Other·January 15, 2019

F000 INITIAL COMMENTS

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 a recertification survey conducted on November 26, 2018 through November 29, 2018. Representing the California Department of Public Health: Surveyors: 39522 38480 39474 Census: 98 Sampled Residents: 21

F582 SS=D Medicaid/Medicare Coverage/Liability Notice CFR(s): 483.10(g)(17)(18)(i)-(v)

F582 12/29/2018 §483.10(g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, 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: IU5T11 Facility ID: CA240000065 If continuation sheet 1 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide written notice of changes to coverage and provide the "Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN of NC)" form for two of three sampled Residents (Residents 77 & 11). These failures had the potential to cause a financial burden upon the Residents involved, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 2 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 addition to the risk of psychosocial harm as a result of the financial burden. Findings: During a review of the clinical records for Resident 77 and Resident 11, on November 28, 2018, at 11:25 AM, the completed "Skilled Nursing Facility Beneficiary Protection Notification Review (SNF BPNR)" form provided by the Administrator (Admin) for these Residents reflected the Residents did not receive the "Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage" (SNF ABN of NC). The SNF ABN of NC form provides communication and clarification to the Resident about their continued care within the facility when it is no longer going to be covered by their Medicare benefits, and how they would like to compensate the facility for their continued care as a Resident of the skilled nursing facility. During an interview with the Admin, conducted on November 28, 2018, at 11:37 AM, the Admin stated the Case Manager (CM) had completed the "Skilled Nursing Facility Beneficiary Protection Notification Review (SNF PNR)" form for Resident 77 and Resident 11. During an interview with the Case Manager (CM), on November 28, 2018, at 12:11 PM, she stated that Resident 77 and Resident 11 were not provided the SNF ABN of NC forms. The CM stated that Resident 77 and Resident 11 did not receive these forms due to their care in the facility now being covered under MediCal (Medicaid), and they are not responsible for the services provided from Medicare. The CM further stated Resident 77 and Resident 11 were not provided any forms communicating to them that their care in the facility is now being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 3 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 covered under Medi-Cal, and Residents 77 and 11 would have been told verbally that their care in the facility was now being covered under Medi-Cal. A review of the facility document titled "Heritage Gardens Health Care Center - Notice of Medicare Non-Coverage - (Form CMS 10123-NOMNC); The Effective Date Coverage of Your Current Skilled Nursing Service Will End:---" with an approved date of December 31, 2011, indicated the following: "Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current skilled nursing services after the effective date indicated above. You may have to pay for any services you receive after the above date...."

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/29/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 4 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of abuse to applicable State Agencies for one of 21 sampled Residents (Resident 64). This failure had the potential to cause physical and psychosocial harm jeopardizing Resident 64's health and well-being. Findings: During an interview, with the aid of a Certified Nursing Assistant (CNA 4 - for Spanish translation/interpretation assistance), with Resident 64, on November 27, 2018, at 10:00 AM, Resident 64 stated CNA 1 "grabbed my hair when I went to use the restroom across the hallway, because my restroom was left dirty by another Resident." Resident 64 further stated CNA 1 told her to go to her own restroom as CNA 1 pulled her hair, and told her that she is "crazy." Resident 64 stated CNA 1 makes faces at her, and sticks her tongue out at her while making those faces. Resident 64 stated when CNA 1 was cleaning her bedside area, she stole a watch and recyclable cans she was collecting for another Certified Nurse Assistant (unknown CNA). Resident 64 further stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 5 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 reported the abuse to the Admin, about 4 weeks prior. Resident 64 stated the Admin told her that CNA 1 would not be working in the Resident's hallway anymore. Resident 64 further stated CNA 1 no longer provides her for care, as she had requested. During an interview with the aid of the Social Services Assistant (SSA - for Spanish translation/interpretation assistance), with Resident 64, on November 27, 2018, at 12:03 PM, she stated the incident occurred during the night-time, at approximately 8 PM, in room 302. Resident 64 stated her hair was pulled when she was sitting on the toilet, and no one had witnessed the incident. Resident 64 re-stated the incident occurred about 4 weeks ago. During an interview with CNA 1, on November 27, 2018, at 1:01 PM, she denied being involved with any incidents of abuse between her and other Residents in the facility - even specifically towards Resident 64. CNA 1 stated that she has had to go into Resident 64's room with the Director of Staff Development (DDS) and housekeeping staff to clean her room of hoarded food that Resident 64 tends to keep for days - CNA 1 further stated Resident 64 tends to hoard things, and was concerned about Resident 64 being harmed by eating old, spoiled food. CNA 1 denied knowledge of any removal of recyclables or a watch from Resident 64, or knowledge of any other Resident's removal of their personal belongings. CNA 1 stated Resident 64 has never seemed to like her, and became upset with her in particular when the old, hoarded food was removed from her room. During an interview with the Admin and Director of Nursing (DON), on November 27, 2018, at 1:26 PM, the Admin stated he talked to Resident 64 about the incident with the CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 6 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 and stated, a full investigation was conducted and that Resident 64 reported the bathroom needed to be cleaned, so she used the bathroom across the hallway from her room. The Admin further stated when the CNA was taking Resident 54 to her restroom, CNA 1 found Resident 64 using the restroom in Resident 54's room (room 302). The Admin further stated CNA 1 gave Resident 64 privacy and did not enter the restroom until Resident 64 was done using it. Admin further stated CNA 3 was cleaning Resident 54's bed (in room 302) and witnessed the incident confirming CNA 1 never entered the restroom while Resident 64 was using it. The Admin stated he had a meeting with Resident 64 and CNA 1, together, and stated Resident 64 stated she felt safe in the facility with CNA 1, but that she did not want CNA 1 caring for her anymore, and that it would be OK with CNA 1 giving her roommate care. The Admin stated the date of the alleged incident was October 27, 2018, but it was reported to him on November 1, 2018, by the Dietary Supervisor. The Admin stated the abuse allegation from Resident 64 was not reported to the California Department of Public Health District Office, due to the Resident's past history of making false allegations and the witness testifying that the allegation was false. The facility policy and procedure titled, "Reporting Abuse", dated February 6, 2013, indicated the following: "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies... 1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 7 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 ...".

F644 SS=D Coordination of PASARR and Assessments CFR(s): 483.20(e)(1)(2)

F644 12/29/2018 §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a Pre Admission Screening Assessment Resident Review for one resident (Resident 66) who returned from the hospital with a new psychiatric diagnosis (Depression). This failure had the potential of not allowing Resident 66 to be referred to state agencies for possible mental health resources. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 8 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 on November 28, 2018 at 4:58 PM, Resident 66 was lying in the bed and stated he did not want to talk. During a clinical record review for Resident 66 on November 28, 2018 at 11:37 AM, the Admission Face Sheet (demographics) indicated Resident 66 was re-admitted to the facility on January 22, 2017 with diagnoses including Congested Heart Failure (heart not pumping blood adequately thru the lungs) and Alcohol Abuse, and End Stage Renal Disease (ESRD - kidneys unable to pass waste out of the body). Resident 66 goes to Hemo-dialysis (HDX - method to remove waste from the kidneys) three times a week. A clinical record review for Resident 66 on November 28, 2018 at 11:38 AM, the Physician Orders dated November, 2018, indicated Resident 66 was prescribed Trazadone (antidepressant) 50 MG (milligram - unit of measurement) 1 tablet at hours of sleep for depression manifested by symptoms of insomnia (difficulty sleeping) and to monitor for Antidepressant drug side effects on January 22, 2017. During a clinical record review for Resident 66 on November 28, 2018 at 11:40 AM, the "Doctor's Progress Notes" dated January 30, 2018 indicated "Psychiatry" followed Resident 66 under consultation on a monthly basis starting March 11, 2018 thru October 29, 2018. During a clinical record review for Resident 66 on November 28, 2018 at 11:45 AM, the Minimum Data Set (MDS - a tool to assess for cognitive and functional abilities) under Section "C" the Basic Interview Mental Status (BIMS) score dated September 28, 2018 the quarterly review indicated Resident 66's BIMS score was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 9 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 12 (able to make decisions). Under Section "D" dated November 28, 2018 indicated Resident 66 had trouble sleeping. Under Section "I" (diagnoses) Resident 66 had a diagnoses for Depression other than Bipolar Disorder. Under Section "N(medications) Resident 66 received antidepressants 7 days. During an interview and concurrent record review with the Business Office Manager (BOM) on November 29, 2018 at 8:47 AM, the BOM reviewed Resident 66's clinical record and could not find an updated PASARR for the new psychiatric diagnoses. The BOM stated a new PASARR should have been completed and submitted with the new diagnoses of depression, and it was not done. During an interview with the Director or Nursing (DON) on November 29, 2018 at 11 AM, the DON stated an updated PASARR should have been completed when the Psychiatrist saw Resident 66 on consultation March 11, 2018. The DON further stated the facility did not have a policy on PASARR.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 12/29/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 10 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to develop and implement a baseline care plan for Diabetes Mellitus (elevated levels of sugar in the blood and urine) for Resident 189. This failure had the potential to cause serious harm for 1 of 21 sampled residents. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 11 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 a review of the clinical record for Resident 189, the Resident's most current plan of care did not include a baseline care plan for Resident 189's diagnosis of Diabetes Mellitus. Review of Medication Administration Record indicated a medication order dated, November 2, 2018 indicates "Lantus (insulin glargine type) 4 units SQ (subcutaneous, under the skin) Q AM (every morning) for Diabetes." During concurrent interview with the Registered Nurse (RN 1), RN 1 reviewed the clinical record for Resident 189 and was unable to locate a baseline plan for Diabetes Mellitus. RN 1 was asked if Resident 189 should have had a care plan for Diabetes Mellitus initiated within 48 hours of admission, RN 1 stated, "Yes, he should have had one since admission, I will create a care plan now for that Resident (Resident 189)." Review of facility policy and procedure titled, "Care Plans-Comprehensive", indicated the following: "An individualized comprehensive care plan that includes measurable objective and timetables to meet the Resident's medical, nursing, mental and psychological needs is developed for each Resident."

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

F657 12/29/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 12 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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. (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 review assessments. This REQUIREMENT is not met as evidenced by: Based on interviews, and record review, the facility failed to include participation of Resident 189 in the revision of his care plan. This failure had the potential for the resident's needs not to be met in 1 of 21 sampled residents. Findings: During an interview on November 27, 2018 at 4:46 PM Resident 189 stated, "I was ordered antibiotics after a doctor visit, I never received any new medications and was never told why the medication was not provided to me." During a review of the clinical record and concurrent interview with a Registered Nurse (RN 1), review of Resident 189's most current plan of care did not include an update indicating changes to Resident 189's medication regimen. RN 1 was asked to identify documentation in the care plan that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 13 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 189 participated in the update of the care plan for changes in medication regimen, RN 1 stated, "No, I don't see an update to the care plan indicating a change in medication regimen." Review of "Departmental Notes" dated November 19, 2018 at 2:41 PM indicated, "Followed up with (name of physician) about Levaquin (antibiotic) 500 mg (milligrams) PO (by mouth) QD (every day) for LLQ (left lower quadrant, a region of the abdomen) pain for 4 doses. Patient's KUB (kidneys, urea and bladder x-ray) showed excess stool to LLQ. (name of physician) gave order for fleets enema and patient to have enema completed and done once he is back from appointment. Per (name of physician), no need for Levaquin order d/t (due to) not indicated. No infection is present at this time." Review of facility policy and procedure titled, "Care Plans-Comprehensive", indicated the following: "An individualized comprehensive care plan that includes measurable objective and timetables to meet the Resident's medical, nursing, mental and psychological needs is developed for each Resident. 8. Assessments of Residents are ongoing and care plans are revised as information about the Resident and the Resident's condition change."

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 12/29/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 14 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement complete daily activity logs for two of 21 sampled Residents (Residents 64 & 69). This failure resulted in the facility being unable to assure that Resident 64 and Resident 69 were offered and participated in activities within the facility. This failure had the potential to result in psychosocial harm, and the potential for a decreased quality of life for these Residents within the facility. Findings: During an interview with the Activities Director (AD), on November 29, 2018, at 4:49 PM, she stated that the Residents' frequency of attendance to activities, and the description of activity participation by the Residents is documented daily. During a review of the facility's documentation for Resident 64's and Resident 69's daily activity inclusion, the following was reflected: 1. For Resident 64, the facility's documentation of activity included only the days Resident 64 attended activity group, and did not include documentation of the days Resident 64 did not attend the activity group, or documentation of in-room visits. 2. For Resident 69, the facility's documentation of any daily activity inclusion was not available and not able to be produced by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 15 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 interview with the AD, on November 29, 2018, at 5:35 PM, she reviewed the records for Resident 64 and Resident 69, and was unable to find documentation of attendance and participation in the daily activities group for both Residents. The AD further stated that facility policy for daily activity documentation was not followed for Resident 64 and Resident 69. The facility policy and procedure titled, "Activities Attendance", (not dated), indicated, "The Activity Department records activities attendance and participation of all residents. 1. Attendance and participation is recorded for every resident in group and individual activities on a daily basis ...".

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

F803 12/29/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 16 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 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 observations, interviews, and record review, the facility failed to provide Resident 84 with desired menu preferences. This failure could have resulted in malnutrition and psychological harm for 1 of 21 sampled Residents (Resident 84). Findings: During an observation on November 26, 2018 at 5:40 PM, Resident 84 was observed sending the provided dinner tray back stating, "I had to send my dinner tray back again, I did not want the sandwich that was provided and the preference menu was never picked up." During a concurrent interview, Resident 84 was asked if the desired food preferences were being provided. Resident 84 stated, "No, I completed a two-week food preference menu which indicated alternate food choices, no one picked up the menu, so I had to send my food back." During an interview on November 26, 2018 at 6:21 PM, with the Administrator (Admin), the Admin was asked why Resident 84 still has not received his dinner tray. The Admin stated, "The resident didn't like the choices on the tray so we had to change the sandwich to another one." During an observation on November 27, 2018, during the lunch meal, Resident 84 had a lunch tray delivered with beef stroganoff and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 17 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 mushroom gravy. The lunch tray preference card indicated, "no mushrooms." During a concurrent interview with the Dietary Services Supervisor (DSS), the DSS was asked if Resident 84's food preferences are being honored. The DSS stated, "Yes, but the kitchen has made mistakes on his food preferences and we did not have his two-week preference menu so we did not know what he preferred to eat." Review of clinical record for Resident 84's care plan dated November 2, 2018 titled, "Nutrition" indicated, "Assess resident's food preferences, likes and dislikes." Review of facility policy and procedure titled, "Resident Food Preferences", indicated the following: "1. Upon the resident's admission, or within twenty-four (24) hours after his/her admission, the Dietician or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident."

F809 SS=D Frequency of Meals/Snacks at Bedtime CFR(s): 483.60(f)(1)-(3)

F809 12/29/2018 §483.60(f) Frequency of Meals §483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. §483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 18 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 resident group agrees to this meal span. §483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide snacks for four of 21 sampled residents (Residents 8, 15, 39, and 57). This failure had the potential of the Residents to not receive nutritional snacks between the evening meal and breakfast. Findings: During an interview with Resident 15 on November 26, 2018 at 3:30 PM, Resident 15 stated snacks are not offered during the day and sometimes "a half of a peanut butter and jelly sandwich at bedtime, but it's not on a regular basis." Resident 15 stated a there is not a variety of snacks, such as fruit, crackers, cookies, only a half sandwich of peanut butter and jelly sandwich. Resident 15 said she has never been asked by the Dietary Department Supervisor (DDS) regarding a variety of snack selections. During a review of the residents' council monthly minutes with Resident 15, from January 26, 2018 thru October 26, 2018, the Resident Council minutes did not indicate the council ever discussed with the DDS a variety or selection of snacks. Resident 15 stated the council was not aware they could request selections or request snacks. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 19 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 on November 27, 2018 at 11:15 AM, the dietary aide brought snacks to Station 1 and left them at the nurse's station. The snacks included grapes, bananas, health shakes, graham crackers, 4 half sandwiches of peanut butter and jelly. During an observation on November 27, 2018 at 11:45 AM, Certified Nursing Assistant 1 (CNA 1) took 5 cartons of healthy shakes and placed the shakes in 5 residents' rooms. The remaining snacks stayed at the nurse's station until after lunch trays were picked. During an observation on November 27, 2018 at 2:30 PM, CNA 1 brought a tray of snacks including grapes, bananas, half (4) half sandwich of peanut and jelly sandwiches, and healthy shakes to nursing station 1. CNA 1 took 5 cartons of healthy shakes and placed at in the rooms on the tray for 5 residents. During an interview with Resident 15, and her roommates (57 and 8) and Resident 39 on November 27, 2018 at 3 PM, they stated they were not offered any snacks on the evening shift of November 26, 2018 or during the midmorning or afternoon snacks on November 27, 2018. During an observation November 28, 2018 at 11:30 AM, snacks of grapes, cut up apples, bananas, graham crackers, peanut butter and jelly (half sandwich) were at the nurse's station. During an interview with Residents 8, 15, 39, and 57 on November 29, 2018 at 11:45 AM, the Residents stated they were not offered snacks on November 27, 2018 at 7:00 PM. During an interview with Resident 8 on November 29, 2018 at 12:15 PM, she stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 20 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 she would love to have snacks during the evening hours but has not been offered snacks. During an interview with Resident 15 on November 29, 2018 at 12:30 PM, she stated she would love to have a variety of different snacks outside of peanut butter or jelly sandwiches and had not been offered any snacks on a regular basis. During an interview with Resident 39 on November 29, 2018 at 2:30 PM, he stated he was not offered any type of snacks during the day or evening shift. During an interview with the Dietary Supervisor (DS) on November 26, 2018 at 3:00 PM, she stated snacks are delivered to the nurse's station at 10 AM, 2 PM and 7 PM daily. The facility posting of snacks on the wall at Station 1 dated November 29, 2018 at 1:30 PM, indicated snacks are delivered to the residents at 10 AM, 2 PM, and 7 PM daily. During an interview with the Director of Nursing (DON) on November 29, 2018 at 3:30 PM, looked at the snacks delivered at 2 PM, and saw half peanut butter sandwiches, grapes, graham crackers still on the tray and had not been delivered to residents at the 2 PM delivery. The DON stated the system was broken and the snacks should have been delivered by the CNA assigned for that shift. The facility policy and procedure titled, "Frequency of Meals" undated, indicated ...Policy ...Each resident shall receive at least one snack daily .... Policy Interpretation and Implementation ... 5. Available snacks will be available for residents who desire additional food between meals. 6. Evening snacks will be offered to all residents not on diets prohibiting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 21 of 22 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: _______________ 055183 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE GARDENS HEALTH CARE CENTER 25271 Barton Rd Loma Linda, CA 92354 (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 bedtime nourishment. 9. The Food Services Manager will solicit input from the residents or residents' council on a selection of snacks available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IU5T11 Facility ID: CA240000065 If continuation sheet 22 of 22