Other·May 23, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the annual Recertification Survey conducted on April 8, 2019 through April 15, 2019. Representing the Department of Public Health: HFEN: 33907 HFEN: 39723 HFEN: 39913 HFEN: 40171 HFEN: 40273 HFEN: 40519 RD/Consultant: 34975 Total Resident Census: 104 Total Resident Sample: 26 There was one Immediate Jeopardy (IJ) identified during this recertification survey. The survey was extended on April 15, 2019. There were two (2) complaints investigated during the recertification survey. CA00632502, unsubstantiated. CA00632158, unsubstantiated. An Immediate Jeopardy (IJ, a crisis situation in which the health and safety of individual(s) are at risk) was called on April 12, 2019 at 1:38 PM under F 689 Free of Accident Hazards/Supervision/Devices, when it was determined the hot water temperature exceeded 120 degrees Fahrenheit, in the presence of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Registered Nurse Supervisor (RN/SUP). A Corrective Action Plan (CAP) was requested. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 1 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An acceptable CAP was submitted by the facility on April 12, 2019 at 4:22 PM. After observations, interviews, and record review were conducted to determine the facility's implementation of the CAP the IJ was lifted on April 15, 2019 at 1:50 PM.

F554 SS=D Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 05/15/2019 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure interventions that would promote safe storage and safe selfadministration of drugs were implemented in accordance to the facility's policy and procedure affecting for one of 26 sampled residents (Resident 13). This failure had the potential to cause unauthorized residents to have access to the medications that could affect the residents' health and safety. Findings: A review of Resident 13's clinical records, indicated Resident 13 was admitted to the facility on July 11, 2016, with diagnoses of muscle weakness (generalized), paraplegia (unable to move legs and lower body), hypertension (high blood pressure), and acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 2 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE kidney failure (kidney damage). A review of Resident 13's "Self Administration of Drugs" assessment, dated July 18, 2018, the Interdisciplinary Team (IDT, a healthcare team from different fields working together to provide the best outcomes for each resident) indicated, "The Interdisciplinary Team has determined that it is not safe for the resident to selfadminister drugs. Describe reasons: resident prefers for licensed staff to administer medications." During an observation on April 11, 2019, at 2:03 PM, in Resident 13's room, Resident 13 had a cup of pills in his left hand. Resident 13 picked up a white pill from the medicine cup and stated, "I don't know what this white pill is for." The cup of pills did not have a label indicating the type of pill or the date and time when the pills were to be administered. Resident 13 removed a bottle of gingko biloba (medication supplement to improve memory) from his drawer and took a pill and swallowed it along with the other pills in the cup. During an interview with Resident 13, on April 11, 2019, at 2:20 PM, Resident 13 stated the nurse had given him the cup of pills and left. Resident 13 further stated the facility had not provided him a place to safely store his pills. During an interview with Licensed Vocational Nurse (LVN 8), on April 11, 2019, at 2:40 PM, LVN 8 stated she gave Resident 13 the cup of pills. LVN 8 stated she had an emergency and left Resident 13's room. She stated she forgot to go back to Resident 13's room to see if he actually took the cup of pills she prepared. She stated she did not know Resident 13 had a bottle of gingko biloba in his bedside drawer. LVN 8 stated the medicine cup she left at Resident 13's bed had amlodipine (high blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 3 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure medicine) 2.5 mg and medication supplements such as, one tablet of cranberry (supplement) 450 milligrams (mg), one tablet of sennosides plus docusate (for constipation), one tablet of hemp oil (supplement) 1000 mg, one capsule of multivitamins, one tablet of zinc (supplement) 220 mg, and one tablet of ascorbic acid (supplement) 500 mg. LVN 8 stated she should not have left the blood pressure medication and supplements unsupervised at Resident 13's bedside. LVN 8 stated, the Interdisciplinary Team (IDT) had determined Resident 13 could not safely selfadminister his medications. During a record review and concurrent interview with the Registered Nurse Supervisor (RN/Sup), on April 12, 2019, at 8:14 AM, the RN/Sup stated the "Self-Administration of Drugs" assessment, dated July 18, 2018, was the most recent assessment. The RN/Sup stated a plan of care had not been developed because the IDT had not determined Resident 13 was safe to self-administer his medications. The RN/Sup further stated there was no physician order indicating which drugs Resident 13 could self-administer. The RN/Sup stated the medication should not have been left at Resident 13's bedside. The facility policy and procedure titled "Policy and Procedure on Self-Administration of Drugs" dated October 2014, indicated Policy: It shall be this facility's policy to assess resident upon admission or readmission to determine if resident wants to self-administer drugs and if resident can safely self-administer. Procedure: 4. If resident requests to self-administer drugs and members of the Interdisciplinary Team considers resident having the ability to safely self-administer drugs, then a physician order reflecting which drugs or medications a resident may self-administer shall be obtained. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 4 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. Based on the recommendation by the Interdisciplinary Team to self-administer drugs or medications, plan of care shall be developed to provide interventions and/or care approaches that will promote safe storage and self-administration of drugs. 6. Interventions or care approaches shall include but not limit to: a. Patient training and education, b. Who will be responsible for storage of medications, c. Who will be responsible for documentation of the administration of medication, d. Location of the drug administration (inside resident's room or in the nursing station)."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 05/15/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - resident care assessment tool) for three of 26 sampled residents (Resident 7, 34 and 79) when: 1. For Resident 7, the MDS assessment dated January 5, 2019, was not coded to include left side hemiplegia (paralysis-unable to move one side of the body) or left side hemiparesis (weakness affecting one side of the body). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 5 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Resident 34's MDS dated February 26, 2019, inaccurately indicated the resident had a foley catheter (a thin, sterile tube inserted into the bladder to drain urine). 3. Resident 79's MDS dated March 29, 2019, inaccurately indicated the resident was taking an anticoagulant medication (medication used to prevent the formation of blood clots and maintain open blood vessels.) These failures in MDS coding had the potential to result in unmet care needs for Residents 7, 34 and 79, which could potentially jeopardize their health and safety. Findings: 1. During a review of the clinical record for Resident 7, the "Record of Admission (demographic and medical information)" indicated Resident 7 was admitted to the facility on July 18, 2017, with diagnoses of hemiplegia and hemiparesis following a cerebral infarction (stroke-blockage or narrowing of blood flow in the brain) affecting non-dominate side, hypertension (high blood pressure), and syncope and collapse (fainting). During a review of Resident 7's "Interdisciplinary Team Conference Notes (IDTa healthcare team from different fields working together to provide the best outcomes for each resident)", dated January 9, 2019, indicated the IDT had conducted a bedside conference with Resident 7, and had discussed the plan of care regarding Resident 7's "CVA and left sided weakness." During an observation on April 8, 2019, at 10:03 AM, in the smoking area, Resident 7 was sitting in a wheelchair smoking a cigarette. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 6 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 7's left hand was rested on her lap. Resident 7 placed the cigarette between her lips and propelled the wheelchair with her right hand closer to an ashtray. Resident 7's left hand remained positioned on her lap. Resident 7 removed the cigarette from her lips with her right hand and dropped the cigarette into the ashtray. During a record review and concurrent interview with the MDS coordinator (MDS 1), on April 8, 2019, at 10:32 AM, MDS 1 reviewed the MDS Quarterly Assessment, dated January 5, 2019, under "Section I (Active Diagnoses)", and stated the MDS assessment was not coded for hemiplegia or hemiparesis during the MDS process. MDS 1 stated the MDS assessment should have been coded for hemiplegia and hemiparesis to reflect Resident 7's hemiplegia and left sided weakness. During an observation on April 9, 2019, at 9:45 AM, Resident 7 was sitting in a wheelchair propelling down the hall way with her right hand and right foot. Resident 7's left hand was positioned on her lap and the left foot was positioned on the foot rest of the wheelchair. During an interview with Resident 7, on April 9, 2019, at 10:05 AM, Resident 7 stated she was not able to move her left hand or left leg without assistance due to a stroke and a hip injury. During a record review and concurrent interview with the physical therapist (PT 1), on April 9, 2019, at 11:30 AM, PT 1 reviewed Resident 7's "Rehabilitation Case Management Assessment" dated April 11, 2018, and stated she had completed the assessment last year on April 11, 2018. PT 1 stated Resident 7's assessment indicated "left sided weakness and hemiplegia due to a late effect of the CVA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 7 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (cerebrovascular accident also known as a stroke)." PT 1 stated Resident 7 could propel the wheelchair with her right hand and was not able to propel the wheelchair with the left hand due to the hemiplegia. The facility policy and procedure titled "Policy and Procedure on Resident Assessment Instrument", dated October 2014, indicated "It is the facility's policy to provide appropriate care and services to residents by conducting initial and periodical comprehensive assessment of each resident's functional capacity ...7. Each member of the interdisciplinary team who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment."2. During a review of Resident 34's clinical record, the document titled "Record of Admission" (contains demographic and medical information), undated, indicated Resident 34 was readmitted to the facility on February 14, 2018, with diagnoses which included Atherosclerotic heart disease (Plaque buildup within the heart's blood vessels), Hypertension (high blood pressure), Diabetes (a disease which results in elevated blood sugar), and hyperlipidemia (high level of fats in the blood). During an observation and concurrent interview with Resident 34, on April 9, 2019, at 9:08 AM, Resident 34 did not have a foley catheter. Resident 34 stated she previously had a foley catheter but it was taken out in December 2018. During a review of the clinical record for Resident 34, the MDS, dated February 26, 2019, section H0100 (Bladder and Bowel Section) indicated Resident 34 had a foley catheter. During further review of the clinical record for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 8 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 34, a physicians order, dated December 9, 2018, indicated "May D/C (discontinue) F/C (foley catheter) per request" (more than two months prior to the completion of the MDS). A review of nurse progress notes, dated December 9, 2018, for Resident 34, indicated the foley catheter was removed. A review of the CNA (Certified Nursing Assistant) ADL (activities of daily living) Tracking Form (a form used to track daily activities such as toileting, bathing and eating), dated January and February 2019, indicated the resident did not have a foley catheter. During record review and concurrent interview with the Assistant Director of Nursing (ADON), on April 11, 2019, at 11:48 AM, the ADON stated she was familiar with Resident 34 and the resident did not have a foley catheter for the last three months. The ADON reviewed the clinical record for the resident and was unable to find a current MD order for a foley catheter. She stated the last foley catheter was discontinued in December 2018. The ADON also reviewed the CNA-ADL Tracking Form for January and February 2019, and stated the documents indicated the resident did not have a catheter and the MDS dated February, 26, 2019, was incorrect. During an interview with the Minimum Data Set Nurse 1, on April 15, 2019, at 10:41 AM, the Minimum Data Set Nurse 1 reviewed the clinical record for Resident 34 and stated the MDS dated February 26, 2019, should not have indicated Resident 34 had a foley catheter and the MDS needed to be corrected. The facility policy and procedure titled "Policy and Procedure on Resident Assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 9 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Instrument" dated October 2014, indicated "Policy. It is this facility's policy to provide appropriate care and services to residents by conducting initial and periodic comprehensive assessment of each resident's functional capacity. The comprehensive assessment of a resident's needs shall be based on the State's RAI (Resident Assessment Instrument) which includes both the Minimum Data Set (MDS) version 3.0 and Care Area Assessments (CAA). A review of the MDS 3.0 RAI Manual titled "Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual" version 1.15, dated October 2018, section H0100 Appliances, indicated "Check next to each appliance [including foley catheters] that was used at any time in the past 7 days. Select none of the above if none of the appliances AD were used in the past 7 days." 3. During a review of Resident 79's clinical record, the document "Record of Admission" (contains demographic and medical information), undated, indicated Resident 79 was readmitted to the facility on December 30, 2017, with diagnoses which included Hypertension (high blood pressure), Chest pain, Shortness of breath and muscle weakness. During a review of the clinical record for Resident 79, the MDS dated March 29, 2019, section N0410 (medications received) indicated the resident received an anticoagulant. A review of Resident 79's Medication Administration Record (MAR - a record used to document the administration of medications), dated March 1, 2019 through March 31, 2019, indicated Resident 79 was not administered an anticoagulant. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 10 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 79's current physicians orders, dated March 1, 2019 through March 31, 2019, indicated Resident 79 did not have a physician's order for an anticoagulant during the time of the completion of the MDS. A review of Resident 79's weekly nursing progress notes dated March 1, 2019 through March 31, 2019, did not indicate an anticoagulant was administered to Resident 79 under the section "Current Medications". During a record review and concurrent interview with the Minimum Data Set Nurse 1, on April 14, 2019, at 8:33 AM, she reviewed the clinical record for Resident 79 and was unable to find evidence that an anticoagulant was administered to the resident in March 2019. Minimum Data Set Nurse 1 stated the MDS dated March 29, 2019, incorrectly indicated the resident was taking an anticoagulant medication. During a record review and concurrent interview with the Assistant Director of Nursing (ADON), on April 12, 2019, at 9:57 AM, She reviewed the clinical record for Resident 79 and stated there was no evidence the resident was taking an anticoagulant and the MDS, dated March 29, 2019, was incorrect. The facility policy and procedure titled "Policy and Procedure on Resident Assessment Instrument" dated October 2014, indicated "Policy. It is this facility's policy to provide appropriate care and services to residents by conducting initial and periodic comprehensive assessment of each resident's functional capacity. The comprehensive assessment of a resident's needs shall be based on the State's RAI (Resident Assessment Instrument) which includes both the Minimum Data Set (MDS) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 11 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE version 3.0 and Care Area Assessments (CAA). A review of the MDS 3.0 RAI Manual titled "Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual" version 1.15, dated October 2018, section N0410 (medications received), indicated "Steps for Assessment - 1. Review the resident's medical record for documentation that any of these medications were received by the resident during the 7 day look-back period ..."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 05/15/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 12 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement a revised comprehensive person-centered care plan (an individualized plan of care written for residents to guide staff in implementing interventions for identified concerns) to prevent further low blood sugar events for one of 26 sampled residents (Resident 82). This failure resulted in no documented interventions to prevent an avoidable low blood sugar event which resulted in a peripheral intravenous (IV-within the vein) access site inserted below the arteriovenous fistula (a surgical access site formed by the joining of a vein and an artery in the arm) on the left arm for hemodialysis (a process of purifying the blood whose kidneys are not working normally). Resident 82 received a second dose of Dextrose 50 % (percentage) through an IVP (intravenous push- a bolus of fluid through an IV line, administered all at once) for neurological impairment, altered level of consciousness, inability to swallow oral glucose, and cold and clammy skin. Findings: During a review of the clinical record for Resident 82, the "Record of Admission (demographic and medical information)" indicated Resident 82 was admitted to the facility on March 18, 2019, with diagnoses of diabetes mellitus (abnormal blood sugar/glucose control) with hypoglycemia (low blood sugar), end stage renal disease (kidney disease), dependence on renal dialysis (machine-artificial kidneys to purifying the blood), and difficulty in walking. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 13 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation and concurrent interview with Resident 82, on April 11, 2019, at 10:07 AM, Resident 82 was sitting in the wheelchair outside of her room. Resident 82 started to cry and stated she did not want to die. Resident 82 was wearing a gray long sleeve blouse that covered her arms and extended over the left wrist. Resident 82 stated she had an IV line in her "left arm". Resident 82 lifted up the blouse and the IV site was observed on the lower part of her left arm and above the hand. Resident 82 lifted her blouse further and the AV-shunt was viewed. Resident 82 stated the "kidney doctor (nephrologist)" had indicated she was not to have a blood pressure or blood drawn from the left arm. Resident 82 stated, "I protect this arm." Resident 82 stated she was worried about the AV-shunt malfunctioning due to the IV line in her left arm. Resident 82 stated she had requested the facility to remove the IV line but the facility did not. Resident 82 stated the facility said the IV line would be removed before she went to the dialysis center. During a record review and concurrent interview with the Minimum Data Set Nurse (MDS 1), on April 11, 2019, at 10:50 AM, MDS 1 stated the care plan was not revised after the hypoglycemic event on April 9, 2019. MDS 1 stated the care plan should have been revised to prevent avoidable declines in functioning or functioning level in accordance to policy and procedure. During an interview with the Registered Nurse Supervisor (RN/Sup), on April 15, 2019, at 12:15 PM, the RN/Sup stated she was the assigned Registered Nurse Supervisor on April 9, 2019 and April 11, 2019. The RN/sup stated the care plan had not been updated after Resident 82's hypoglycemic event on April 9, 2019. The RN/sup stated the care plan should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 14 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE have been updated or revised to reflect the change in care and Resident 82's condition. During an interview with the Director of Staff Development (DSD), on April 15, 2019, at 11:55 AM, the DSD stated the facility should have assessed for the potential risk or the underlining cause of Resident 82's change in condition to guide the revision of the care plan. The DSD stated the care plan was not revised after the change in condition. The facility policy and procedure titled, "Policy and Procedure on Care Plan" dated October 2014, indicated "7. Care Plans should be oriented to prevention of avoidable declines in functioning or functioning level. 8. Care Plans must show evidence of facility's effort to address or manage risk factors." The facility policy and procedure titled, "Policy and Procedure on Pre and Post Dialysis Monitoring" dated October 2014, indicated "Procedures: 1. Licensed nurse shall monitor resident and document on pre and post dialysis observations in the clinical record or using prescribed form. 2. Licensed nurse shall monitor and document on patient's condition before and after dialysis treatment such as vital signs including pain, conditions of hemodialysis access, blood sugar level, level of consciousness, others as indicated. Before Dialysis Procedure: ...3. If resident present with changes in condition (abnormal vital signs, shunt malfunction, altered level of consciousness) notify physician immediately. Also call and notify dialysis center of resident condition. 4. If resident is cleared to go to dialysis center, arrange transportation services and secure transfer information for the dialysis center."

F684 Quality of Care FORM CMS-2567(02-99) Previous Versions Obsolete

F684 Event ID: 207B11 05/15/2019 Facility ID: CA240000060 If continuation sheet 15 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.25 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure treatment and services were provided in accordance to the facility's policy and procedure for two of 26 sampled residents (Residents 7 and 86) when: 1. For Resident 7, a smoking protective apron and supervision was not provided when the quarterly smoking assessment and care plan indicated Resident 7 could not safely light and hold a cigarette in her left hand due to hemiplegia (unable to move one side of the body). These failures placed Resident 7 at a greater risk for injury, such as skin burns. 2. For Resident 86, Restorative Nursing Services (RNA) was not provided in accordance to the physician's order. This failure had the potential to worsen Resident 86's hand contractures (abnormal stiffness) that could negatively affect Resident 86's highest practicable level of health and well-being. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 16 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. During a review of the clinical record for Resident 7, the "Record of Admission (demographic and medical information)" indicated Resident 7 was admitted to the facility on July 18, 2017, with diagnoses of hemiplegia and hemiparesis (weakness to one side of the body) following a cerebral infarction (stroke-blockage or narrowing of blood flow in the brain) affecting non-dominate side, hypertension (high blood pressure), and syncope and collapse (fainting). During an observation on April 8, 2019, at 10:03 AM, in the smoking area, Resident 7 was sitting in a wheelchair unsupervised smoking a cigarette without a protective apron, with her right hand. Resident 7's left hand was rested on her lap. Resident 7 placed the cigarette between her lips and propelled the wheelchair with her right hand closer to an ashtray. Resident 7's left hand remained positioned on her lap. Resident 7 removed the cigarette from her lips with her right hand and dropped the cigarette ash into the ashtray. During an interview with Resident 7, on April 8, 2019, at 10:04 AM, Resident 7 stated the facility did not provide supervision for her when she smoked. Resident 7 asked, "Are they supposed to supervise me when I smoke?" Resident 7 stated she had never been offered a protective apron. Resident 7 asked, "Where do I get a protective apron from?" Resident 7 stated she was not able to use her left hand due to weakness in the left hand. During an interview with the Licensed Vocational Nurse (LVN 5), on April 8, 2019, at 10:09 AM, in the nurse's station, LVN 5 stated the smoking hours were posted on the door which lead to the designated smoking area. LVN 5 stated smoking monitoring staff (SMS) were assigned to monitor the residents during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 17 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE smoking hours. LVN 5 stated she did not know who was assigned to monitor the smoking area on April 8, 2019, at 10:00 AM. LVN 5 went out to the smoking area and stated she had observed Resident 7 smoking in the smoking area without supervision and without a protective apron. LVN 5 stated a SMS should have been in the smoking area when a resident is smoking. During a follow-up observation on April 8, 2019, at 10:25 AM, Resident 7 was in the smoking area, without supervision or a protective apron. Resident 7 was using her right hand to smoke and the left hand was positioned on her lap. There was no movement observed from Resident 7's left hand. During a record review and concurrent interview with the Minimum Data Set Nurse (MDS 1), on April 8, 2019, at 10:43 AM, MDS 1 stated Resident 7's smoking assessment score was two, dated January 7, 2019, indicating Resident 7 should have been supervised during smoking hours. MDS 1 stated Resident 7's care plan for "Smoking" dated April 4, 2019, indicated Resident 7 should have had a smoking protective apron applied when smoking. MDS 1 stated smoking assessments are conducted on admission to the facility, quarterly and as needed. MDS 1 stated she was not able to find documentation in the clinical chart indicating Resident 7 had refused a smoking protective apron. During an interview with SMS 1, on April 9, 2019, at 9:25 AM, SMS 1 stated he arrived at the smoking area on April 8, 2019, at 10:30 AM. SMS 1 stated he was 30 minutes late to the smoking area. SMS 1 stated he did not know who would monitor the smoking area if he was late. SMS 1 stated he should have notified the charge nurse that he was going to be late. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 18 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SMS 1 stated he had been employed by the facility for one year and he had not monitored Resident 7 for smoking. SMS 1 stated the facility provides a list of the residents that requires smoking monitoring and supervision. SMS 1 stated Resident 7 has never been on the smoking list for monitoring and supervision. During a record review and concurrent interview with the physical therapist (PT 1), on April 9, 2019, at 11:30 AM, PT 1 reviewed Resident 7's "Rehabilitation Case Management Assessment" dated April 11, 2018, and stated she had completed the assessment last year on April 11, 2018. PT 1 stated Resident 7's assessment indicated "left sided weakness and hemiplegia due to a late effect of the CVA (cerebrovascular accident also known as a stroke)." PT 1 stated Resident 7 propelled the wheelchair with her right hand and was not able to propel the wheelchair with the left hand due to the hemiplegia. PT 1 stated Resident 7 could not hold a cigarette in her left hand on April 11, 2018. During an interview with the Registered Nurse Supervisor (RN/Sup), on April 15, 2019, at 1:40 PM, the RN/Sup stated residents should have been monitored in the smoking area during the posted smoking schedule. During a follow-up interview with Resident 7, on April 15, 2019, at 1:40 PM, in Resident 7's room, Resident 7 stated she had weakness in the left hand. Resident 7 stated her left hand shakes involuntarily and she could not safely hold a cigarette in the left hand or safely light a cigarette using the left hand. Resident 7 stated her cigarettes had fallen from her mouth and right hand on occasions, especially when it was windy. Resident 7 stated she would ask other residents in the smoking area for assistance if she was unable to light her cigarette. Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 19 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 7 stated the facility did not offer her a protective apron. A review of the Care Plan for Resident 7, titled "Discharge Planning" dated April 7, 2019, indicated "Goal/target Date: Family and physician recognize the need for 24 hour nursing intervention to maintain to maintain present level of functioning. LTC (long term care): Anticipated based on Resident's current healthcare needs. LTC: Resident is dependent in all ADL's (activity of daily living) maintain level of functioning ...LTC: Resident is unable to perform ADL's. The facility policy and procedure titled "Policy and Procedure on Resident Smoking", undated, indicated "It shall be this Facility's policy to allow residents to smoke provided smoking is done in an area and in a manner that does not pose any harm or danger to the Facility, personal property or personal endangerment ...Procedure: 12. Residents who are not capable of smoking paraphernalia (smoking supplies) safely may be placed on schedule and/or supervised smoking ..." The facility policy and procedure titled "Policy and Procedure on Care Plan" dated October 2014, indicated " ... 7. Care Plans should be oriented to prevention of avoidable declines in functioning or functioning levels. 8. Care Plans must show evidence of facility's effort to address or manage risk factors."2. During an observation on April 9, 2019, at 11:56 AM, Resident 86 was asleep and was observed lying on the left side of the bed. Resident 86 was holding both hands towards her chest and observed bilateral hand contractures. Resident 86 was unable to verbalize due to her medical condition. During an interview on April 9, 2019, at 12:12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 20 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE PM, Resident 86's son stated he was aware of the hand contractures. During a record review of Resident 86's physician orders, dated August 8, 2018, it indicated, "Right Hand Splint (a supportive device to immobilize affected limb) and Right Elbow Splint to Prevent Further Contractures and Skin Breakdowns" and "Bilateral Knee Orthotics for Extension." During a second observation on April 11, 2019, at 10:00 AM, Resident 86 did not have splints applied for right hand and right elbow. During an interview on April 11, 2019, at 12:25 PM, the Restorative Nursing Assistant (RNA 1) stated Resident 86 wears a knee splint to prevent contractures and skin breakdown. RNA 1 further stated the splinting was done off and on and interventions for restorative nursing care orders were documented in an RNA binder. During a concurrent record review with RNA 1 of Resident 86's RNA Documentation Sheet, dated for the month of January 2019, it indicated right elbow splint as applied to Resident 86. There was no documented evidence found that right hand splint was being applied for Resident 86. During a concurrent interview with the Licensed Vocational Nurse (LVN 6), she stated the physician ordered the splint to prevent further hand contractures for Resident 86. LVN 6 further stated if the hand splint was not being provided, Resident 86's hand contractures will worsen. A review of facility's policy and procedure titled, "Policy and Procedure On Restorative Nursing Care," dated October 2014, indicated, "10. If FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 21 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE restorative nursing care is provided by the restorative nurse assistant, restorative program including resident's level of performance should be documented in the RNA Progress Notes. 11. Restorative nursing care provided by a certified nurse assistant, e.g., passive range of motion during ADL care, should be documented in the ADL Sheet and/or licensed nurse progress notes.

F689 SS=L Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/15/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of hazards when water temperatures within the facility reached 136.6 °F (Fahrenheit - unit of measure for temperature) in areas where hot water was accessible to residents. This failure lead to unsafe hot water temperatures which had the potential to cause severe burns and scalding to a vulnerable population of 103 Residents. Findings: On April 12, 2019, at 8:46 AM, during the recertification survey, a surveyor returned from using the common restroom located near Nurses Station 2 and across from Room 28. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 22 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The surveyor informed the survey team, the water coming from the sink was noted to feel extremely hot to the touch. The surveyor stated he had to pull his hands back quickly due to how hot the water was despite his attempts to try and balance the temperature with cold water. On April 12, 2019, at 8:51 AM, a surveyor calibrated a digital probe thermometer per the manufacturers recommendations and requested the presence of a member from the maintenance department. The Assistant Maintenance Supervisor (AMS) arrived to assist the surveyor. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:00 AM, The AMS placed his hand under the running water from the sink in the common restroom and snatched his hand back immediately and stated the water was really hot . The AMS further stated he did not have a thermometer with him and that he would use the surveyor's thermometer to test the temperature of the hot water in the sink. The AMS filled a cup with hot running water from the sink and placed a thermometer into the cup for the reading. The AMS read the hot water temperature reading aloud "133.8 °F". The surveyor viewed the thermometer reading for verification and the display showed 133.8 °F. During an observation and interview with AMS, on April 12, 2019, at 9:17 AM, the AMS stated the water temperature in the common restroom was too high and could cause an accident. The AMS rechecked the hot water temperature from the sink in the common restroom located near Nurses Station 2 and stated the temperature was 133.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.8 °F FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 23 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:24 AM, in Room 28's bathroom, the AMS checked the hot water temperature from the sink and stated it was 131 °F. The surveyor viewed the thermometer reading for verification and the display showed 131 °F. The AMS stated the temperature was too high and could cause injury. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:28 AM, in Room 27's bathroom, the AMS checked the hot water temperature from the sink and stated it was 129.4 °F. The surveyor viewed the thermometer reading for verification and the display showed 129.4 °F. The AMS stated the temperature was too high. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:32 AM, in Room 26's bathroom, the AMS checked the hot water temperature from the sink and stated it was 132 °F. The surveyor viewed the thermometer reading for verification and the display showed 132 °F. The AMS stated the temperature should be less than 120 °F. He further stated he did not understand why the temperature was so high. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:37 AM, in Room 25's bathroom, the AMS checked the hot water temperature from the sink and stated it was 132.4 °F. The surveyor viewed the thermometer reading for verification and the display showed 132.4 °F. The AMS stated he would need to discuss the findings with the Maintenance Supervisor (MS). During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:41 AM, in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 24 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Room 29's bathroom, the AMS checked the hot water temperature from the sink and stated it was 136.6 °F. The surveyor viewed the thermometer reading for verification and the display showed 136.6 °F. The AMS stated the water temperature was not getting better. He further stated the water temperature needed to be adjusted for safety. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:47 AM, in Room 16's bathroom, the AMS checked the hot water temperature from the sink and stated it was 136 °F. The surveyor viewed the thermometer reading for verification and the display showed 136 °F. The AMS stated he needed to discuss the high water temperatures with the Maintenance Supervisor (MS). He stated the temperatures needed to be adjusted immediately. He further stated he knew it would take only a minute or two for a burn to occur with water temperatures at 136 °F. During an observation and concurrent interview with the MS, on April 12, 2019, at 9:58 AM, the MS stated he had turned the water temperature up for residents to shower and had forgot to turn the water temperature back down. He further stated the water temperature was turned up to 136 °F, from 6:00 AM to 8:30 AM. The MS stated he monitors the temperature of the water by the gauge in the boiler room. He stated he rarely monitored the water with a thermometer in individual resident rooms. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:15 AM, in Room 5's bathroom, the MS checked the hot water temperature from the sink and stated it was 135.7 °F. The surveyor viewed the thermometer reading for verification and the display showed 135.7 °F. The MS stated the water temperature should be between 105-120 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 25 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE °F and water temperatures above 120 °F could cause injury to the residents and staff. MS further stated he had been turning the water up to 136 °F since 2017. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:24 AM, in Room 16's bathroom, the MS checked the hot water temperature from the sink and stated it was 136 °F. The surveyor viewed the thermometer reading for verification and the display showed 136 °F. The MS stated "too hot." During an observation and concurrent interview with the MS, on April 12, 2019, at 10:33 AM, in the boiler room, the MS stated the boiler room gauge was previously set at 136 °F but he recently adjusted the temperature back to 118 °F after the AMS had notified him of the water temperature findings. The MS demonstrated on the gauge where he set the temperature. He stated he would set the boiler temperature at 136-138 °F. The MS stated it was no determining factor about turning the temperature to 136 °F versus 138 °F, he stated those numbers were just the ones he had used. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:48 AM, in Room 20's bathroom, the MS checked the hot water temperature from the sink and stated it was 134.2 °F. The surveyor viewed the thermometer reading for verification and the display showed 134.2 °F. The MS stated he did not know how long it took for the temperature of the water to reach 120 °F after turning the boiler/heater down. He stated the cooling of the water would depend on if the shower was in use or the hot water was being used. He further stated the water in the resident's sink could possibly burn a resident during shower time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 26 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation and concurrent interview with the MS, on April 12, 2019, at 10:55 AM, in Room 21's bathroom, the MS checked the hot water temperature from the sink and stated it was 133.9 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.9 °F. The MS stated the water temperature was not safe. During an observation and concurrent interview with the MS, on April 12, 2019, at 11:05 AM, in Room 2's bathroom, the MS checked the hot water temperature from room 2's bathroom sink and stated it was 134.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 134.8 °F. The MS stated he had not ever timed how long it took for the water temperature to reach a safe temperature in the residents' room after he had turned the water temperature back to 118 °F. During an interview with Resident 66, on April 12, 2019, at 11:25 AM, Resident 66 stated sometimes the water temperature in the shower gets too hot. Resident 66 further stated while showering, she has tried to turn the knob to balance the water temperature but due to weakness of her hands, she cannot balance the water temperature and would throw the nozzle away from her body to keep from being scalded. During an interview with Resident 75, on April 12, 2019, at 11:33 AM, she stated the water in the sink gets too hot. During an interview with Resident 51, on April 12, 2019, at 11:39 AM, she stated the water gets hot and the knobs are hard to turn due to her hand weakness. During an interview with the Registered Nurse Supervisor (RN/SUP) on April 12, 2019, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 27 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11:50 AM, the RN/SUP stated contact with water temperatures in excess of 120 °F can cause burns within seconds. During a follow up interview with MS, on April 12, 2019, at 12:20 PM, the MS stated he would manually increase or decrease the water temperature on the water heaters/boilers. The MS stated he routinely overrode the automatic shutoff temperature control safety valve. He further stated if the temperature was set at 120 °F, when the temperature reached 120 °F, the boiler would shut off. The MS stated he knew the valve was a safety device but he would override the safety device to warm up the water quickly and had been doing so since January 2017. The MS stated he forgot to decrease the boiler temperature on April 12, 2019. The MS stated he could not explain how each resident was monitored to ensure there were no accidents when the water was turned up during shower time. During an interview with the ADMIN, on April 12, 2019, at 1:44 PM, the ADMIN stated the override of the water temperatures were very disappointing. She further stated she was not aware the water temperatures were being overridden at any time. Review of the facility policy and procedure titled "Policy and Procedure on Patient's Safety" dated October 2014, indicated "Policy. It is the policy of this facility to provide services to each resident that will allow them to maintain their highest practicable level of function and wellbeing, without jeopardy to their safety." Review of the facility policy and procedure titled "Maintenance Service" dated December 2009, indicated "Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 28 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building in good repair and free from hazards ...j. Maintaining water temperatures daily in patient rooms and nursing areas M-F (selected areas on floor plan) maintaining the degrees between 105 degrees to 120 degrees." An Immediate Jeopardy (IJ, a crisis situation in which the health and safety of individual(s) are at risk) was called on April 12, 2019, at 1:38 PM, after water temperature readings taken from one common facility restroom sink and ten resident's bathroom sinks reached temperatures of up to 136.6 ° F. It was discovered a staff member of the facility manually overrode the automatic shutoff temperature control safety valve for the hot water and increased the water temperature of the heaters/boilers to 136 ° F for two and a half hours every day (between 6:00 AM and 8:30 AM). The IJ was called in the presence of the Administrator (ADMIN), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) , and the RN Supervisor (RN/SUP). A Corrective Action Plan (CAP-a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and was received on April 12, 2019, at 4:22 PM. A review of the CAP conducted on April 12, 2019, at 4:57 PM, indicated water heaters/boilers supplying hot water to shower rooms, common restrooms, and residents bathrooms, were returned or remained at a maximum temp of 120 °F and hot water temperature checks were to be taken every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 29 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hour to ensure water temperatures were no longer a danger to residents. Residents were assessed for burns and/or scalding and the staff member who manually overrode the automatic shutoff temperature control safety valve, was given directives to never override the water safety valve. Additionally, an inservice was conducted with all staff members instructing them to report to the maintenance department, any water temperatures that feel too hot. During a follow up interview with the ADMIN, on April 15, 2019, at 9:46 AM, the ADMIN stated she was shocked the MS was manually adjusting the water temperature on the water heaters and increasing the temperature above the safety guidelines indicated by the state. She further stated it is not ok to override the automatic shutoff temperature control safety valve and increase the water temperature of the boilers because it can cause burns to the residents. During an interview with the ADON on April 15, 2019, at 10:18 AM, the ADON stated the water temperature in sinks and showers should always be between 105 °F and 120 °F. She further stated if the water exceeds 120 °F, it can cause burns to the residents. After the acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review the IJ was lifted on April 15, 2019, at 1:50 PM, in the presence of the ADMIN, ADON and RN/SUP.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 05/15/2019 §483.25(l) Dialysis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 30 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide communication to the dialysis center for one of 26 sampled residents (Resident 82) when Resident 82 had a hypoglycemia (low blood sugar) event. This failed practice had the potential for unmet coordination of care between the facility and dialysis center, which had the potential to jeopardize Resident 82's health, safety and welfare. Findings: During a review of the clinical record for Resident 82, the "Record of Admission (demographic and medical information)" indicated Resident 82 was admitted to the facility on March 18, 2019, with diagnoses of diabetes mellitus (abnormal blood sugar/glucose control) with hypoglycemia, end stage renal disease (kidney disease), dependence on renal dialysis (machine-artificial kidneys to purifying the blood), and difficult in walking. During an observation and concurrent interview with Resident 82, on April 11, 2019, at 10:07 AM, Resident 82 was sitting in the wheelchair outside of her room. Resident 82 was alert, oriented (to place, time, and place), and started to cry. Resident 82 stated she did not want to die. Resident 82 was wearing a gray long FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 31 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sleeve blouse that covered her arms and extended over the left wrist. Resident 82 stated she had an IV line in her "left arm". Resident 82 lifted up the blouse and the IV site was observed on the lower part of her left arm and above the hand. Resident 82 lifted her blouse further and the AV-shunt was viewed. Resident 82 stated the "kidney doctor (nephrologist)" had indicated she was not to have a blood pressure or blood drawn from the left arm. Resident 82 stated, "I protect this arm." Resident 82 stated she was worried about the AV-shunt malfunctioning due to the IV line in her left arm. Resident 82 stated she had requested the facility to remove the IV line but the facility did not. Resident 82 stated the facility said the IV line would be removed before she went to the dialysis center. During a telephone interview with the Dialysis Registered Nurse Supervisor (DSRN), on April 15, 2019, at 9:58 AM, the DSRN stated the facility had not communicated the change in Resident 82's health status when the IV line was accessed in the same extremity where the AV-shunt was located, the altered level of consciousness, the low blood sugar, or the dextrose (sugar) administration. The DSRN stated the "Dialysis Medical Director" should have been informed that the extremity where the AV-shunt was located had been used to administer fluids. The DSRN stated the facility did not follow the contract agreement titled "Nursing Home Dialysis Transfer Agreement" dated 2018, for providing treatment information to the dialysis center including medications and any changes in the resident's condition (physical or mental) to ensure proper care was provided for Resident 82. During an interview with the Registered Nurse Supervisor (RN/Sup), on April 15, 2019, at 12:15 PM, the RN/Sup stated the facility did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 32 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notify the dialysis center about Resident 82's change in condition or the treatment provided on April 9, 2019 and April 11, 2019, in accordance to the facility policy and the written agreement between facility and dialysis center. The facility policy and procedure titled, "Policy and Procedure on Pre and Post Dialysis Monitoring" dated October 2014, indicated "Procedures: 1. Licensed nurse shall monitor resident and document on pre and post dialysis observations in the clinical record or using prescribed form. 2. Licensed nurse shall monitor and document on patient's condition before and after dialysis treatment such as vital signs including pain, conditions of hemodialysis access, blood sugar level, level of consciousness, others as indicated. Before Dialysis Procedure: ...3. If resident present with changes in condition (abnormal vital signs, shunt malfunction, altered level of consciousness) notify physician immediately. Also call and notify dialysis center of resident condition. 4. If resident is cleared to go to dialysis center, arrange transportation services and secure transfer information for the dialysis center." The facility policy and procedure titled, "Policy and Procedure on Dialysis Care" dated October 2014, indicated "Procedure: "2. Written contract and/or agreements shall contain provisions on how to maintain communication by and between facility and dialysis centers to ensure proper care is provided to residents ..."

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 05/15/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 33 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a licensed nurse administered medication as ordered by the physician for one of 26 sampled residents (Resident 68) when an ipratropium bromide 0.5 milligram (mg-unit of measurement) and albuterol sulfate 3 mg (a combination of two drugs used to treat and prevent wheezing and shortness of breath-SOB) inhalation solution (solution of medication in the form of a mist inhaled into the lungs.) was administered to the resident instead of albuterol sulfate 2.5 mg inhalation solution sulfate. This failure had the potential to alter the desired effect of the medication and administering the wrong medication could jeopardize the health and well-being of the resident. Findings: During a medication administration observation on April 10, 2019, at 5:33 AM, Licensed Vocational Nurse (LVN 1) removed the ipratropium bromide and albuterol sulfate solution from the bottom drawer of the Station 3's medication cart and poured the solution into the medicine nebulizer (med neb - a drug delivery device used to administer the medicine in the form of a mist inhaled in to the lungs) and administered the medication to Resident 68. During a review of Resident 68's clinical record, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 68 was admitted on February 9, 2019, with a diagnosis of Chronic Obstructive pulmonary disease (COPD- progressive lung disease makes hard FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 34 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to breathe). A review of Resident 68's History and Physical examination (H&P), dated February 11, 2019, indicated Resident 68 had the capacity to understand and make decisions. During a review of Resident 68's monthly recapitulation (an order summary report, usually each month to summarize patient's medical information and doctor's orders) for April 1, 2019, through April 30, 2019, indicated, "albuterol med neb 0.5% Q 4H (Every four hours) PRN (as needed) for SOB (Shortness of Breath)." A further review of Resident 68's "Transfer Medication Order Sheet", dated February 9, 2019, indicated "albuterol medneb [medication nebulizer] 2.5 mg every 4 hours as needed PRN and ipratropium medneb every 4 hours as needed for SOB" was discontinued. During further review of the Medication Administration Record (MAR- record of drugs administered to the resident) for Resident 68, indicated Resident 68 had only albuterol 0.5% ordered Q4 hours PRN for SOB. During a concurrent interview and record review with LVN 1, on April 10, 2019, at 7:28 AM, LVN 1 reviewed Resident 68's MAR and confirmed Resident 68 did not have an order for ipratropium bromide and albuterol sulfate. LVN 1 stated the resident was supposed to have albuterol sulfate inhalation solution alone. LVN 1 further confirmed she took the ipratropium bromide and albuterol sulfate inhalation solution from another resident's (Resident 699) medication box and administered the it to Resident 68. LVN 1 acknowledged she did not follow the physician's order by checking the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 35 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MAR and did not follow the five rights of medication administration (right drug, right dosage, right patient, right route, right time). During a review of Resident 699's clinical record the form titled "Medications and Treatments", dated April 3, 2019, indicated "ipratropium-albuterol 2.5mg-0.5mg/3ml SOB." During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on April 12, 2019, at 8:25 AM, the ADON reviewed Resident 68's monthly recap dated April 1 through April 30, 2019, and stated Resident 68 did not have an order for ipratropium bromide and albuterol sulfate inhalation and staff are not supposed to administer medications to any resident other than who it was prescribed for. She further stated staff are expected to check the MAR against the physician's order prior to administering the medications. The ADON further reviewed the facility's policy and procedure titled "Medication and treatment administration", dated October 2014, and stated the staff did not follow the policy and procedure. A review of the facility's policy and procedure titled "Policy and Procedure on Medication Administration and Treatment" dated October 2014, indicated " ...16. Before administering medication, check every medication against physician's order and transcription in the medication administration or treatment record ... 17. No medication shall be used for any resident other than the resident for whom the medication was prescribed ..."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/15/2019 §483.45(g) Labeling of Drugs and Biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 36 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure: 1. For Resident 47, Norco ( a controlled medications {medications regulated by the government for use and possession} used to treat pain was labeled for the resident was stored separately from facility stock; 2. For Residents 33 and 351, medications discontinued by the physician were properly marked and disposed of in accordance to the facility's policy and procedure and, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 37 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. For Residents 94, 348, 349, 350, and 5, medications labeled for individual residents were stored separately from facility stock medications in accordance to the facility's policy and procedure. These failed practices placed the facility's residents at a greater risk for medication error affecting eight of 26 sampled residents. Findings: 1. During a review of Resident 47's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 47 was readmitted to the facility on February 9, 2019, with diagnoses of rheumatoid arthritis (swollen, painful joints), muscle weakness, and diabetes (abnormal blood sugar control). During an observation with the Assistant Director of Nursing (ADON), on April 10, 2019, at 8:10 AM, in Station 2's medication room, a bottle containing sixteen Norco (controlled pain reliever) 5-325 mg (milligrams-unit of measurement) tablets were stored with the facility's stock medications (non-controlled medications). The sixteen Norco tablets were labeled for Resident 47. During an interview with the ADON, on April 10, 2019, at 8:20 AM, the ADON stated she did not know Resident 47's Norco tablets were stored with the facility's stock medications. The ADON stated the Norco tablets should not have been stored with the stock medication. The ADON further stated controlled medications should not have been stored unsupervised. 2a. During a review of Resident 33's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 33 was readmitted to the facility on January 30, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 38 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2019, with diagnoses of chronic obstructive pulmonary (lung disease), chronic viral hepatitis (liver disease), and muscle weakness. During an observation with the Registered Nurse (RN 1), on April 10, 2019, at 5:40 AM, in Station 3's intravenous medication room, Levofloxacin (medication used to treat infections) 500 mg was labeled for Resident 33 and was available for use. During an interview with RN 1, on April 10, 2019, at 5:42 AM, RN 1 stated Levofloxacin was discontinued on April 4, 2019, and the medication should have been removed from the medication room. RN 1 stated when a physician discontinues a medication, the medication is flagged (marked) on the medication container. RN 1 stated there was no sticker or handwritten note indicating Levofloxacin was discontinued on April 4, 2019. 2b. During a review of Resident 351's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 351 was admitted to the facility on April 1, 2019, with diagnoses of paraplegia (not able to move the legs and lower body), open wound to right lower leg, open wound to left lower leg, and methicillin resistant staphylococcus aureus (MRSA-bacterial infection). During an observation with RN 2, on April 10, 2019, at 7:26 AM, on Station 3 in the intravenous cart, two vials of vancomycin 1gm (medication to treat infections) were labeled for Resident 351 and were available for use. During an interview with RN 2, on April 10, 2019, at 7:31 AM, RN 2 stated the two doses of vancomycin were discontinued on April 9, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 39 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2019, and the medication should have been removed from the intravenous medication cart. 3a. During a review of Resident 94's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 94 was admitted to the facility on February 27, 2019, with diagnoses of hemiplegia (paralysisunable to move one side of the body) and hemiparesis (weakness affecting one side of the body), muscle weakness, hypertension (high blood pressure), upper respiratory infection (lung infection), and peripheral autonomic neuropathy (nerve damage). During an observation with RN 1, on April 10, 2019, at 5:15 AM, in Station 3's intravenous medication room, quetiapine (medicine to treat mental disease) tablets 50 mg, gabapentin (seizure medication) 100 mg tablets, Lisinopril (blood pressure medication) 5 mg tablets, spironolactone (medicine to treat blood pressure and to reduce body fluid) 25 mg tablets, carvedilol (medicine to treat heart failure) 6.25 mg tablets, Furosemide (medicine to reduce body fluid) 40 mg tablets, and potassium chloride (mineral supplement) 10 mg tablets were labeled for Resident 94 and were available for use. During an interview with RN 1, on April 10, 2019, at 5:26 AM, RN 1 stated Resident 94 was discharged on March 30, 2019. RN 1 stated Resident 94's medications should have been sent home with Resident 94 or discarded on March 30, 2019. RN 1 stated Resident 94's medications should not have been stored in Station 3's medication room with intravenous medications and supplies. 3b. During a review of Resident 348's clinical record the "Record of Admission (demographic and medical information)" indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 40 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 348 was admitted to the facility on March 9, 2019, with diagnoses of diverticulosis (bulging pouches in the digestive tract), peripheral autonomic neuropathy (nerve damage), abnormal gait (difficulty in walking), and muscle weakness. During an observation with RN 1, on April 10, 2019, at 5:09 AM, in Station 3's medication room, erythromycin (medicine to treat infections) .5% (percent-unit of measurement) ointment was labeled for Resident 348 and was available for use. During an interview with RN 1, on April 10, 2019, at 5:12 AM, RN 1 stated Resident 348 was discharged on March 23, 2019. RN 1 stated the medication should have been discarded on March 23, 2019. 3c. During a review of Resident 349's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 349 was admitted to the facility on January 23, 2019, with diagnoses of hypertension (high blood pressure), diabetes mellitus (abnormal blood glucose control), and hypothyroidism (an underproduction of chemicals in the blood that convert food into energy). During an observation with RN 1, on April 10, 2019, at 5:21 AM, in Station 3's intravenous medication room, levothyroxine (medicine to treat hypothyroidism) 100 mg was labeled for Resident 349 and was available for use. During an interview with RN 1, on April 10, 2019, at 5:24 AM, RN 1 reviewed the medication label and stated Resident 349 was discharged on March 5, 2019. RN 1 stated the levothyroxine should have been properly marked and disposed in accordance to the facility's policy and procedure on March 5, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 41 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2019. 3d. During a review of Resident 350's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 350 was admitted to the facility on April 4, 2019, with diagnoses of chronic obstructive pulmonary disease (lung disease), diabetes (abnormal blood glucose control), and shortness of breath (difficult breathing). During an observation with RN 1, on April 10, 2019, at 5:26 AM, in Station 3's intravenous medication room, Lactulose (medicine to treat constipation) 10 gm/15 ml (milliliter-unit of measurement) was labeled for Resident 350 and was available for use. During an interview with RN 1, on April 10, 2019, at 5:30 AM, RN 1 stated Resident 350 expired (died) on April 5, 2019. RN 1 stated the medication should have been properly marked and disposed on April 5, 2019. 3e. During a review of Resident 5's clinical record the "Record of Admission (demographic and medical information)" indicated Resident 5 was readmitted to the facility on March 18, 2019, with diagnoses of end stage renal disease (kidney disease), diabetes mellitus (abnormal blood glucose control), and muscle weakness. During an observation with the ADON, on April 10, 2019, at 6:32 AM, in Station 3's intravenous medication room, sertraline hydrochloride (medicine to treat depressive disorders) 50 mg tablets were labeled for Resident 5 and were available for use. During an interview with ADON, on April 10, 2019, at 6:35 AM, the ADON reviewed the label on the medication bottle and stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 42 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 5's sertraline hydrochloride was labeled for home use and should not be stored with the intravenous medications and supplies. The facility policy and procedure titled "IV (Intravenous) Medication Storage in the Facility" undated, "Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Procedure: Medications labeled for individual residents are stored separately form floor stock medications when not in the medication cart ..." The facility policy and procedure titled "Policy and Procedure on Drug Disposition" dated October 2014, indicated "Policy: Drugs discontinued by a physician order and outdated drugs cannot be returned to the pharmacy and are to be properly marked and disposed in accordance with California's Medical Waste Management Act. Documentation of the disposal is to be maintained. Procedures: If a physician discontinues a non-controlled drug or controlled drug, the drug container is to be flagged with a discontinued drug sticker or handwritten of a similar meaning."

F801 SS=F Qualified Dietary Staff CFR(s): 483.60(a)(1)(2)

F801 05/15/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 43 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 44 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the competency of staff and adequate oversite of the kitchen when: 1. The Certified Dietary Manager (CDM): a. Did not ensure dietary staff covered facial hair; b. Did not ensure the menu was followed for mechanical soft diet; c. Did not ensure proper cool down procedures for ambient temperature prepared food. 2. The Registered Dietician (RD): a. Did not ensure dietary staff covered facial hair; b. Did not ensure the menu was followed for mechanical soft diet; c. Did not know the cool down requirement for ambient temperature prepared food. These failures had the potential to lead to an inadequate nutrient intake as well as intake of food with an inappropriate texture; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 45 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contamination of food, utensils, and equipment; and food borne illness to an already compromised universe of 103 residents who ate food from the kitchen out of a census of 104. 1. a. A review of the facility's "Director of Food Services" job description signed by the CDM on June 6, 2016, indicated his responsibilities included monitoring of "food service personnel to assure that they are following established safety regulations in the use of equipment and supplies." During an observation in the kitchen on April 8, 2019, at 11:35 AM, the Dietary Cook (DC 1) was observed with an uncovered mustache and short beard while preparing resident meals during trayline (a preparation of meal trays in the kitchen to be delivered to residents). During an interview with the CDM on April 9, 2019, at 9:53 AM, the CDM stated all facial hair should be covered. The CDM further stated, "Well if it's [the facial hair] thin, then that's okay." The facility document titled "Competencies for Food and Nutrition Services Employees" dated March 13, 2018, indicated DC 1 successfully completed the critical skill of "Infection Control Practice/Employee Hygiene ...Uses Hair restraints and beard guards properly ..." when the CDM; who is responsible for evaluating the competency of dietary staff regarding food and nutrition safety and regulations, signed off DC 1's competency evaluation. The Federal Food Code, dated 2017, indicated " ...food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 46 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-serve and single-use articles." b. A review of the lunch "Daily Spreadsheet" dated Fall/Winter 2018/2019 Monday-Day 2 (April 8, 2019), indicated, wild rice blend or steamed white rice for a resident on a mechanical soft diet (a change in the texture of food). The menu also indicated "Broth 1 oz [ounce]"written under the rice. During an interview and concurrent observation on April 8, 2019, at 11:55 AM, DC 1 did not add broth to the mechanical soft rice. He stated he did not add broth because only white rice needed the broth and he served the wild rice. When the surveyor asked the CDM if the menu indicated that both types of rice were supposed to have 1 ounce of broth added, he stated he did not think so and he would get confirmation from the company that provided the menus. A review of the email correspondence from the company that provided the menu, dated April 9, 2019, at 3:38 PM, indicated "We have spoken with our Menu Development team ...we added 1 oz of broth to all rice for Mech [mechanical] Soft to add moisture and especially to cover instances with poorly rice execution ..." in response to the CDM asking why does the steam white rice require 1 oz of broth for mechanical soft diet. During an interview with the CDM on April 10, 2019, at 8:47 AM, after reviewing the e-mail from the menu company that stated all rice for mechanical soft diets receives broth, the CDM stated the dietary cooks make the decision to add or remove broth from the specified food item. The CDM stated the dietary cooks were trained by himself and the RD to know if the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 47 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE food was moist enough for a mechanical soft diet. The CDM further acknowledged DC 1 did not follow the menu by not having broth readily available to add to the rice for mechanical soft diets for lunch on 4/8/19. The facility's policy and procedure titled "Facility Nutrition Program" revised April 2007, indicated the CDM "will oversee the activities and functions of the kitchen staff (i.e. those responsible for storing, preparing, and delivering meals), including food storage and preparation, sanitation issues, personnel matters, and menu planning and preparation. The facility was unable to provide documented evidence of dietary cook training and comprehensive evaluation/testing on determining appropriate moisture of mechanically altered food when dietary cooks are independently making the decision to omit a food item on the menu spreadsheet. The facility's policy and procedure titled "Menus" revised October 2008, indicated "Menus shall ...c) be followed." c. The facility's policy and procedure titled "Facility Nutrition Program" revised April 2007, indicated the CDM "will oversee the activities and functions of the kitchen staff (i.e. those responsible for storing, preparing, and delivering meals), including food storage and preparation, sanitation issues, personnel matters, and menu planning and preparation. An interview with DC 2 on April 9, 2019 at 9:36 AM, she stated there is a cool down process but indicated the staff rarely perform the cool down procedure since they don't use leftovers. During a concurrent interview with the CDM and DC 2 on April 9, 2019, at 9:42 AM, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 48 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CDM stated that dietary staff will make large amounts of tuna from large cans of tuna stored in the refrigerator. Also, the dietary staff would get a small can of tuna from the dry storeroom when small quantities of tuna salad was made. The CDM further stated, any leftover tuna salad is stored in the refrigerator. The DC 2 stated when making tuna salad "we use what we need, date it, then store it in the refrigerator" for 3 days. During an interview with the Dietary Aide (DA 1) on April 9, 2019, at 9:45 AM, she stated both small and large cans of tuna are obtained from the dry storeroom to make tuna salad. The DA 1 stated she places leftover tuna salad made from the ambient temperature (room temperature) tuna in the refrigerator for up to 3 days. She acknowledged she does not take the temperature of the tuna salad to ensure safe cooldown. A review of the facility's "Cool Down Log" dated January 2019 through March 2019, indicated "Examples of potentially hazardous food to be monitored ...cold sandwich fillings such as tuna or egg salad ..." The Federal Food Code, dated 2017, indicated "Time/Temperature control for safety food shall be cooled within 4 hours to 5°C [degrees Celsius-a unit of measurement] (41°F) [degrees Fahrenheit, a unit of measurement] or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna." 2. a. A review of the facility's "Dietitian" job description signed by the RD on August 1, 2017, indicated the purpose of position was "to plan, organize, develop and direct the overall operation of the Food Service Department in accordance with current federal, state, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 49 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE local standards ..." her responsibilities included assuming "the administrative authority, responsibility and accountability of directing the Food Services Department" and to "Be sure food service personnel are performing required duties and appropriate food service procedures are being rendered to meet the needs of the facility," in addition, ensure that food service work areas are maintained in a clean and sanitary manner." During an observation in the kitchen on April 8, 2019, at 11:35 AM, the Dietary Cook (DC 1) was observed with an uncovered mustache and short beard while preparing resident meals during trayline.(Cross-reference F801; 1,a) During an interview with the RD on April 10, 2019, at 10:08 AM, the RD stated she would not expect staff to wear a facial hair covering if the hair is thin. She further stated if there was a large amount of hair, "like a full beard, then yes I would expect it to be covered." A review of "The Federal Food Code,"dated 2017, indicated " ...food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-serve and singleuse articles." A review of the email correspondence from the company that provided the menu, dated April 9, 2019, at 3:38 PM, indicated "We have spoken with our Menu Development team ...we added 1 oz of broth to all rice for Mech [mechanical] Soft to add moisture and especially to cover instances with poorly rice execution ..." in response to the CDM asking why does the steam white rice require 1 oz of broth for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 50 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mechanical soft diet. A review of the email correspondence from the company that provided the menu, dated April 9, 2019, at 3:38 PM, indicated "We have spoken with our Menu Development team ...we added 1 oz of broth to all rice for Mech [mechanical] Soft to add moisture and especially to cover instances with poorly rice execution ..." in response to the CDM asking why does the steam white rice require 1 oz of broth for mechanical soft diet. During an interview with the RD on April 10, 2019, at 9:58 AM, when the surveyor reviewed the e-mail with her from the provider of the menus that indicated all mechanical soft diets received broth with rice, she stated she would let the cooks make the decision if rice needed broth or gravy and she trusted the CDM to ensure cooks were trained about the correct safe moisture of food for mechanical soft diets. She added there might not be documentation for this training. The facility was unable to provide documented evidence of dietary cook training and comprehensive evaluation/testing on determining appropriate moisture of mechanically altered food when dietary cooks are independently making the decision to omit a food item on the menu spreadsheet. The facility's policy and procedure titled "Menus" revised October 2008, indicated "Menus shall ...c) be followed." c. Over the course of the survey, it was found that ambient temperature tuna salad was made and not cooled safely (Cross-reference F801; 1,c) During an interview with the RD on April 10, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 51 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2019, at 10:04 AM, she stated she expected for dietary staff to know where to look if they are unsure of the cool down procedure. The RD further stated the facility rarely performs the cool down procedure as they discard any unused food items daily. She stated she would not expect staff to perform the cool down procedure on leftover tuna salad prepared with ambient temperature canned tuna that was placed in the refrigerator because "it's not a hot item to begin with." A review of the facility's "Cool Down Log" dated January 2019 through March 2019 read "Examples of potentially hazardous food to be monitored ...cold sandwich fillings such as tuna or egg salad ..." The Federal Food Code, dated 2017, indicated "Time/Temperature control for safety food shall be cooled within 4 hours to 5°C [degrees Celsius-a unit of measurement] (41°F) [degrees Fahrenheit, a unit of measurement] or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna."

F802 SS=F Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 05/15/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 52 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the competency of staff when: 1. A Dietary Aide (DA 2) did not demonstrate appropriate knowledge on the use of the sanitization bucket; 2. A Dietary Aide (DA 3) did not know the correct procedure when using the threecompartment sink; and 3. A Dietary Cook (DC 1) did not know the appropriate cool down procedures. These failures had the potential to lead to food borne illness in an already compromised universe of 103 residents who ate food from the kitchen out of facility's total census of 104. Findings: 1. The Dietary Aide (DA 2) stated in the event the [Brand Name] multi-quat sanitizer solution (a sanitizer solution used to sanitize foodcontact surface areas such as countertops) remained out of range after testing the strength twice, she would use the facility's backup method which consists of a bleach and water mixed concentration. The DA 2 demonstrated by filling the sanitizer bucket with hot water and stated the temperature of the water should be at least 110 degrees. The DA 2 added one capful of bleach to the sanitizer bucket and was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 53 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observed testing the bleach and water mixed solution with a quaternary ammonia test strip (a test strip used to check the concentration of a quaternary ammonia sanitizer), the test strip showed no change in color. The DA 2 stated the test strip results should be at least 200 ppm (parts per million) and proceeded to add another two capfuls of bleach; for a total of three capfuls, to the solution in the sanitizer bucket. The DA 2 was observed retesting the solution with a quaternary ammonia test strip with the results indicating no change in color. During an interview with the Assistant Dietary Supervisor (ADS), on April 8, 2019, at 10:50 AM, she stated if the [Brand Name] multi-quat sanitizer is out of range, the dietary staff are to notify herself or the CDM immediately. She further stated if the [Brand Name] multi-quat sanitizer is out of range, the dietary staff use the facility's back-up method of a bleach and water mixed concentration. The ADS stated the sanitizer bucket is two gallons and the dietary staff would add only two capfuls of bleach indicating one capful of bleach per every ten gallons of water when this method is used. During an interview with the Registered Dietician (RD), on April 10, 2019, at 10:09 AM, she stated her expectation when the [Brand Name] multi-quat sanitizer is out of range is for dietary staff to add more solution to the sanitizer bucket then retest the solution with a quaternary ammonia test strip. She stated if the solution remained out of range, the dietary staff would first repeat the process and retest the solution. If the solution remained out of range after repeating the process, the dietary staff are to notify the ADS or CDM immediately. The RD further stated, she was not aware of another process being utilized by the dietary staff for the sanitizer buckets and she would not recommend the use of a bleach and water FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 54 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mixed concentration as a back-up method. A review of the facility's "Competencies for Food and Nutrition Services Employees" signed by DA 2 on March 9, 2018, indicated using appropriate equipment and supplies to evaluate the safe operation of ... the washing of pots and pans (e.g ... appropriate chemical test strips ...) was a function that she was expected to be competent in. A review of the facility's "Towel Sanitizing Solution" dated May 2008, indicated "Use 1 tablespoon (1 capful) bleach per gallon of warm water ...Solution should be 100 parts per million (ppm) chlorine. You must use test strips for chlorine to verify the concentration." The facility was unable to provide a policy and procedure on the use of bleach and water mixed concentration as a back-up method for the sanitizer bucket. 2. During an observation and concurrent interview with the DA 3, on April 9, 2019, at 9:30 AM, the DA 3 described the process for the manual dishwashing procedure. DA 3 stood in front of the three-compartment sink for manual dishwashing and stated it is used when the low temperature dishwasher is out of order. She stated, the first step was to fill all three compartments with hot water. The first compartment is to wash, the second compartment is for rinsing, and third compartment is for sanitizing. The DA 3 further stated, each compartment holds ten gallons of liquid and she would add one capful of bleach per gallon in the third compartment to equal a total of ten capfuls of bleach. DA 3 stated, she does not check the strength of the solution concentration in the third compartment, she "just adds the number of capfuls" needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 55 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's "Competencies for Food and Nutrition Services Employees" signed by DA 3 on March 9, 2018, indicated use of the 3-compartment sink was a function that she was expected to be competent in. During an interview with the ADS, on April 9, 2019 at 9:32 AM, she stated when the threecompartment sink is used for manual dishwashing, the third compartment used for sanitizing should be checked with a chlorine test strip to verify the concentration is at 100 ppm. During an interview with the RD, on April 10, 2019, at 10:09 AM, she stated when the threecompartment sink is used for manual dishwashing, her expectation is for the dietary staff to check the concentration of the sanitizing solution in the third compartment. A review of the facility's "Three Sink Compartment Procedure" undated, indicated " ...Step 3. Third sink add 10 tablespoon or 10 capfuls of beach. Check Bleach must be 100 PPM with chlorine ..." The facility's policy and procedure titled "3 Compartment sink procedures" undated, " ...The third compartment is to be filled with hot water (170 degrees F [Fahrenheit, a unit of measurement]), and to the water will be added 2 oz [ounce, a unit of measurement] of bleach to 10 gallons of water to make a sanitizing solution equal to 100 ppm, periodically checking to make sure that the solution does not fall below 50 ppm." 3. During an interview with the Dietary Cook (DC 2), on April 9, 2019, at 9:36 AM, she stated if the cool down procedure was performed to cool food items such as a pot roast and the temperature did not reach 70 degrees or below FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 56 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in the first two hours, she would continue to cool the food item by using a cooling method such as ice. DC 2 further stated, if the food item did not reach the temperature of 41 degrees or below within the total six hour cool down process, she would quickly cool down the food item by using a cooling method such as ice. A review of the facility's "Cool Down Log" between January 2019 and February 2019 showed that staff cooled food items such as beef, sausage and shrimp. The document further indicated "Food must be cooled down from 135 F (Fahrenheit) to 70 Degrees F or less within 2 hours and from 70 degrees F to 41 degrees F or lower in an additional four hours, for a total cooling time of six hours. If food has not reached 70 [degrees Fahrenheit] within two hours, it must be discarded or properly reheated to 165 [degrees Fahrenheit] for fifteen seconds and then cool it properly." During an interview with the RD, on April 10, 2019, at 10:04 AM, she stated the facility rarely uses left-over food items but she would expect the dietary cooks to know where to look in regards to following the cool down procedure. A review of the facility's "Competencies for Food and Nutrition Services Employees" signed by DC 2 on March 13, 2018, indicated cooling methods to achieve 135 degrees F to 70 degrees F in 2 hours, and 70 degrees F to 41 degrees F in 4 additional hours was a function she was expected to be competent in. The facility's policy and procedure titled "Food Preparation and service" revised July 2014, indicated: " ...Rapid Cooling: 1. Potentially hazardous foods should be cooled rapidly. This is defined as cooling from 135 [degrees FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 57 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fahrenheit] to 70 [degrees Fahrenheit] within two hours and then to a temperature of below 41 [degrees Fahrenheit] within the next 4 hours. The total cooling time between 135 [degrees Fahrenheit] and below 41 [degrees Fahrenheit] is not to exceed 6 hours."

F803 SS=F Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 05/15/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow the approved FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 58 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE menu when: 1. The Dietary Cook (DC 1) did not follow the portion sizes for the resident's lunch meal tray for the following items: a. Puree chicken; b. Puree ham; c. Puree steamed white rice; d. Puree buttered zucchini; e. Mechanical soft chicken; and f. Mechanical soft ham. 2. Food listed on the menu was not prepared for the following items: a. Gravy for mechanical soft and puree ham; and b. Puree soft bread/roll. 3. The Assistant Dietary Supervisor (ADS) did not follow the portion sizes for the resident's lunch meal tray for the following items: a. Sour cream coffee cake; and b. Yellow cake. These failures had the potential for residents to receive inadequate nutrients and nutrients which could be harmful due to a medical condition or worsening of a medical condition for 103 residents who received food from the kitchen out of a census of 104. Findings: 1. A review of the lunch "Daily Spreadsheet" dated Fall/Winter 2018/2019 Monday-Day 2 (April 8, 2019), indicated puree ham, puree steamed white rice, mechanical soft chicken, and mechanical soft ham was to be served with a number 8 serving scoop (equates to one-half cup); puree chicken was to be served with a number 6 serving scoop (equates to two-thirds cup); and puree zucchini was to be served with a number ten serving scoop (equates to threeFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 59 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE eighths cups). During an observation in the kitchen during trayline (a preparation of meal trays in the kitchen to be delivered to residents) on April 8, 2019, at 11:35 AM, the Dietary Cook (DC 1) was observed preparing resident's lunch meal trays with incorrect portion size serving scoops according to the approved menu for the following items: a. Puree chicken was served with a green number 12 serving scoop (that equates to onethird cup instead of a number 6 scoop (2/3 cup) so residents received half the amount that the menu indicated; b. Puree ham was served with a green number 12 serving scoop instead of a number 8 scoop so the resident received one-third of a cup of ham which was less than the half of cup of ham indicated on the menu; c. Puree steamed white rice was served with a green number 12 serving instead of a number 8 scoop so the resident received one-third of a cup of pureed rice which was less than the half of cup of rice that was indicated on the menu; d. Puree buttered zucchini was served with a green number 12 serving scoop instead of a number 10 scoop so residents received onethird of a cup of zucchini instead of threeeighths cup which was less than what was indicated on the menu; e. Mechanical soft chicken was served with a blue number 16 serving scoop (that equates to one-fourth cup) instead of a number 8 scoop so residents received half the amount of chicken than what was indicated on the menu; and f. Mechanical soft ham was served with a black FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 60 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ladle marked as 2 ounces (or one-fourth cup) instead of a number 8 scoop which was half the amount than what was indicated on the menu. During a concurrent interview and record review with the DC 1 and the Registered Dietitian (RD), on April 8, 2019, at 12:20 PM, they confirmed the serving scoops/ladle being utilized for the puree chicken, puree ham, puree steamed white rice, puree buttered zucchini, mechanical soft chicken, and the mechanical soft ham was an incorrect portion size based on the approved menu. During a follow-up interview with the RD, on April 10, 2019, at 9:54 AM, she stated she expected the dietary staff to follow the portion sizes listed on the approved menu. The facility's policy and procedure titled "Menus" revised October 2008, indicated "Menus shall ...c) be followed." 2. A review of the lunch "Daily Spreadsheet" dated Fall/Winter 2018/2019 Monday-Day 2 (April 8, 2019), indicated mechanical soft and puree spiral baked ham was to be served with one ounce of gravy, and a puree or slurry bread was to be served for puree meal trays. During an observation in the kitchen during trayline on April 8, 2019, at 11:55 AM, the following items were not readily available to be served on the resident's lunch meal tray: a. A review of the approved menu indicated the gravy for mechanical soft and puree prepared spiral baked ham was not readily available for use. When asked if gravy was to be served with the mechanical soft and puree prepared spiral baked ham, DC 1 stated "I don't know", reviewed the approved menu, and then stated "yes." DC 1 acknowledged the gravy was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 61 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prepared or readily available for use. b. An observation showed that DC 1 did not place pureed bread on the plates for pureed diets. A review of the approved menu indicated pureed diets received pureed bread. The DC 1 acknowledged the puree bread was not made according to the approved menu. During a concurrent interview and record review with the Registered Dietitian (RD) on April 10, 2019, at 9:43 AM, she reviewed the lunch menu spreadsheet from April 8, 2019 and stated the approved menu should have been followed. A review of the facility's "Menu Substitution Record" dated April 2019, showed no documented evidence of an omitted food item, a food item that was substituted, or the reason for a substitution for the date of April 8, 2019. The facility's policy and procedure titled "Menus" revised October 2008, indicated "Menus shall ...c) be followed ...Deviations from menus that have already been posted will be noted (including the reason for the substitution and/or deviation) in the kitchen and/or in the record book used solely for recording such changes." 3. A review of the lunch "Daily Spreadsheet" dated Fall/Winter 2018/2019 Monday-Day 2 (April 8, 2019), indicated the sour cream coffee cake for regular diets and the yellow cake for all other diet types should be served in three by two-inch portion sized quantities. During an observation in the kitchen during trayline on April 8, 2019, at 12:34 PM, the Dietary Aide (DA 3) stated the dessert placed on the resident's lunch meal tray were either sour cream coffee cake or yellow cake FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 62 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE depending on the resident's diet. The cakes were observed in a large plastic tray and differentiated in size when: a. The sour cream coffee cake designated for residents on a regular diet measured two by two inches and another piece measured two and one-quarter by two inches when the approved menu called for the sour cream coffee cake to be cut and served at three by two inches per piece; and b. The yellow cake designated for all other diet types measured one and three-fourths by one and one-half inches and another piece measured two and one-half by two and onequarter inches when the approved menu called for the yellow cake to be cut and served at three by two inches per piece. During an interview with the Assistant Dietary Supervisor (ADS), on April 8, 2019 at 12:40 PM, she acknowledged the pieces of sour cream coffee cake and yellow cake differentiated in size. The ADS further stated "yeah, I didn't cut them evenly." She stated she had problems cutting the pieces of cake to the correct size due to the knife she was using. During an interview with the RD, on April 10, 2019, at 9:54 AM, she stated she expected the dietary staff to follow the portion sizes listed on the approved menu. The facility's policy and procedure titled "Menus" revised October 2008, indicated "Menus shall ...c) be followed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 63 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/15/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure: 1. Safe food storage and preparation when one of one ice machine was not clean for a highly vulnerable population of 103 residents. 2. Food was not disposed of by a use-by-date, and some food items did not have a use by date. 3. Containers used for food service were not air dried and were stacked wet. 4. Cracked and discolored food service containers were not discarded. 5. Kitchen staff facial hair was not covered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 64 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE These failures had the potential to contaminate resident food sources that can cause foodborne illness in vulnerable population, resulting in severe resident harm, and even death. Findings: 1. During an observation and concurrent interview on April 09, 2019 at 08:45 AM, of the ice machine with the Maintenance Supervisor (MS), the inside of the machine had a significant amount of black and pink residue on the plastic that surrounded the evaporator plate (the part of the ice machine where water is frozen and made into ice). The residue had a shiny, slimy appearance and wiped off easily with a paper towel. Water that could be frozen into ice came into contact with the pink and black slimy residue. The plastic cover that fit over the evaporator plate also had brownish, orange residue on the inside surface that faced the evaporator plate. The residue came off when it was rubbed with a paper towel. MS confirmed there was residue on the evaporator plate cover and on the plastic surrounding the evaporator plate and stated he did not consider the ice machine clean and that it probably needed to be cleaned more often. He also stated this was how the ice machine looked, with black and pink slimy residue, before regular scheduled cleanings of the machine and stated "it gets worse closer to the cleaning time". According to the 2017 Federal Food Code, equipment food-contact surfaces shall be kept clean to sight and nonfood-contact surfaces shall be kept free of an accumulation of debris. In addition equipment is to be cleaned at a frequency to prevent an accumulation of soil residue. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 65 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. During an observation and concurrent interview on April 08, 2019 at 08:50 AM, with the Certified Diet Manager (CDM), cinnamon raisin bread was on a bread storage rack (outside of the freezer and refrigerator). The bread had a date of March 21, 2019 to September 21, 2019 on the package which CDM stated is the date for how long the bread may stay frozen. He then said once the bread was removed from the freezer it was good for four days. CDM also stated the bread should be dated when it was taken out of the freezer, and he confirmed it was not dated to show when it should be used or discarded. In a concurrent observation, one package of hamburger buns was had a significant amount of green fuzzy substance on four out of six buns. This package had one date on it which read, March 24, 2019. CDM stated "I see mold growing on these hamburger buns and they do not have a use by date, they should have been thrown away". CDM also stated cooks and the "grocery person" were responsible for discarding the bread by the use by date. During record review of "Dry Goods Storage Guideline", it revealed, "bread opened and unopened on shelf five to seven days ...". An observation and concurrent interview on April 08, 2019 at 09:12 AM, with CDM during the initial kitchen tour, showed peanut butter and jelly sandwiches were wrapped and not dated. On one of the sandwiches, the peanut butter and jelly had soaked completely through the bread and it appeared soggy. CDM confirmed the sandwiches were not dated. During record review of "Food Receiving and Storage", it revealed, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated by (use by date). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 66 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the document titled "In-Service Topic Outline and Attendance Record" dated December 24, 2018, showed a summary of the information presented during the in-service to kitchen staff, prepared food that was not used immediately needed to be labeled and dated and, food needed to be used within 3 days or discard in the morning. 3. During an observation on April 08, 2019 at 09:05 AM, in the kitchen, five of ten plastic containers were stacked wet. Upon interview with Diet Aide 4 (DA 4) and Diet Aide 3 (DA 3), they both confirmed the containers were stacked wet and stated they should be air dried. They also stated these containers were used for ice to keep drinks cold during tray line. During an interview with CDM, he stated these containers should not be stacked wet. During an interview on April 10, 2019 at 09:43 AM, with RD, she stated plastic containers should be air dried before they are stacked. During record review of "Dishwashing Machine Use" Policy Statement, 1. f. After running items through entire cycle, allow to air-dry. 4. During an observation and concurrent interview on April 08, 2019 at 09:05 AM, one plastic container was cracked and 3 plastic containers had a black residue covering the surface. DA 3, confirmed the containers were used to hold ice to keep drinks cold on the tray line and stated the crack and black residue was due to the old age of the containers. During an interview on April 08, 2019 at 09:10 AM, with CDM, he confirmed the containers were discolored and cracked and stated the cracked container should have been discarded and the discolored container should have been cleaned with bleach to remove the back FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 67 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residue. During an interview on April 10, 2019 at 09:43 AM, with RD, she stated the discolored and cracked plastic containers should have been thrown away. During record review of "Sanitization Policy Statement" it revealed, 2. All utensils ..., and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning ...". 5. During an observation on April 08, 2019, at 11:35 AM, DC 1, a cook did not have his beard and mustache covered when he prepared and served food for tray line. During an interview on April 09, 2019 at 09:53 AM, with CDM, he stated all facial hair should be covered but he was not concerned about the cooks' beard and mustache being uncovered because it was short. During an interview on April 10, 2019 at 10:08 AM, with RD, she stated her expectation was to cover facial hair if it is a large amount of hair, "full beard" not for thin amount of facial hair. During record review of "Dietary Services Meals and Service", 7. Dietary staff shall wear hair restrains (hair net, hat, beard restraint, etc.), so that hair does not contact food. According to the 2017 Federal Food Code, food employees are to wear hair restraints such as beard restraints that are designated and worn to effectively keep hair from contacting exposed food, clean equipment, utensils ...".

F880 Infection Prevention & Control FORM CMS-2567(02-99) Previous Versions Obsolete

F880 Event ID: 207B11 05/15/2019 Facility ID: CA240000060 If continuation sheet 68 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.80(a)(1)(2)(4)(e)(f) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 69 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement their policy and procedure on infection control and prevention when: 1. Twenty-seven expired peripheral intravenous catheters (PIVC- a tube inserted into the vein to deliver medication, nutrition, and fluids) were stored on Station 3's intravenous (into the vein) medication room were available for use and had a manufacturer' expiration date (a date placed on medical supplies noting when the items should no longer be used) of August 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 70 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. One expired sacrum dressing (a germ-free wound dressing) was stored in Station 3's treatment cart and had a manufacturer's expiration date of August 2018. The dressing was available for use. 3. One box of expired hydrocolloid tegaderm dressings (a germ-free wound dressing) were stored in the central supply room and had a manufacturer's expiration date of 2015, Three boxes of expired hydrocolloid tegaderm dressings were stored in the central supply room and had a manufacturer's expiration date of March 2019, and Two individual wafer dressings (a germ-free wound dressing) were observed in the central supply room and stored in open packaging. The dressings were available for use. 4. Two glucometers (glucometer - a device used to perform a finger stick blood sugar test) were not disinfected with the specified Environmental Protection Agency (EPA) approved disinfectant (a chemical agent that destroy bacteria, virus, and fungi) in accordance with the manufacturer's guidelines, for five of 22 sampled residents (Resident 77, 96, 249, 703 and 704) in the universe of 103 residents. 4a. Licensed Vocational Nurse (LVN 1) did not disinfect the glucometer before use on Resident 703, 96 and 77. 4b. LVN 2 did not disinfect the glucometer before use on Resident 249. 4c. LVN 3 did not disinfect the glucometer before use on Resident 704. These failures placed the facility's residents at a greater risk for exposure to germs and had the potential to result in a preventable infection. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 71 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. During an observation with the Registered Nurse (RN 1), on April 10, 2019, at 5:05 AM, PIVCs were observed stored in Station 3's medication room. The PIVCs had a manufacturer's expiration date of August 2018, and were available for use. During an interview with RN 1, on April 10, 2019, at 5:13 AM, RN 1 counted the PIVCs and stated there were 27 expired PIVCs. RN 1 stated the expired PIVCs should have been removed from the medication room on or before the manufacturer's expiration date. During an interview with the Assistant Director of Nursing (ADON), on April 10, 2019, at 7:05 AM, the ADON stated expired items should not be stored in the medication room. During an interview with the Central Supply Supervisor (CSS), on April 11, 2019, at 9:10 AM, the CSS stated the expired PIVCs should have been discarded in accordance to the manufacturer's expiration date. 2. During observation with the treatment nurse (LVN 7), on April 10, 2019, at 7:09 AM, a sterile sacrum dressing was observed in Station 3's treatment cart. The dressing had a manufacturer's expiration date of August 2018, and was available for use. During an interview with LVN 7, on April 10, 2019, at 7:15 AM, LVN 7 stated the expired dressing should have been discarded on or before August 2018, in accordance to the manufacturer's expiration date and directions. During an interview with the Assistant Director of Nursing (ADON), on April 10, 2019, at 8:05 AM, the ADON stated expired items should not be stored in the treatment cart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 72 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. During an observation with the CSS, on April 11, 2019, at 9:48 AM, in the central supply room, there was one box of hydrocolloid tegaderm dressings with a manufacturer's expiration date of 2015, three boxes of hydrocolloid tegaderm dressings with a manufacturer's expiration date of March 2019, and two opened wafer dressings. The dressings were available for use. During an interview with the CSS, on April 11, 2019, at 10:02 AM, the CSS stated one box of dressings expired 2015 and three boxes of dressings expired March 2019. The CSS stated, "There should not be expired supplies stored in the central supply room." The CSS stated opened wafer dressings are not germfree and should have been discarded to prevent cross-contamination (the transfer of harmful bacteria). A review of the policy and procedure titled "Central Supply" dated January 2017, indicated "Policy: The facility will have an area designated for central supplies and personnel designated to monitor and maintain central supply. Procedure: ...Central supply will be audited monthly and nothing outdated will be maintained. Expired supplies will be discarded in the trash or as recommended by the manufacturer."4. a. During an observation on April 10, 2019, at 5:07 AM, LVN 1 was preparing to perform Resident 703's finger stick blood sugar test. LVN 1 then removed the glucometer from Nursing Station 3's medication cart and placed it on a white towel kept on the medication cart. LVN 1 then proceeded to perform Resident 703's finger stick blood sugar test without disinfecting the glucometer prior to resident use. A review of the clinical record for Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 73 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 703, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 703 was admitted on April 9, 2019, with diagnoses that included, Hypertension (high blood pressure), and Type 2 diabetes Mellitus (DM- elevated blood sugar). During a review of Resident 703's clinical record, the document titled "Medications and Treatments" dated April 9, 2019, indicated order for an "accucheck (finger stick blood test) AC meals (before meals) ..." During an observation on April 10, 2019, at 5:40 AM, LVN 1 was preparing to perform Resident 96's finger stick blood sugar test. LVN 1 then removed the glucometer from Nursing Station 3's medication cart and placed it on a white towel kept on the medication cart. LVN 1 then proceeded to perform Resident 96's finger stick blood sugar test without disinfecting the glucometer prior to resident use. A review of the clinical record for Resident 96, the "Admission Record", indicated Resident 96 was admitted on April 2, 2019, with diagnosis of sepsis (presence of bacteria or other infectious organisms in the blood). A review of Resident 96's History and physical (H&P), dated March 28, 2019, indicated Resident 96 had diabetes Mellitus (DMElevated blood sugar). During a review Resident 96's "Physician's orders", dated April 2, 2019, indicated "finger stick QID (medical abbreviation -four times each day) AC (before) meals and HS (bedtime) ..." During an observation on April 10, 2019, at 6:00 AM, LVN 1 was preparing to perform FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 74 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 77's finger stick blood sugar test. LVN 1 then removed the glucometer from Nursing Station 3's medication cart and placed it on a white towel kept on the medication cart. LVN 1 then proceeded to perform Resident 77's finger stick blood sugar test without disinfecting the glucometer prior to resident use. A review of the clinical record for Resident 77, the "Admission Record" (a document containing demographic and medical information), indicated Resident 77 was admitted on April 4, 2019, with diagnoses that included End stage renal disease (ESRD- a disease which causes irreversible kidney failure), and Dialysis ((process of cleaning and purifying the blood). During a further review of Resident 77's "Physician's orders dated April 4, 2019, indicated "QID (medical abbreviation -four times each day) AC (before) meals and HS (bedtime) ..." During an interview with LVN 1 on April 10, 2019, at 6:05 AM, LVN 1 stated she disinfects the glucometers with the facility's approved disinfectant wipe [BRAND NAME] after each resident's use and waits for 3 minutes to air dry. LVN 1 stated she did not disinfect the glucometer before resident's use. 4b. During an observation on April 10, 2019, at 6:15 AM, LVN 2 removed the glucometer from the first drawer of the Station 2's medication cart 2B and placed it on top of the medication cart, wore gloves and attached the strip to the glucometer and placed the glucometer on Resident 249's bed and pricked the left index finger with a lancet and obtained blood sample. LVN 2 disinfected the glucometer with [BRAND NAME] wipes after finger stick read was completed and placed the glucometer on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 75 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication cart. LVN 2 did not disinfect the glucometer before use on Resident 249. A review of the clinical record for Resident 249, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 249 was admitted on April 1, 2019, with diagnosis of diabetes Mellitus (DM- elevated blood sugar). During a further review of Resident 249's "Physician's orders dated April 1, 2019, indicated QID (medical abbreviation -four times each day) AC (before) meals and HS (bedtime) ..." During an interview with LVN 2 on April 10, 2019, at 6:19 AM, LVN 2 stated her practice of disinfecting the glucometer was always after use with the residents. LVN 2 further stated [BRAND NAME] wipes were the facility approved disinfectant and it needed to air dry for 3 minutes. 4c. During an observation on April 11, 2019, at 11:42 AM, LVN 3 removed the glucometer from the first drawer of the Station 3's medication cart and placed it on a white plastic tray on top of the medication cart, placed the white tray with glucometer, alcohol wipe and lancet (tiny needle to obtain blood) on the bedside table and obtained blood sample. LVN 3 Disinfected the glucometer after use and placed on the medication cart in a clear disposable cup to dry. A review of the clinical record for Resident 704, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 704 was admitted on March 14, 2019, with diagnosis of type 2 diabetes Mellitus (DM- elevated blood sugar). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 76 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of resident 704's "Physician's telephone orders dated march 21, 2019, indicated accucheck (finger stick blood test) AC meals (before meals) ... ." During an interview with LVN 3, on April 11, 2019, at 12:16 PM, LVN 3 stated she usually disinfects the glucometer after each residents use with the facility's approved wipes [BRAND NAME] and lets it air dry for 2-3 minutes. During an interview with Infection Preventionist (ICP) on April 11, 2019, at 2:41 PM, the ICP stated staff are expected to disinfect the glucometer before and after use with the residents in order to prevent further cross contamination (transfer of bacteria or other contaminants from one surface or another due to improper disinfection). During an interview with the Assistant Director of Nursing (ADON) on April 11, 2019, at 2:53 PM, the ADON stated staff are expected to disinfect the glucometer before and after each resident use with the facility approved disinfectant [BRAND NAME] wipes and wait for three minutes contact time and let air dry. The [BRAND NAME] Blood Glucose Monitoring System User Instruction Manual under cleaning and disinfection guidelines indicated, we suggest cleaning and disinfecting the meter between patient use. To use a wipe, remove from container and follow product label instructions to disinfect the meter. A review of the disinfectant wipe [BRAND NAME] product label indicated the kill time was three minutes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 Facility ID: CA240000060 If continuation sheet 77 of 78 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055076 (X3) DATE SURVEY COMPLETED 04/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SPRING VALLEY POST ACUTE LLC 14973 Hesperia Rd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 207B11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000060 (X5) COMPLETE DATE If continuation sheet 78 of 78