15, 2025, at 10:07 AM, with the Director of Nursing (DON), the DON reviewed Resident 62's clinical record and was not able to find documentation of Resident 62's ST evaluation. The DON stated the Registered Nurse from the registry (independent contractors hired through a third party) was the one who carried out Resident 62's physician's order and the nurse did not communicate with the facility nor with Resident 62's hospice provider. 055183 Page 6 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on January 16, 2025, at 2:20 PM, with the DON, the DON reviewed the facility's policy and procedure (P&P) titled, Hospice Program revised on July 2017, which indicated . 10. In general, it is the responsibility of the facility to meet the president's personal care and nursing in needs in coordination with the hospice representative . c. Notifying the hospice about the following: . (2) clinical complications that suggest a need to alter the plan of care . d. communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day . The DON stated the P&P was not followed. 055183 Page 7 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary care and services to ensure activities of daily living were being provided for two of four residents (Residents 44 and 54) reviewed for position and mobility when: 1. Resident 44's Restorative Nursing Program (RNP- planned healthcare approach within long-term care facilities that aims to help residents maintain or regain their independence by providing targeted interventions to improve their functional abilities) recommendation from the Physical Therapist (PThealthcare provider who helps you improve how your body performs physical movements) was not implemented. 2. Resident 54's RNP recommendation from the PT and Occupational Therapist (OT- healthcare provider who helps you improve your ability to perform daily tasks) were not implemented. These failures had the potential to delay the continuity of care for Residents 44 and 54, which could prevent them from maintaining or improving the activities of daily living. Findings: 1. During a concurrent observation and interview on January 13, 2025, at 11:55 AM, in Resident 44's room, Resident 44 was lying on her bed. She stated she has not been working with anyone on walking or exercises. During a review of Resident 44's admission Record (contains demographic and medical information), it indicated Resident 44 was admitted to the facility on [DATE], with diagnoses which included muscle (a part of your body that helps you move by stretching and contracting) weakness and difficulty of walking. During a review of Resident 44's PT Discharge summary, dated [DATE], it indicated . discharged status and recommendation . Prognosis to maintain CLOF [Current Level of Function] = Good with consistent staff follow through . discharged recommendations: RNP . ambulation [walk] w/ [with] fww [front wheel walker (a type of walker with wheels in the front to help people walk more easily)] During a concurrent interview and record review, with the Director of Nursing (DON), on January 15, 2025, at 10:30 AM, the DON reviewed Resident 44's clinical records, and was not able to find documented evidence to indicate the PT's recommendation for RNP had been implemented for Resident 44. The DON stated I was not aware of the PT recommendation. The DON further stated the recommendation was not communicated to the nursing department, hence it was not followed up and implemented. During a follow up interview and concurrent record review with the Director of Rehabilitation (DOR), on January 15, 2025, at 2:15 PM, the DOR reviewed Resident 44's clinical records and confirmed the PT had recommended ambulation with a front wheel walker for Resident 44. The DOR stated she had just learned about the recommendation (seven months and thirteen days after it was made). The DOR further explained there should have been communication between the nursing and rehabilitation departments regarding this recommendation, but there was not. 055183 Page 8 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During a concurrent observation and interview, on January 14, 2025, at 9:55 AM, in Resident 54's room, Resident 54 was lying on his geriatric chair (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility). He stated that he has not been working with anyone on any exercises. During a review of Resident 54's admission Record, it indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included contracture (a condition where muscles or joints become tight and stiff, making it hard to move them) of muscle and muscle weakness. During a review of Resident 54's PT Discharge summary, dated [DATE], it indicated . discharged status and recommendation . Prognosis to maintain CLOF = Good with consistent staff follow through . discharged recommendations: RNP . ROM (Range of Motion- type of exercise that helps you move your joints as far as they can go, like stretching or bending your arm or leg) . During a review of Resident 54's OT Discharge summary dated [DATE], it indicated . discharged status and recommendation . Prognosis to maintain CLOF = Good with consistent staff follow through . discharged recommendations: d/c [discharged ] to nsg [nursing] care . ROM to BUE [bilateral (both) upper extremities] as tolerated. During a concurrent interview and record review, with the DON, on January 15, 2025, at 10:45 AM, the DON reviewed Resident 54's clinical records, and was not able to find documented evidence to indicate the PT's and OT's recommendations had been implemented for Resident 54. The DON stated, I was not aware of the PT and OT recommendation. The DON further stated the recommendation was not communicated to the nursing department, hence it was not followed up and implemented. During a follow up interview and concurrent record review with the DOR, on January 15, 2025, at 2:40 PM, the DOR reviewed Resident 54's clinical records and confirmed that PT had recommended ROM and OT had recommended ROM to BUE for Resident 54. The DOR stated she had just learned about the recommendation. The DOR further explained that there should have been communication between the nursing and rehabilitation departments regarding this recommendation, but there was not. During a concurrent interview and record review, with the DOR, on January 15, 2025, at 3:05 PM, the DOR reviewed the facility's policy and procedures titled Restorative Nursing Services, revised on July 2017, which indicated, Policy Statement Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care . The DOR stated the facility policy was not followed. 055183 Page 9 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen therapy (administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of decreased perfusion of oxygen to the tissues) was obtained for one of three residents (Resident 33) reviewed for oxygen. Residents Affected - Few This failure had the potential for Resident 33 to develop oxygen toxicity (conditions that occurs when someone breaths too much oxygen, damaging lungs and potential for death) from the lack of monitoring from a physician. Findings: During a review of Resident 33's admission Record, it indicated Resident 33 was admitted to the facility with the diagnoses of dementia (medical condition that causes a person to lose ability to think, remember, and reason), retropharyngeal and parapharyngeal abscess (severe infection in the neck that involve a collection of pus in the deep neck spaces), and shortness of breath (difficulty breathing). During an observation on January 13, 2025, at 10:11 AM, in Resident 33's room, Resident 33 was lying in bed, talking nonchalantly to the wall. Resident 33 was wearing nasal cannula tubing (a flexible plastic tube that delivers oxygen through small tubes that sit in the nose) attached to an oxygen concentrator, which was running at 2 liters per minute (amount of oxygen given to a patient). During an interview and concurrent record review, on January 13, 2025, at 2:41 PM, with the Director of Nursing (DON), the DON reviewed Resident 33's clinical record and was unable to find a physician's order for Resident 33's oxygen therapy. The DON stated there should have been an order. During a concurrent interview and record review, on January 13, 2025, at 3:48 PM, with the DON, the DON reviewed the facility's policy and procedure (P&P) titled, Oxygen Administration revised on October 2010, which indicated, . Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order . for oxygen therapy . The DON stated the P&P was not followed. 055183 Page 10 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner as required by the facility's policy. Residents Affected - Many This failure posed potential risk for contamination of ice, which could lead to foodborne illness (food poisoning, is a sickness caused by eating food or drinking water that is contaminated with harmful bacteria, viruses, parasites, or chemicals.) and negatively impact the health and safety of 96 of 96 vulnerable residents who received food and beverages from the kitchen. Findings: During a concurrent observation and interview, on January 14, 2025, at 8:20 AM, with the Dietary Services Supervisor (DSS), in the kitchen, the ice machine was inspected. The ice scoop was found resting inside an uncovered blue container located near the ice machine. The DSS stated the ice scoop must always be stored in a clean, covered container to ensure safety and prevent contamination. During a concurrent observation and interview on January 14, 2025, at 8:30 AM, in the kitchen, with the Maintenance Director, (MD-1), the MD-1 stated, It's not my job to place the ice scoop back properly. The MD-1 acknowledged the ice scoop should have been stored on the side of the ice machine in a covered container. During a concurrent interview and record review, on January 16, 2025, at 8:55 AM, with the MD-1, the MD-1 reviewed the facility's policy and procedure (P&P) titled, Ice Machines and Ice Storage Chest dated January 2012, which indicted 1. Ice-making machines, ice storage chest/containers, and ice call all become contaminated by: a. Unsanitary manipulation by employees .2. To help prevent contamination of ice machines, ice storage chest/containers or ice, staff shall follow these precautions .e. keep the ice scoop/bin in a covered container when not in use ., clean and sanitize the tray and ice scoop daily . The MD-1 acknowledged the policy was not followed. During an interview with the Infection Control Prevention Nurse (ICP Nurse), on January 16, 2025, at 9:32 AM, the ICP Nurse stated the ice scoop placement did not follow the protocol. She further stated it should be placed in a designated area and covered with a lid because leaving it uncovered can lead to contamination. The IP Nurse further stated ice was considered a food item, and for infection control purposes, it must be protected with a lid to prevent contamination. 055183 Page 11 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure their professional staff maintained an active and current license (legal permit that allows a person to practice nursing) when a Licensed Vocational Nurse (LVN 2) worked with an expired license on [DATE], through [DATE]. Residents Affected - Few This failure had the potential to place 101 highly vulnerable residents whose health conditions are already compromised at risk of receiving care from an unqualified nurse with an expired license, which could have affected and altered their health and well-being. Findings: During a review of a facility provided document titled Board of Vocational Nursing and Psychiatric Technicians Licensing Details dated [DATE], it indicated LVN 2 nursing license was delinquent (license that is not renewed within the allotted timeframe). During a concurrent interview and record review on [DATE], at 1:32 PM, with the Director of Nursing (DON), the DON reviewed and acknowledged a facility document titled Nursing Staff Assignment and Sign-in Sheet dated [DATE] through [DATE], which indicated LVN 2 worked throughout those dates. During a follow up interview with the DON, on [DATE], at 1:46 PM, the DON stated it was her responsibility to check on the nurses' licenses. The DON further stated she checked LVN 2's license last [DATE], and it was still active. The DON stated she checks nurses' licenses monthly to see if it was active, but she did not check for the expiration dates. During a concurrent interview and record review, on [DATE], at 1:57 PM, with the DON, the DON reviewed an undated facility document titled Patient Care Supervisor - LVN Job Description which indicated, . E. Qualifications: Current nursing licensure in the state of California required. The DON stated the job description was not followed. The DON further stated LVN 2 should not have worked from [DATE] through 5, 2025. 055183 Page 12 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were being followed for six of 25 sampled residents (Residents 44, 33, 65, 4, 484 and 47) when: Residents Affected - Many 1. Resident 44's Central Venous Catheter (CVC- thin, flexible tube inserted into a vein to provide access to the heart) dressing was not changed in accordance with facility policy. 2. Resident 44's Intravenous tubing (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) was not dated in accordance with facility policy. 3. Resident 33's oxygen tubing (flexible plastic tube that is used to deliver oxygen from an oxygen supply to a person who needs extra oxygen) was not changed in accordance with facility policy. 4. Resident 65's oxygen tubing was not dated in accordance with facility policy 5. License Vocational Nurse 1 (LVN 1) did not perform hand hygiene (practice of washing hands with soap and water or using an alcohol-based hand sanitizer to remove germs) during medication administration for Resident 5. 6. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene when assisting Residents 484 and 47 with breakfast. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 101 highly vulnerable residents whose health conditions were already compromised. Findings: 1. During a review of Resident 44's clinical record, the Face Sheet (contains demographic and medical information), indicated Resident 44 was admitted to the facility on [DATE], with diagnoses which included bacteremia (bloodstream infection that occurs when bacteria enter the blood) and hypertension (high blood pressure). During a concurrent observation and interview, on January 13, 2025, at 11:55 AM, with a Registered Nurse 1 (RN 1), Resident 44's CVC, which was located on her right upper arm, was inspected. RN 1 confirmed the CVC dressing was dated January 1, 2025, indicating when the dressing was last changed. RN 1 stated the facility's practice required the dressing to be changed every seven days or when it becomes soiled or dislodged. RN 1 further stated that the dressing should have been changed on January 8, 2025 (five days ago), but it had not been. A concurrent interview and record review, on January 16, 2025, at 10:30 AM, with the Director of Nursing (DON) and Infection Control Prevention Nurse (ICP Nurse), the DON and the ICP Nurse reviewed the facility's policy and procedure (P&P) titled, Central Venous Catheter Dressing Changes, revised on April 20, 2016, which indicated, Purpose. The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings General Guidelines . 5. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN [as needed] wet, soiled, or not intact) . The DON stated the facility should have a system to 055183 Page 13 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0880 Level of Harm - Minimal harm or potential for actual harm ensure CVC dressings were changed according to policy, but no system were currently in place to monitor this. The ICP Nurse confirmed the policy was not followed. 2. During a review of Resident 44's clinical record, the Face Sheet indicated Resident 44 was admitted to the facility on [DATE], with diagnoses which included bacteremia and hypertension. Residents Affected - Many During a review of Resident 44's physician's order, dated January 13, 2025, it indicated Resident 44 had an order for Vancomycin (a prescription antibiotic used to treat serious bacterial infections) . IV solution .1 gram (GM - unit of measure) intravenously one time a day . During a concurrent observation and interview, on January 13, 2025, at 11:40 AM, with RN 1, in Resident 44's room, Resident 44's Vancomycin 1 GM IV solution, which was hanging on the IV pole, was inspected. The IV solution was connected to an undated IV tubing. RN 1 stated that he administered Resident 44's IV medication that morning around 9:15 AM. RN 1 explained that facility practice required dating the IV tubing once it was opened and assembled for use. RN 1 further stated he should have dated, timed, and initialed the IV tubing, but he did not. A concurrent interview and record review, on January 16, 2025, at 10:14 AM, with the DON and ICP Nurse, they reviewed the facility's policy and procedure (P&P) titled, Administration Set/Tubing Changes, revised on April 20, 2016, which indicated, Purpose The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment. Preparation 1. Label new tubing with date, time, and initials. If facility requires, label may include the date and time that tubing was initiated and when tubing should be discontinued. General Guidelines: . 6. All tubing is labeled with start and change date and time. Any tubing that is observed not to have a label must be changed and then labeled accordingly . Both the DON and ICP Nurse stated the facility did not follow this policy. 3. During a review of Resident 33's admission Record, it indicated Resident 33 was admitted to the facility with the diagnoses of dementia (medical condition that causes a person to lose ability to think, remember, and reason), retropharyngeal and parapharyngeal abscess (severe infection in the neck that involve a collection of pus in the deep neck spaces), and shortness of breath (difficulty breathing). During an observation on January 13, 2025, at 10:11 AM, in Resident 33's room, Resident 33 was lying in bed, talking nonchalantly to the wall. Resident 33 was wearing oxygen cannula with its tubing attached to an oxygen concentrator, which was running at 2 liters per minute (amount of oxygen given to a patient). The date on oxygen tubing was December 27, 2024. (17 days ago) During an interview on January 13, 2025, at 3:26 PM, with the Infection Control ICP Nurse, the ICP Nurse stated Resident 33's oxygen tubing should have been changed sooner than 17 days. The ICP Nurse further stated it was all the nurse's responsibility to check the labels and change as needed. During a concurrent interview and record review, on January 13, 2025, at 3:48 PM, with the DON, the facility's P&P titled, Oxygen Administration dated revised October 2010 was reviewed. The P&P indicated, .Steps in the Procedure . 23. Change the oxygen cannula and tubing every seven (7) days, or as needed . The DON stated the P&P was not followed. The DON further stated it should not have been left unchanged for 17 days due to the risk of infection. 4. During a review of Resident 65's admission Record, it indicated Resident 65 was admitted to the 055183 Page 14 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility with the diagnoses of chronic obstructive pulmonary disease (COPD-lung disease that makes it difficult to breath), acute respiratory failure with hypoxia (medical condition when there is not enough oxygen in the body), and asthma (lung disease that causes inflammation in the airways of the lungs). During a review of Resident 65's Physician Order dated September 17, 2024, the Physician Order indicated, Titrate (slowly increase or decrease over a period of time) O2 (oxygen) via n/c (nasal cannula- a type of oxygen tubing) between 2-5 L/min (L-liters- unit of measurement/min-minutes) to keep oxygen saturations (levels of oxygen in the blood) above 92% (95-100 is considered normal, with lower levels being acceptable for COPD) . During an observation on January 13, 2025, at 10:35 AM, in Resident 65's room, Resident 65 was lying in bed, watching television. Resident 65's oxygen tubing was adjacent to Resident 65's bed. There was no label on the oxygen tubing. During an interview on January 13, 2025, at 3:26 PM, with the ICP Nurse, the ICP Nurse stated Resident 65's oxygen tubing should have been labeled with the date. The ICP Nurse further stated it was the nurse's responsibility to label oxygen tubing. During a concurrent interview and record review on January 13, 2025, at 3:48 PM, with the DON, the DON reviewed the facility's P&P titled, Oxygen Administration revised on October 2010, which indicated .Steps in the Procedure . 23. Change the oxygen cannula and tubing every seven (7) days, or as needed . Documentation . After completing the oxygen setup or adjustment, the following information should be recorded . 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure . The DON stated the P&P was not followed. 5. During a review of Resident 5's admission Record, it indicated Resident 5 was admitted to the facility with the diagnoses of hemiplegia (condition that causes weakness or paralysis on one side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (athologic process that results in an area of necrotic tissue in the brain) affecting right dominant side, aphasia (loss of ability to understand or express speech) following cerebral infarction, and gastrostomy status (a tube inserted into the stomach that delivers food and liquids). During a medication administration observation, on January 15, 2025, at 9:11 AM, with LVN 1, LVN 1 checked Resident 5's blood pressure then touched the computer, which was by the medication cart. LVN 1 then proceeded with administering Resident 5's medication, without performing hand hygiene. During a follow up interview on January 15, 2025, at 11:10 AM, with LVN 1, LVN 1 stated she should have performed hand hygiene after touching Resident 5. During an interview on January 15, 2025, at 11:25 AM, with the ICP Nurse, the ICP Nurse stated the expectation was for nurses to wash their hands after touching a patient. The ICP Nurse stated LVN 1 should have performed hand hygiene before administering Resident 5's medication. During a concurrent interview and record review on January 16, 2025, at 2:24 PM, with the DON, the DON reviewed the facility's P&P titled, Handwashing/Hand Hygiene revised on August 2019, which indicated, . 7. Use an alcohol-based hand rub . ; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the follow situations; . b. before and after direct contact with residents; c. 055183 Page 15 of 16 055183 01/16/2025 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0880 before preparing or handing medications . The DON stated the P&P was not followed. Level of Harm - Minimal harm or potential for actual harm 6. During a concurrent observation and interview, on January 15, 2025, at 7:38 AM, with CNA 1, CNA 1 walked into Residents 47 and 484's shared room. (Both residents were placed on Enhanced Barrier Precaution [EBP- set of infection control measures that use gowns and gloves to reduce the spread of resistant organism.]) An isolation cart (mobile storage unit that holds protective equipment such as gloves, mask, gown) was near the entrance of their room. CNA 1 donned on gown and gloves prior to entering room, then opened the curtain divider and set up Resident 47's breakfast tray. CNA 1 then cut up Resident 47's food and proceeded on feeding Resident 47. CNA 1 wore the same gown and gloves. Without performing hand hygiene, CNA 1 proceeded to set up the breakfast tray and feed Resident 484. Resident 47 stated CNA 1 comes in every morning to feed me and Resident 484 at the same time. CNA 1 acknowledged when residents were on EBP, the staff should not wear the same gown and gloves for the care of more than one person. Residents Affected - Many During a concurrent interview and record review on January 15, 2025, at 8:30 AM, with the ICP Nurse, the IPN Nurse reviewed the facility's P&P titled, Handwashing/ Hand Hygiene policy, revised on August 2019, which indicated Use an alcohol-based hand rub . ; or, alternatively, soap (antimicrobial and non-antimicrobial) and water for the following situations: before and after assisting a resident with meals . The ICP Nurse stated CNA 1 should have followed the P&P, but she did not. 055183 Page 16 of 16