Health inspection·May 26, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to discuss and provide information on advanced directives (a written statement of a person's wishes regarding medical treatment, should the person be unable to communicate with the doctor) for one of six sampled residents reviewed for advanced directives (Residents 70) when the Physician's Orders for Life Sustaining Treatment (POLST) for one resident (Resident 70) was not initiated upon admission. This failure had the potential to cause Resident 70's values and desires related to end-of-life care not to be carried out. Findings: 1. A review of Resident 70's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of [DATE], with a diagnosis of chronic obstructive pulmonary disease (airway obstruction from the lungs), dysphasia (difficulty speaking), chronic respiratory failure with hypercapnia (not able to exchange oxygen due to not having enough oxygen in blood). A review of Resident 70's MDS, Minimum Data Set (a process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Cognitive Patterns, dated [DATE], indicated Resident 70 was severely impaired for cognitive skills for daily decision making. During a review of Resident 70's clinical record, the POLST, undated, was reviewed and indicated, Resident 70's first and last name listed with medical record number. However, Section A: Cardiopulmonary Resuscitation (CPR), B: Medical Interventions, C: Artificially administered nutrition, D: Information and Signatures section, were all left blank. The second page of POLST was reviewed, the section for patient information, nurse practitioner/physician assistant supervising physician and additional contact were blank. During a concurrent interview and record review on [DATE], at 12:55 PM, with the Social Services (SS), Resident 70's POLST form was reviewed. The SS stated the POLST form was blank and needed to be completed within 24 hours of admission. She indicated the admitting nurse initiates the form and Social Services checks to make sure it got completed timely. The SS stated Resident 70 was readmitted from the hospital on [DATE], and the old POLST was with the medical records in their office. During an interview on [DATE], at 1:14 PM, with the Licensed Vocational Nurse (LVN 1), the LVN stated, I would go to my supervisor if I saw a blank POLST form and I would start CPR if I would not know what the Resident wanted as their wishes. Page 1 of 17 055708 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE], at 2:23 PM, with the Licensed Vocational Nurse (LVN 2), the LVN 2 stated, when the patient returned from the hospital the POLST needed to be completed on admission because the Residents may change their POLST wishes. During an interview on [DATE], at 12:21 PM, with the Director of Nursing (DON), the DON stated POLST needed to be completed within 24 to 48 hours of admission and the admission nurse needed to initiate it, but it was not initiated. When asked Social Services about POLST policy the facility gave POLST Cover sheet 2020 form. A review of POLST form 2020, indicated, . Physician Orders for Life Sustaining Treatment (POLST) is a medical order that helps give people with serious illness more control over their care during a medical emergency. POLST can help make sure you get the care you want, and also protect you from getting medical treatments you DO NOT want . The POLST form is not valid until it is signed by both you (or your designated decision maker) AND your physician, nurse practitioner, or physician assistant. 055708 Page 2 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

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 observations, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion for two of 11 sampled residents (Resident 8 and 52), when range of motion exercises and splints were not provided as per physician orders, by the restorative nursing assistants (RNA- certified nursing assistants specially trained to do range of motion and splints) 1. For Resident 8, Restorative Nursing Assistant (RNA-a certified nursing assistance with training on range of motion and the application of splints) services were not provided to resident as ordered by the physician, for the month of May 2022. 2. For Resident 52, Restorative Nursing Assistant services were not provided to the resident, as ordered by the physician, for the month of May 2022. This failure had the potential to decrease in the range of motion and could have resulted in worsening of contractures (joint stiffness) and mobility for Residents 8 and 52. Findings: 1. During a review of Resident 8's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE] , 2017, with diagnoses which included chronic respiratory failure with hypercapnia (low blood oxygen level cause hypoxemic respiratory failure and high carbon dioxide levels causes hypercapnic respiratory failure), subdural hemorrhage ( a pool of blood between the brain and its outermost covering), dysphagia (difficulty swallowing foods or liquids), hypertension (A condition in which the force of the blood against the artery walls is too high), chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breath). During a review of Resident 8's Order Listing Report [a summary of physician orders], dated May 25, 2022, indicated the following physician orders for restorative nursing: a. Physician's order dated April 12, 2022, indicated, RNA [restorative nursing assistant] for PROM [passive range of motion] to RUE [right upper extremity], daily 5x [five times]/week everyday shift. b. Physician's order dated April 12, 2022, indicated, RNA [restorative nursing assistant] for PROM [passive range of motion] to LUE [left upper extremity], daily 5x [five times]/week everyday shift. c. Physician's order dated April 12, 2022, indicated, RNA to don/doff [put on/take off] left elbow extension splint x 4 hours or as tolerated daily 5x/week everyday shift. During a review of Resident 8's Restorative Nursing sheet (a sheet used by facility staff to document restorative nursing activities) dated May 1, 2022, through May 31, 2022, indicated, Resident 8 did not receive RNA services as per physician orders for range of motion for RUE, LUE and don/doff of left elbow extension splint on May 2,5,6,17 and 23 of 2022. During a concurrent interview and record review on May 25, 2022, at 2:38 PM, with a Restorative 055708 Page 3 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing Assistant 1 (RNA 1), a Licensed Vocational Nurse 3 (LVN 3) and an Occupational Therapy Manager (OT manager). Resident 8's Restorative Nursing sheet, dated May 1, 2022, through May 31, 2022, was reviewed. RNA1, LVN 3 and OT manager confirmed there was no documented evidence that Resident 8 received RNA services as ordered by the physician on May 2, 5, 6,17 and 23 of 2022. RNA 1 stated, she was a staff member who performed RNA services for the residents and if the services were performed, there would have been documentation written on the Restorative Nursing sheet but confirmed there was no such documentation on May 2, 5, 6, 17 and 23. RNA 1 and LVN 3 both stated if the resident refused services, that would have also been documented on the Restorative Nursing sheet. Both RNA 1 and LVN 3 confirmed there was no documentation of refusal of services. During an interview on May 25, 2022, at 3:15PM, with Resident 8, Resident 8 was observed to be lying in his bed with limited mobility of his right arm. Resident 8 stated, he could not remember the last time staff performed range of motion exercises with his right and left arm. During a review of Resident 8's care plan (an individualized plan for the medical care of a resident) (untitled), dated May 9, 2022, the care plan indicated, ADL [activities of daily living] self-care deficit r/t [related to] muscle weakness and contracture. Interventions/Tasks .RNA for PROM exercises to RUE, LUE daily 5x/week .RNA to don/doff left elbow extension splint x 4 hours or as tolerated daily 5x/week. During a review of the facility's policy and procedure titled, Restorative Program, revised March 2022, the policy indicated, It is the policy of this facility to provide a Restorative Program designed to restore or maintain a resident's mobility skills to maximum independence and safety and prevent loss of functioning in existing functional abilities .The program will be conducted in the facility with reduced distractions, and interruptions . 2. During a review of Resident 52's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body), heart failure, lack of coordination, and cerebral infarction (also known as a stroke is damage to tissues in the brain as a result of a lack of oxygen). During a review of Resident 52's Order Listing Report [a summary of physician orders], dated May 26, 2022, indicated the following physician orders for restorative nursing: a. Physician's order dated April 28, 2022, indicated, RNA [restorative nursing assistant] for PROM [passive range of motion] to LUE [Left arm], daily 5x [five times]/wk everyday shift. b. Physician's order dated April 28, 2022, indicated, RNA to don/doff [put on/take off] left elbow extension splint x 2.5 hours or as tolerated daily 5x/wk everyday shift. c. Physician's order dated April 22, 2022, indicated, RNA to sit resident @ [at] EOB [edge of bed] x 10 mins [minutes] or as tolerated, daily 5x week everyday shift . During a review of Resident 52's Restorative Nursing sheet (a sheet used by facility staff to document restorative nursing activities) dated May 1, 2022, through May 31, 2022, the document was blank for each of the prescribed RNA services dated from May 1, 2022, through May 23, 2022 (three weeks). There was no documented evidence RNA services were provided to the resident during that time. 055708 Page 4 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on May 26, 2022, at 10:25 AM, with a Certified Nursing Assistant 1 (CNA 1) and a Licensed Vocational Nurse 3 (LVN 3), Resident 52's Restorative Nursing sheet, dated May 1, 2022, through May 31, 2022, was reviewed. CNA 1 and LVN 1 both confirmed there was no documented evidence that Resident 52 received RNA services as ordered by the physician between May 1, 2022, and May 23, 2022. CNA 1 stated she was a staff member who performed RNA services for the residents and if the services were performed, there would have been documentation written on the Restorative Nursing sheet but confirmed there was no such documentation. CNA 1 and LVN 1 both stated if the resident refused services, that would have also been documented on the Restorative Nursing sheet. Both CNA 1 and LVN 1 confirmed there was no documentation of refusal of services. During an interview on May 26, 2022, at 11:15 AM, with Resident 52, Resident 52 was observed to be lying in his bed with limited mobility of his left arm. Resident 52 stated he could not remember the last time staff put on his left elbow extension splint or performed range of motion exercises with his left arm. Resident 52 further stated it had been about a month since someone sat him at the edge of his bed. During an interview on May 26, 2022, at 11:35 AM, with the Director of Nursing (DON), the DON reviewed Resident 52's Restorative Nursing sheet, dated May 1, 2022, through May 31, 2022. The DON confirmed the sheet was blank from May 1, 2022, through May 23, 2022 (3 weeks) and stated her expectation was that the RNA services were performed and documented immediately afterward. The DON further stated the facility policy was not followed because there was no documented evidence that RNA services were provided to the resident as was ordered by the physician. The DON further reviewed the clinical record for Resident 52 and was unable to find documented evidence RNA services were provided to the resident during that time. During a review of Resident 52's care plan (an individualized plan for the medical care of a resident) (untitled), dated March 16, 2022, the care plan indicated, ADL [activities of daily living] self-care deficit r/t [related to] Cerebral infarction affecting left non-dominant side at risk fo [sic] developing complications associated the [sic] decreased ADL self-performance .Interventions/Tasks .RNA for PROM exercises to LUE, daily 5x/wk .RNA to don/doff left elbow extension splint x 2.5 hours or as tolerated daily 5x/wk .RNA to sit resident @ EOB x 10 mins or as tolerated, daily 5x week. During a review of the facility's policy and procedure titled, Restorative Program, revised March 2022, the policy indicated, It is the policy of this facility to provide a Restorative Program designed to restore or maintain a resident's mobility skills to maximum independence and safety and prevent loss of functioning in existing functional abilities .The program will be conducted in the facility with reduced distractions, and interruptions . 055708 Page 5 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0692 Provide enough food/fluids to maintain a resident's health. 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 did not maintain acceptable parameters of nutritional status when Resident 53's enteral feeding (nutrition taken through a tube that goes directly to the stomach or small intestine) was not assessed correctly by the Registered Dietitian after re-admission to the facility from a hospital stay. This failure resulted in the Resident losing 3% of his body weight in one month after re-admission. Unintentional weight loss in the elderly population is associated with increased morbidity and mortality. Residents Affected - Few Findings: During a review of Resident 53's admission Record, indicated Resident 53 was initially admitted to the facility on [DATE], with a diagnosis of dysphagia ( difficulty swallowing ) and hemiplegia ( a condition, caused by a brain injury , that results in varying degrees of weakness, stiffness and lack of control in one side of the body) . During an observation on May 24, 2022 at 3:30 PM, Reident 53 was in bed and appeared to be sleeping, he was unresponsive to his name being called. Resident was connected to enteral feeding, at a rate of 70 milliliters per hour from 2:00 PM to 10:00 AM. During a review of Residents 53's Weights and Vital Summary, records indicated Resident 53 weighted teh following: 180 pounds on February 7, 2022 171 pounds on March 9, 2022 165 pounds on April 4, 2022 166 pounds on May 2, 2022 During a review of the progress notes, Resident 53 was admitted to [Name of general acute care hospital] on March 4, 2022, with coffee ground emesis (vomit that looks like coffee grounds) . Resident 53 was re-admitted back to the facility on March 8, 2022. During an interview and concurrent record review on May 25, 2022, at 9:44 AM, with the Registered Dietitian (RD 1) she stated that Resident 53 had some weight loss, and was currently tolerating his enteral feeding. The RD1 stated that his enteral feeding order was put in wrong on March 8th, 2022 when he was re-admitted . The order stated he would receive 2200 calories from a rate of 55 milliliters per hour for 20 hours, however per the RD1 it wasn't possible to provide that rate twice in a 20 hour period, so that rate only provided a total of 1320 calories. When she did her re-assessment of the resident after he was re-admitted to the facility on [DATE]th, 2022, she did not catch that the order was written wrong. She assumed the resident was receiving 2200 calories. She stated that she did not catch that he was only receiving 1320 calories until her next review of the resident on March 25, 2022. At that time she increased the rate to 65 milliliters per hour for 20 hours for him to receive 1560 calories. She stated she should have caught that he was actually only receiving 1320 calories from that tube feeding rate on March 8, 2022. 055708 Page 6 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 53's medical administration record (MAR), indicated on March 8, 2022, Glucerna 1.2 two times per day at a rate of 55 milliliters per hour for 20 hours, resident to receive 2200 calories. Review of the resident 53's orders indicated on March 24, 2022 a new order was done for Glucerna 1.2 at 65 milliliters/hour for 20 hours, resident to receive 1560 calories. On April 8, 2022 order was increased again to 70 milliliters per hour for 20 hours to provide 1680 calories. During review of the RD-Nutritional Assessment dated March 9, 2022, indicated the estimated calorie needs for Resident 53 (estimate of calories needed to maintain current body weight) to be 1900 to 2300 calories per day. Also noted under Enteral Nutrition/Total Parenteral Nutrition order stated Glucerna 1.2 at 55 milliliters per hour for 20 hours equals 2200 calories. During an interview on May 25, 2022, at 10:30 AM, The Food and Nutrition Resource Dietitian (RD 2) that oversees RD 1, stated that her expectation is that the RD would ensure the tube feeding order is correct when she does her assessment. During a review of the standards of practice for Registered Dietitians from the Pocket Resource for Nutrition Assessment by Dietetics in Health Care Communities, dated 2009, indicates The Registered Dietitian (RD), is responsible for the analysis of nutrition data to determine Nutrition Diagnosis, Intervention, and Evaluation. The RD needs to Define and implement interventions that are consistent with resident needs. 055708 Page 7 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an enteral nutrition container (container with liquid nutritional formula administered to a resident through a feeding tube inserted directly into the stomach) for one resident (Resident 53) was labeled with nurse initials and start time (time the feeding was started) as indicated in the facility's policy and procedure. This failure had the potential for the bottle to exceed the manufacturer's prescribed hang-time (the time a feeding is safe to use after opened), and for Resident 53 to not receive the prescribed amount of nutritional calories resulting in weight loss. Findings: During a review of Resident 53's clinical record, the admission Record [contains demographic and medical information], indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included heart failure, chronic respiratory failure, and diabetes mellitus (a chronic metabolic disease which results in elevated blood sugar levels). During an observation on May 23, 2022, at 10:38 AM, Resident 53 had an enteral nutrition container at his bedside which was infusing through a pump. The enteral nutrition was labeled with the date (5/22), the flow rate in milliliters per hour (70 mls/hr), and Resident 53's name and room number. It was not labeled with the initials of the nurse who started the tube feeding or the start time. During an interview on May 23, 2022, at 10:40 AM, with Licensed Vocational Nurse 5 (LVN 5), LVN 5 observed the enteral nutrition container which was being administered to Resident 53 and confirmed there was no nurse's initials or start time documented on the container. LVN 5 stated both the nurse's initials and the start time were required to be written on the container. During an interview on May 23, 2022, at 12:36 PM, with the Director of Nursing, the DON stated enteral nutrition containers should have the residents name, date, flow rate, start time, and nurse's initials documented on it per the facility's policy and procedure. During an interview on May 23, 2022, at 1:44 PM with the Infection Preventionist Nurse (IPN), the IPN stated the requirement for labeling of the enteral nutrition containers included the residents name, date, flow rate, start time, and nurse's initials. During a review of the facility's policy and procedure titled, Enteral Formulas, Administration of Closed System, dated October 2021, the policy indicated, .This policy provides a means to safely administer a complete nutritional feeding to the resident using a premixed formula in a closed container system .Equipment: .6. Label formula container with resident's name, room #, date, starting time, rate @ [at] ml/hr [milliliters per hour], and your initials . 055708 Page 8 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff identified an irregularity during medication administration and monthly drug regimen review for one of one residents (Resident 72) reviewed for anticoagulants (blood thinners) when it was not identified that the resident had a physician's order for heparin (an anticoagulant) to be administered intramuscularly (into the muscle tissue) instead of subcutaneously (into fatty tissue). Nursing staff administered the medication subcutaneously and did not identify the discrepancy, nor seek clarification from the physician regarding the route of administration. This failure had the potential for the resident to receive heparin intramuscularly which may have resulted in the formation of a hematoma (abnormal collection of blood outside of a blood vessel). Findings: During a review of Resident 72's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included hemorrhagic disorder due to extrinsic circulating anticoagulants (bleeding disorder due to the use of anticoagulants) ,dependence on respirator (ventilator - a machine which aids in mechanical ventilation by moving breathable air into and out of the lungs), diabetes mellitus (a chronic metabolic disease which results in elevated blood sugar levels), and acute (severe and sudden onset) and chronic (long-term) respiratory failure. During a review of Resident 72's Order Summary Report [list of physician's orders], printed May 25, 2022, an order dated July 9, 2021, with a start date of February 1, 2022, indicated, Heparin Sodium (Porcine) Solution 5000 UNIT/ML [units per milliliter] inject 5000 unit intramuscularly every 8 hours for clotting prevention. During a review of Resident 72's Medication Administration Records [MAR - a document where medication administration is recorded], dated February 2022, through May 2022, the MARs all included a physicians order dated July 9, 2021, which indicated, Heparin Sodium (Porcine) Solution 5000 UNIT/ML inject 5000 unit intramuscularly every 8 hours for clotting prevention. This order was present on the MARs for all four months reviewed (February 2022 through May 2022). Additionally, documentation on the MARs indicated nursing staff had been administering the medication via the subcutaneous route. During a concurrent interview and record review on May 25, 2022, at 12:54 PM, with the Director of Nursing (DON), Resident 72's MARs, dated February 2022, through May 2022, were reviewed. The DON confirmed there was a physician's order dated July 9, 2021, which indicated Heparin was to be administered via intramuscular route. The DON further stated heparin is usually administered subcutaneously (into fatty tissue). The DON further stated the documentation on the MARs indicated nursing staff had been administering the heparin via the subcutaneous route. The DON stated there was no evidence that the order was ever clarified with the physician as to which route was intended in the order (subcutaneous or intramuscular) and that the order needed to be clarified. During a follow up interview on May 25, 2022, at 2:28 PM, with the DON, the DON stated she and the nursing staff in the facility were responsible to perform monthly medication review for all residents. The DON stated Resident 72's physician order for intramuscular administration of heparin was not 055708 Page 9 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0755 identified as needing clarification, but it should have been clarified. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on May 26, 2022, at 12:31 PM, with Licensed Vocational Nurse 6 (LVN 6), Resident 72's MARs dated February 2022, through May 2022, were reviewed. LVN 6 stated she assisted the facility in performing physicians order recap reviews every month and any irregularity identified would need to be clarified with the physician and a new order obtained. LVN 6 stated she was the individual who reviewed Resident 72's physicians orders for May 2022, and she was the one who signed the order recap along with Physician 1 (P 1). LVN 6 stated she should have identified that Resident 72's heparin order needed clarification regarding the route of administration, but it was an oversight. LVN 6 further stated the nurse who signed for review of the MAR for March 2022 also missed the irregularity and the nurse was no longer working at the facility. LVN 6 was unable to find documented evidence that a physicians order recap was performed for Resident 72's orders for the month of April 2022. Residents Affected - Few During a review of the facility's policy and procedure titled, Physician's Orders, Telephone Orders and Recapitulation [summary review] Process, dated February 2022, the policy indicated, .Monthly Physician's Orders Recap Process .3. Printing of the physician orders, medication/treatment sheets and any other forms for the facility will take place the 1st of the month (midnight). 4. All printed forms will be delivered to the nursing station or to the licensed staff member(s) responsible for review. 5. All orders shall be reviewed by a licensed nurse prior to the placement of these orders in the resident's medical record .8. Monthly recaps shall be noted by a licensed nurse when the physician signs the recapitulation of orders. During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, dated February 23, 2015, the policy indicated, .B. Administration .3. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 055708 Page 10 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the monthly medication review was implemented per the facility's policy and procedure for one of six residents (Resident 72) reviewed for medication regimen review when the pharmacist failed to identify Resident 72's physician's order for heparin (an anticoagulant or blood thinner) was to be administered intramuscularly (into the muscle tissue) every 8 hours. This failure had the potential for the resident to receive heparin intramuscularly which may have resulted in the formation of a hematoma (abnormal collection of blood outside of a blood vessel). Findings: During a review of Resident 72's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included hemorrhagic disorder due to extrinsic circulating anticoagulants (bleeding disorder due to the use of anticoagulants), dependence on respirator (ventilator - a machine which aids in mechanical ventilation by moving breathable air into and out of the lungs), diabetes mellitus (a chronic metabolic disease which results in elevated blood sugar levels), and acute (severe and sudden onset) and chronic (long-term) respiratory failure. During a review of Resident 72's Order Summary Report [list of physician's orders], printed May 25, 2022, an order dated July 9, 2021, with a start date of February 1, 2022, indicated, Heparin Sodium (Porcine) Solution 5000 UNIT/ML [units per milliliter] inject 5000 unit intramuscularly every 8 hours for clotting prevention. During a review of Resident 72's Medication Administration Records [MAR - a document where medication administration is recorded], dated February 2022, through May 2022, the MARs all included a physicians order dated July 9, 2021, which indicated, Heparin Sodium (Porcine) Solution 5000 UNIT/ML inject 5000 unit intramuscularly every 8 hours for clotting prevention. This order was present on the MARs for all four months reviewed (February 2022 through May 2022). During a concurrent interview and record review on May 25, 2022, at 12:54 PM, with the Director of Nursing (DON), Resident 72's MARs, dated February 2022, through May 2022, were reviewed. The DON confirmed there was a physician's order dated July 9, 2021, which indicated Heparin was to be administered via intramuscular route. The DON further stated heparin is usually administered subcutaneously (into fatty tissue). During a follow up interview on May 25, 2022, at 2:28 PM, with the DON, the DON stated every month the facility's Consultant Pharmacist (C. PHARM) performed a monthly review of the medication regimen for all residents. The DON further stated for the months of February 2022, through May 2022, the C. PHARM did not report any irregularities or discrepancies regarding Resident 72's physician's order for heparin to be administered intramuscularly every 8 hours. During an interview on May 25, 2022, at 2:38 PM, with the C. PHARM, the C. PHARM stated he performed a monthly medication review for the residents in the facility. The C. PHARM further stated he did not identify Resident 72's heparin order was written for intramuscular administration and had he 055708 Page 11 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few identified it, he would have given the facility a recommendation to change it from intramuscular to subcutaneous administration. The C. PHARM confirmed he did not make any recommendations to the facility regarding Resident 72's heparin order in February, March, April, or May of 2022. During a review of the facility's policy and procedure titled, Medication Regimen Review (MRR), dated February 2022, the policy indicated, Policy: It is the policy of this facility that: 1. The drug regimen of each resident, which includes a review of the resident's medical chart; will be reviewed at least once a month by a licensed pharmacist; 2. Irregularities will be documented on a separate written report; that is sent to the attending physician, the facility's Medical Director and the Director of Nursing Services and lists the resident's name, the relevant drug, and the irregularity the pharmacist identified .Procedures: 1. The pharmacist reviews each resident's medication regimen at least once a month in order to identify irregularities and to identify clinical significant risks and/or adverse consequences resulting from or associated with medications . 055708 Page 12 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (a written medical order from a physician, nurse practitioner or physician assistant that specifies the type of medical treatment to provide an individual during serious illness) was signed by a physician, nurse practitioner, or physician's assistant, for one of six sampled residents investigated for advanced directives (Resident 52). This failure resulted in information and decisions determined on the POLST to not be an official physician's order which had the potential for the needs and desires regarding end-of-life medical treatment to not be carried out in accordance with the resident's request. Findings: During a review of Resident 34's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain in the absence of trauma or surgery), dysphasia (difficulty speaking), and seizures. During a review of Resident 34's clinical record, the POLST, dated September 11, 2020, was reviewed. The POLST indicated, .A copy of the signed POLST form is a legally valid physician order .To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker . Further review of the POLST indicated Section D for Information and Signatures: indicated there was no signature present by a physician, nurse practitioner or physician's assistant. This section was blank. During a concurrent interview and record review on May 25, 2022, at 7:27 AM, with the Social Services Designee (SSD), Resident 34's POLST, dated September 11, 2020, was reviewed. The SSD stated Resident 34's POLST was incomplete because it was missing a physician signature. The SSD stated she had oversight of the completion of the POLST for the facility's residents and she was responsible to ensure the POLST was completed in its entirety for each resident soon after they were admitted . The SSD further stated the POLST was supposed to be signed by the physician or provider within 24-72 hours or as soon as possible after the resident is admitted to the facility. The SSD the missing signature on Resident 34's POLST was an oversight. The SSD was unable to find any other documented evidence of a POLST in the client's clinical record or medical record storage. During a concurrent interview and record review on May 25, 2022, at 7:56 AM, with the Director of Nursing (DON), Resident 34's POLST, Dated September 11, 2020, was reviewed. The DON stated the nursing staff and social service department was responsible to ensure the POLST is completed for each resident. The DON further stated Resident 34's POLST was incomplete, and it should have had a physician or provider signature but did not. During a review of the facility's policy and procedure titled, What is a POLST, undated. The policy indicated, .The POLST form should be completed by your doctor or another trained medical provider after you've had a good conversation about the form's medical terms and options .The POLST form is not valid until it is signed by both you (or your designated decisionmaker) AND your physician, nurse 055708 Page 13 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0842 practitioner, or physician assistant . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055708 Page 14 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

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 implement their infection control program to prevent the spread of infectious microorganisms when three staff members (Licensed Vocational Nurse 4 [LVN 4], Admissions Coordinator [AC], and Certified Nursing Assistant 2 [CNA 2]) did not follow precautions when they were observed to enter the room of a resident (Resident 83) on contact precautions (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment) for Candida Auris (a fungus capable of causing severe infection) and all three staff members did not have on a gown. Residents Affected - Few This failure had the potential for the contamination of the environment and the spread of Candida Auris to the 88 vulnerable residents living within the facility who did not already have Candida Auris infection. Findings: During a review of Resident 83's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included candidiasis (a fungal infection), encephalopathy (disease, damage or malfunction of the brain), and hemiplegia and hemiparesis (weakness and paralysis of one side of the body). During further review of Resident 83's clinical record, an untitled facility document indicated a physicians order, dated May 21, 2022, which indicated, .Transmission based precaution - contact isolation for positive of Candida Auris . During a review of Resident 83's untitled care plan (an individualized plan for the medical care of a resident), dated April 29, 2022, the care plan indicated, Has infection of the candida Auris (admitted positive) .interventions/tasks .Maintain transmission based precaution - contact isolation for positive of candida Auris . During an observation on May 24, 2022, at 10:18 AM, Resident 83 was observed to be in her room and had signs posted outside the doorway and a cart near the entrance which contained personal protective equipment (PPE - equipment worn to prevent or minimize exposure to a hazard. i.e., gowns, gloves, eye protection etc.). One sign posted at the entryway indicated, Stop - Contact Precautions .providers and staff must also: . put on gown before room entry. discard gown before room exit . During a concurrent observation and interview on May 24, 2022, at 10:19 AM, with a Licensed Vocational Nurse 4 (LVN 4), LVN 4 entered Resident 83's room without a gown. LVN 4 proceeded to touch the enteral nutrition bag (liquid nutrition administered through a tube directly inserted into the stomach) hanging next to Resident 83's bed. LVN 4 then exited the room and never put on a gown while he was in the resident's room. LVN 4 stated he did not put on a gown upon entering into Resident 83's room and stated he should have. During a follow up interview on May 24, 2022, at 3:14 PM, with LVN 4, LVN 4 stated staff were supposed to wear the PPE indicated on the signage outside the resident's door if they are on transmission-based precautions. LVN 4 further stated if he had any questions regarding the facility's infection control practices, he would refer to the Director of Nursing (DON). 055708 Page 15 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on May 25, 2022, at 12:40 PM, with the DON, the DON stated all staff were supposed to put on all required PPE prior to entering the room of a resident in transmission-based precautions. The DON further stated the PPE required to enter the individual's room is posted outside the door at the entryway. The DON stated the PPE required to enter Resident 83's room included a gown. During a concurrent observation and interview on May 25, 2022, at 12:42 PM, with the Admissions Coordinator (AC), the AC entered Resident 83's room without a gown or gloves. Upon exiting the room, the AC stated she entered Resident 83's room because the call light was on and she went to attend to the resident. The AC further stated she did not put on a gown or gloves because she was confused about the signage posted outside the doorway and thought she did not need to wear a gown or gloves. During a follow up interview on May 25, 2022, at 12:47 PM, with the DON, the DON stated all staff members who enter Resident 83's room should have on a gown and gloves before entering. During an interview on May 25, 2022, at 1:36 PM, with the Infection Preventionist Nurse (IPN), the IPN stated all staff entering Resident 83's room should have put on a gown and gloves because the resident was on contact precautions for Candida Auris. During a concurrent observation and interview on May 26, 2022, at 4:34 PM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 entered Resident 83's room without a gown. Upon exiting the room, CNA 2 stated she changed Resident 83's depends (diaper or brief) while she was in the room and that she did not wear a gown because she forgot. CNA 2 further stated she did not see the contact precaution sign posted outside the entryway or the PPE cart at the entryway and stated it was an oversight. During a review of the facility's policy and procedure titled, COVID-19 Mitigation Plan, dated February 25, 2022, the policy indicated, .3. Personal Protective Equipment (PPE) .Signs are posted immediately outside of resident rooms indicating appropriate infection control and prevention precautions and required PPE in accordance with CDPH guidance. 055708 Page 16 of 17 055708 05/26/2022 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to do maintenance on the stove in the kitchen on an annual basis per their policy , when two of the burners were not lit because the gas lines were clogged with grease/corrosion and five out of eight dials that function to turn on the burners and adjust gas flow were missing. Residents Affected - Many This failure had the potential to cause a grease fire and put staff and 91 residents at risk. Findings: 1. During an observation and concurrent interview with the Dietary Services Supervisor (DSS) on May 23, 2022,at 10:10 AM, the six burner industrial stove was missing five plastic knobs that were used to turn on the burners and adjust the gas flow. The left front and rear middle pilot burners were not lit, the remaining four burners were lit with a low flame. According to the DSS, the cook grabs a plastic knob from another location and uses it on the missing knobs to turn on and adjust the gas for the burners. She stated that she was not sure why two of the burners were not lit. She stated that the cook uses a lighter and the knob to turn on the gas and light the two burners that were not currently lit. During an interview with the DSS, on May 23, 2022, at 3:03 pm, she stated that they tried ordering the knobs for the stove but the company did not have them in stock. She stated that she was not aware that all the stove burners needed to be constantly lit. During an interview on May 23, 2022, at 3:41 pm, with the Maintenance Resource, he stated the two stove burners that were not lit were not working. He stated he did not think gas was leaking but planned to call a technician out as soon as possible to see what the issue was. He stated all the burners are usually constantly lit because gas was flowing to each burner all the time. During an interview on May 24, 2022, at 2:55 pm, with a Technician from [company name], he stated that the pilots of the two burners that were not lit, were clogged from grease or corrosion. He stated they need to be cleaned out every so often and it should be done by a professional with experience in maintenance of industrial stoves. He stated he recommend that maintenance be done yearly. During an interview on May 24, 2022, at 3:30 PM, the DSS stated that they have not had the stove serviced before. During Record Review of the Kitchen Equipment Annual Inspection log, dated May 12, 2022, the log indicated, there were no records which showed the stove burner maintenance was performed. During a review of the facility policy, titled Cooking Equipment Preventive Maintenance, dated February, 2022, indicated that Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons. Cooking equipment that collects grease below the surface, behind the equipment, or in cooking equipment gas exhaust, such as griddles or char broilers, shall be inspected and, if found with grease accumulation, cleaned by a properly trained, qualified person. 055708 Page 17 of 17