Other·January 9, 2020

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 finding of California Department of Public Health during a recertification survey conducted November 18, 2019 through November 25,2019. Facility Reported Incidents investigated: CA00664496 (unsubstantiated) and CA00664800 (unsubstantiated) Complaint investigated: CA00664455 (unsubstantiated) Representing the Department: 39907 39431 33786 38869 An immediate Jeopardy (IJ) was called under 483.12 (a) (1) F 600 Freedom from Abuse, Neglect and Exploitation on November 22, 2019 at 4:25 PM, in the presence of the Administrator (ADM) and Director of Nursing (DON) when licensed nursing staff were signing for medications they were not giving and were not available in the medication carts. The ADM and DON were verbally notified of the IJ situation identified based on the facility's failure to ensure medications were available to be administered for Residents 1 and 37. The facility submitted a corrective action plan (CAP) which was reviewed and accepted on November 25, 2019 at 10:11 AM, in the presence of the ADM and DON. After interview to confirm implementation of the CAP and review of medication availability for 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: CHNI11 Facility ID: CA240000065 If continuation sheet 1 of 47 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 11/25/2019 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 Residents 1 and 37, the IJ was lifted on November 25, 2109 at 5:05 PM, in the presence of the ADM and DON.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 12/25/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 2 of 47 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 11/25/2019 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 representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to notify the doctor of lab test results for one of 22 sampled Residents (Resident 196) when the lab test results were available and the doctor was not notified. This failure had the potential to jeopardized the health and safety of resident 196 by delaying medical services. Findings: During a review of the clinical record for Resident 196, the face sheet (a document which contains basic information about the resident) indicated Resident 196 was admitted to the facility on November 7, 2019, with diagnoses which included hypertension (High blood pressure), and hypothyroidism (a disease that affects the hormones). A review of Resident 196's physician's orders dated November 8, 2019, indicated "CBC (Complete Blood Count-a lab test) and BMP (Basic Metabolic Panel-a lab test) on Monday FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 3 of 47 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 11/25/2019 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 (November 11, 2019)." During a review of the clinical record for Resident 196, there was no documented evidence the CBC and BMP lab test results were available in the clinical record and the doctor was notified. During an interview with the Director of Staff Development (DSD) on November 21, 2019 at 1:45 PM, the DSD confirmed there was no documented evidence the labs test results were available in Resident 196's clinical record and the doctor was notified. The DSD stated, "The lab test results should be available in the chart and there should be documentation that the nurses should have notified the doctor." The DSD further stated, "I will get the lab results right now and have the nurse notify the doctor." During an interview with the Director of Nursing (DON) on November 21, 2019 at 2 PM, the DON confirmed there was no documented evidence the labs test results were available in Resident 196's clinical record for review and the doctor was notified about the lab test results. The DON stated, "The labs should be in the chart. The doctor should have been notified about the lab results." A review of the facility's policy and procedure titled, "Test Results," undated, indicated, "The resident's attending physician will be notified of the results of diagnostic tests."

F600 SS=K Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 12/25/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 4 of 47 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 11/25/2019 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 property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for two of 22 sampled residents (Resident 1 and 36) they were free from neglect when prescribed medications were not provided as follows: 1.For Resident 1, the medication atorvastatin (a medication used for high cholesterol levels) was not available to be administered, because it had not been reordered for 74 days and the nurses were documenting they were administering the medication from September 10, 2019, through November 22, 2019. 2.For Resident 36, the medication amiodarone (a medication used for a heart condition) was not available for 32 days because it had not been reordered and was not available for administration and the nurses were documenting they were administering the medication as being given from September 21, 2019 through October 8, 2019, and from November 7, 2019 through November 22, 2019. This failure to provide necessary medication as prescribed by the doctor, failure to reorder the medication timely from the pharmacy, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 5 of 47 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 11/25/2019 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 failure to notify the attending physician's that these residents had missed prescribed doses resulted in Residents 1 and 36's medical need being neglected which had the potential to cause harm. Findings: 1.During a review of the clinical record for Resident 1, indicated Resident 1 was admitted on May 8, 2019, with diagnoses which included hyperlipidemia (high cholesterol levels in the blood). A review of Resident 1's physician's orders dated, August 19, 2019, indicated, "Atorvastatin 80 mg (milligram-a unit of measurement) PO (by mouth) q HS (every bedtime) for hyperlipidemia." During a medication review for Resident 1 in the 400 hall medication cart on November 22, 2019 at 1:45 PM, with Licensed Vocational Nurse (LVN 3), the medication Atorvastatin 80 mg was not located in the cart to be available for administration. LVN 3 confirmed the medication Atorvastin 80 mg was not available in the medication cart. LVN 3 stated, "I will call the pharmacy and re-order the medication." During an interview with pharmacy technician (PHT-a person who keeps track of medications delivered to the facility from the pharmacy) on November 22, 2019 at 3:10 PM, she stated the last time the medication was re-ordered by the facility and sent by the pharmacy was on August 19, 2019. The PHT stated the pharmacy had sent a 21-day supply which would last through September 9, 2019. There was no documented evidence the medication has been refilled after the completion of the 21FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 6 of 47 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 11/25/2019 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 day supply. The PHT stated there was no Atorvastin 80mg available for administration for September 10 through September 30, 2019, or for the months of October or November 2019. During a review of the document titled, "EScript New Prescription Request," dated August 19, 2019, indicated, "Atorvastin 80 mg by mouth daily for 21 days." Further review of the document indicated a note from the pharmacy. It indicated, "Need to clarify why there is a stop date. Tried calling nurse to clarify but left on hold. Please follow-up with M.D." During a review of the Electronic Medication Administration Record (E-MAR) for the month of September 2019, the form indicated after September 9, 2019, the nurses were documenting the medication was available and being administered from September 10 through September 25, 2019. It was documented as not being administered on September 26 and 27, 2019, without explanation for the medication not being given. It was documented as being given from September 28 through September 30, 2019. There was no documented evidence the physician had been notified the medication had not been available or evidence that it had been re-ordered from the pharmacy. During a review of the E-MAR for the month of October 2019, the E-MAR indicated the nurses were documenting the medication Atrovastin 80 mg was available and administered on October 1 through October 31, 2019. There was no documented evidence the physician had been notified the medication had not been available or that it had been re-ordered from the pharmacy. During a review of the E-MAR for the month of November 2019, the E-MAR indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 7 of 47 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 11/25/2019 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 nurses were documenting the medication Astrovastin 80 mg. was available and administered from November 1 through November 21, 2019. There was no documented evidence the physician had been notified the medication had not been available or that it had been re-ordered from the pharmacy. During an interview with the Director of Staff Development/Infection Control Preventionist (DSD/ICP) on November 22, 2019 at 4 PM, she confirmed the medication was not available to be administered and the nurses were documenting the medication as having been available and having been administered evidenced by their signature on the E-MAR. The DSD stated, "They should not document the medication as being given when the medication is not available." During an interview with the Director of Nurses (DON) on November 22, 2019 at 4:30 PM, he confirmed there is no documented evidence the nurses clarify the order with the doctor why there is a stop date on Resident 1's Atorvastin 80 mg by mouth for 21 days. The DON stated, "The nurses should have clarified the order." During a review of the facility's policy and procedure titled, "Abuse Prevention," dated October 11, 1999, indicated, "Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals. All staff participate in Abuse Prevention activities to ensure that all is being done within the facilities control to prevent occurrences" Under the section titled, "Procedure ...2 Employee training on abuse prevention will be conducted during orientation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 8 of 47 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 11/25/2019 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 on an on-going basis ...which includes ...d. What constitutes abuse, neglect and misappropriation of property. ...11. The administrator or his/her appointed designee will report to the State Nurse Aide Registry of Licensing authorities any knowledge it has of any action ...which would indicate an employee is unfit for service including known incidents of resident abuse ..." During a review of the facility's policy and procedure titled, "Administering Medications," undated, indicated, "Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed ... 15. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document "Medication not administered" for that drug and dose." During a review of the facility's Policy and Procedure titled, "Physician Medication Orders," undated, indicated, "Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than (3) days prior to the last dosage being administered to ensure that refills are readily available." 2.During a review of the clinical record for Resident 36, indicated Resident 36 was admitted on June 9, 2018, with diagnoses which included atrial fibrillation (a condition of the heart which can cause a heart attack). A review of Resident 36's physician's orders dated, July 9, 2018, indicated, "Amiodarone 100 mg (Milligram -a unit of measurement) PO (by mouth) QD (everyday) for Atrial Fibrillation." During a medication review for Resident 36 in the 300 hall medication cart on November 22, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 9 of 47 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 11/25/2019 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 2019 at 2:45 PM, with Licensed Vocational Nurse (LVN 4), the medication amiodarone 100 mg PO QD was not located in the cart. LVN 4 confirmed the medication Amiodarone 100 mg was not located in the medication cart. LVN 4 stated, "I gave the last dose and I threw the bubble pack in the shredder. I ordered the medication from the pharmacy today." During an interview with the MDS Director (MDS-minimal data set- MDSD-a nurse who performs an assessment on a resident) on November 22, 2019 at 5:10 PM, she stated, "I checked the shredder to see if I could find the bubble pack, but I couldn't find it. It was not there." During an interview with the pharmacy technician (PHT-a person who keeps track of medications delivered to the facility from the pharmacy) on November 22, 2019 at 3:10 PM, she stated the last time the medication was reordered and sent was on August 21, 2019. She stated the pharmacy had sent a 30-day supply which would last until September 20, 2019. During a review of the Electronic Medication Administration Record (E-MAR) for the month of September 2019, the form indicated after September 20, 2019, the nurses were continuing to document the medication was available and being administered on September 21, September 22, September 23, September 24, September 25, September 28, September 29, and September 30. The medication was not administered on September 26 and September 27. There was no documented reason the medication was not administered. There was no documented evidence the physician had been notified the medication had not been available or evidence that it had been re-ordered from the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 10 of 47 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 11/25/2019 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 E-MAR for the month of October 2019, the nurses were documenting the medication was available and being administer on October 1, October 2, October 3, October 4, October 5, October 6, October 7, and on October 8, 2019. There was no documented evidence the physician had been notified the medication had not been available or evidence that it had been re-ordered from the pharmacy prior to October 8, 2019. During a review of the pharmacy delivery manifest, dated October 8, 2019, the form indicated Resident 36's medication amiodarone 100 mg 30-day supply was delivered to the facility. The facility had medication through November 6, 2019. During a review of the E-MAR for the month of November 2019, the E-MAR indicated the nurses were documenting the medication was available and being administered on November 7, November 8, November 9, November 10, November 11, November 12, November 13, November 14, November 15, November 16, November 17, November 18, November 19, November 20, and November 21. During an interview with the Director of Staff Development/Infection Control Preventionist (DSD/ICP) on November 22, 2019 at 4 PM, she confirmed the medication was not available to be administered and the nurses were documenting the medication as having been available and having been administered evidenced by their signature on the E-MAR. The DSD stated, "They should not document the medication as being given when the medication is not available." During a review of Resident 36's electrocardiogram (ECG- a test to identify problems in conduction of the heart) dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 11 of 47 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 11/25/2019 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 November 22, 2019, the ECG which was ordered following the identification of the amiodorone not being administered indicated Resident 36 had "Atrial Fibrillation with rapid ventricular response ... Abnormal ECG". During a review of the facility's policy and procedure titled, "Abuse Prevention," dated October 11, 1999, indicated, "Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals. All staff participate in Abuse Prevention activities to ensure that all is being done within the facilities control to prevent occurrences." Under the section titled, "Procedure ...2 Employee training on abuse prevention will be conducted during orientation on an on-going basis ...which includes ...d. What constitutes abuse, neglect and misappropriation of property. ...11. The administrator or his/her appointed designee will report to the State Nurse Aide Registry of Licensing authorities any knowledge it has of any action ...which would indicate an employee is unfit for service including known incidents of resident abuse ..." During a review of the facility's policy and procedure titled, "Administering Medications," dated undated, indicated, "Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribe .... 15. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document "Medication not administered" for that drug and dose." During a review of the facility's policy and procedure titled, "Physician Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 12 of 47 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 11/25/2019 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 Orders," undated, indicated, "Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than (3) days prior to the last dosage being administered to ensure that refills are readily available. An immediate Jeopardy (IJ-a situation with the potential to harm the health and safety of the patients) was called under 483.12 (a) (1) F 600 Freedom from Abuse, Neglect, and Exploitation on November 22, 2019 at 3:15 PM, in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and the DON were verbally notified of the IJ situation identified based on the facility's failure to ensure Resident's 1 and 36 were free from neglect when prescribed medications which were not provided as follows: 1.For Resident 1, the medication atorvastatin (a medication used for high cholesterol levels) was not available to be administered, because it had not been reordered and was not available for administration for 74 days and the nurses were documenting they were administering the medication from September 10, 2019, through November 22, 2019. 2.For Resident 36, the medication amiodarone (a medication used for a heart condition) was not available for 32 days, because it had not been reordered and was not available for administration and the nurses were documenting they were administering the medication as being given from September 21, 2019 through October 8, 2019, and from November 7, 2019 through November 22, 2019. This failure to provide necessary medication as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 13 of 47 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 11/25/2019 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 prescribed by the doctor, failure to reorder the medication timely from the pharmacy, and failure to notify the attending physician's that these residents had missed prescribed doses resulted in Residents 1 and 36's medical need being neglected which had the potential to cause harm. The facility submitted a corrective action plan (CAP) which was reviewed and accepted on November 25, 2019 at 4:15 PM, in the presence of the ADM and DON. After interviews to confirm implementation of the CAP and a review of medication availability for Resident 1 and 36, and interviews with staff regarding the in-services on neglect, and medication administration, the IJ was lifted on November 25, 2019 at 4:55 PM, in the presence of the ADM and DON.

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

F641 12/25/2019 §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 medications during the 7-day look back assessment period in the Minimum Data Set (MDS - resident assessment tool), for three of 22 sampled residents (Resident's 94, 75, and 77) when, 1. For Resident 94, antiplatelet medication (prevents platelets [blood cells] from clumping and forming blood clots) was inaccurately coded as an anticoagulant (blood thinner) in "section N- Medication". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 14 of 47 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 11/25/2019 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 2. For Resident 75, antiplatelet medication (preventions platelets (blood cells) from clumping and forming blood clots) was inaccurately coded as an anticoagulant (blood thinner) in "Section N-medication." 3. For Resident 77, the MDS was inaccurately coded for Diabetes Mellitus (DM-a group of diseases that result in too much in the blood) and insulin medication given (controls blood sugar levels in the body). These failures had the potential to result in unmet care needs by not being accurately assessed for Resident 94, 75, and 77, which could potentially jeopardize their health and safety. Findings: 1. During an observation on November 27, 2019, at 1:29 PM, Resident 94 was sitting in his wheelchair in the dining room, had finished eating lunch, and was well groomed. During a review of Resident 94's clinical record, the face sheet (contains demographic information) indicated Resident 94 was readmitted to the facility on January 17, 2019, with diagnoses of deep vein thrombosis of lower extremity (blood clots in the vein) and atherosclerotic heart disease (deposition of fatty substance in the heart vessels). A review of Resident 94's MDS, under Section N - Medications, dated October 28, 2019, indicated Resident 94 had received "Anticoagulant (e.g., warfarin, heparin, or lowmolecular weight heparin)" seven times at the time of assessment period. A review of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 15 of 47 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 11/25/2019 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 94's "Physician Orders" dated October 2019, indicated Resident 94 had an order for "Plavix 75 mg tablet" (antiplatelet medication) daily for atherosclerotic heart disease and the medication was ordered by the physician on January 17, 2019 and there was no order for anticoagulant medication. A concurrent interview and record review on November 20, 2019 at 1:30 PM, of Resident 75's "Medication Administration Record" (MAR) dated October 2019, and the quarterly MDS dated October 28, 2019, with the Minimum Data Set Nurse (MDS 1) was conducted on November 20, 2019. MDS 1 reviewed the document and stated she had coded the Plavix medication as an anticoagulant, as she was not aware that Plavix was not an anticoagulant. During a concurrent interview and record review on November 20, 2019 at 1:35 PM, of "CMS's [Center for Medicare and Medicaid] RAI (Resident Assessment Instrument) Version 3.0 Manual" dated October 2017, with MDS 1, it indicated "Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel [Plavix] here." MDS 1 reviewed and verified that she should not have coded Plavix as an anticoagulant medication. During an interview with the Director of Nursing (DON) on November 21, 2019, at 4:46 PM, the DON acknowledged that Plavix was inaccurately coded for anticoagulant and the expectation was to follow the CMS coding guidelines. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 16 of 47 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 11/25/2019 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 2. During a review of Resident 75's clinical record, the face sheet (a document that contains basic information about the resident) indicated Resident 75 was readmitted to the facility on April 9, 2019, with diagnoses which included atrial fibrillation (a condition of the heart that can cause blood clots). During a review of Resident 75's quarterly MDS (minimal date set-an assessment tool), under Section N - Medications, dated October 16, 2019, indicated Resident 75 had received an Anticoagulant (blood thinner) seven times. During a review of Resident 75's "Physician Orders" dated May 9, 2019, indicated Resident 75 had an order for "Plavix (an antiplatelet medication-reduces the ability of a type of cell to stick together) 75 mg (milligram- a unit of measurement) tablet" daily for atherosclerotic heart disease (condition caused by narrowing of the arteries). There was no order for an anticoagulant (blood thinner) medication. During a review Resident 75's quarterly MDS dated October 16, 2019, indicated Plavix medication was coded as an anticoagulant. During a review of "CMS's [Center for Medicare and Medicaid] RAI (Resident Assessment Instrument) Version 3.0 Manual" dated October 2017, indicated, "Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel [Plavix] here." During an interview with MDS 2 on November FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 17 of 47 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 11/25/2019 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 20, 2019 at 3:55 PM, the MDS 2 confirmed Plavix was coded as an anticoagulant in Resident 75's quarterly MDS. The MDS 1 stated, "I was not aware the Plavix was not an anticoagulant. I should have not coded as an anticoagulant." During an interview with the Director of Nursing (DON) on November 21, 2019, at 4:36 PM, the DON acknowledged that Plavix was inaccurately coded for anticoagulant and the expectation was to follow the CMS coding guidelines. 3. During a review of the face sheet for Resident 77, dated November 25, 2019, indicated Resident 77 was admitted on October 23, 2019. Under "Current Diagnoses", Diabetes was not documented. During a concurrent interview and record review with the MDS Nurse on November 25, 2019, at 11:02 AM, the MDS stated after reviewing Resident 77's MDS under Section IActive Diagnoses, dated October 29, 2019, shows that resident has diagnosis of Diabetes Mellitus (DM) and the medication section N indicated he received insulin. During a concurrent interview and record review of the MDS, physician's history and physical, physician's progress notes dated November 8, 2019, and of the Medication, Administration Record (MAR) for November 2019, with the MDS Nurse, on November 25, 2019, at 11:02 AM, she stated that there was no diagnosis of DM for Resident 77. The MDS Nurse stated that the diagnosis should not have been put in the MDS. She stated the facility gets information for the MDS from the diagnosis entered by Medical Records into the electronic chart and from the physician's History and Physical. The MDS nurse stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 18 of 47 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 11/25/2019 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 after review of the MAR that insulin was not ordered and insulin was not given, and it should not have been entered into MDS. During a concurrent interview and record review with the Director of Nurses (DON) on November 25, 2019, at 11:21 AM, the DON stated that insulin was accidentally coded and acknowledged that there was no order for insulin. The DON further acknowledged that the resident did not have a diagnosis of DM and that should not have been entered into the MDS. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Section N: Medications, dated April 2012, indicated that "1. review resident's medication administration records for the 7-day look-back period. 2. Determine if resident received insulin injections during the look-back period." The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Section I: Active Diagnoses, dated April 2012, indicated that "Identify Diagnoses: The disease conditions in this section require a physiciandocumented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered."

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

F684 Event ID: CHNI11 12/25/2019 Facility ID: CA240000065 If continuation sheet 19 of 47 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 11/25/2019 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) SS=E 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 3 out of 22 sampled residents (resident's 35, 250, and 21) facility's policies and procedures were followed when: 1. For Resident 35, doctor's order for a Dilantin level was not done and the doctor was not notified on a timely manner. This failure had the potential to jeopardize the health and safety of Resident 35. 2. For Resident 250, the facility failed to weigh resident weekly for one month after admission to determine a trend in weight. This failure had the potential to result in untreated weight loss or gain which could cause significant medical complications and death. 3. For Resident 21, the consultant pharmacist's medication regimen review was not carried out by staff in a timely manner. This failure had the potential for Resident 21's not to get the full benefits of the medication. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 20 of 47 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 11/25/2019 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 1.During a review of the clinical record for Resident 35, the face sheet (a document which contains basic information about the resident) indicated Resident 35 was admitted to the facility on September 3, 2016, with diagnoses which included intracranial hemorrhage (stroke), and diabetes (high blood sugar). A review of Resident 35's physician's orders dated October 25, 2019, indicated "Dilantin (a medication for seizures) Level on November 7, 2019." During a review of the Clinical record for Resident 35, there was no documented evidence a Dilantin level was done on November 7, 2019. Further review of the clinical record, indicated, the doctor was not notified about Dilantin level not being done. During an interview and record review with the Director of Nursing (DON) on November 21, 2019, at 10:00 AM, the DON review resident 35's clinical record and confirmed there was no documented evidence the Dilantin level was done and the doctor was notified. The DON stated, "It should have been done as ordered." During an interview with the Director of Staff Development (DSD) on November 21, 2019, at 11:00 AM, the DSD confirmed there was no documented evidence a Dilantin level was done and the doctor was notified. The DSD stated, "The nurses should have notified the lab about the Dilantin level order." The DSD further stated, "There was no lab slip filled out. The lab was not notified about the Dilantin level to be done. That is how it was missed. The doctor should have been notified." A review of the facility's policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 21 of 47 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 11/25/2019 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 titled, "Test Results," undated, indicated, "The resident's attending physician will be notified of the results of diagnostic tests." 2. During review of the clinical record for Resident 250, the current diagnoses found in the History and Physical that can affect weight were major depressive disorder (mood disorder that interferes with daily life), mild proteincalorie malnutrition (not enough protein intake), Vitamin B12 deficiency anemia due to intrinsic factor deficiency (a decrease in red blood cells when the body can't absorb enough vitamin B12), sick sinus syndrome (sinus node or natural pace maker in the heart is malfunctioning), chronic obstructive pulmonary disease (COPD-A group of lung diseases that block airflow and make it difficult to breath), gastroesophageal reflux disease (GERD-A digestive disease in which stomach acid or bile irritates the food pipe lining), dementia (thinking and social symptoms that interferes with daily functioning), hemiplegia (muscle weakness or partial paralysis on one side of the body). During a review of the clinical record, indicated Resident 250's weight was documented the day after admission on November 3, 2019, as 123 pounds. There were no further weights taken after this time. During a concurrent interview and record review with the Registered Dietician (RD) on November 21, 201,9 at 2:28 PM, she stated Resident 250 had a history of difficulty swallowing and laryngeal cancer (Cancer of the vocal cords) which resulted in a 20-pound weight loss prior to admission in the past year. The RD reviewed the weight documented on admission and acknowledged that weights had not been documented since then. She stated that the weights should have been recorded weekly since admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 22 of 47 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 11/25/2019 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 concurrent interview and record review with Restorative Nurse Assistant (RNA 1) on November 21, 2019, at 2:29 PM, RNA1 reviewed weight logs and confirmed no weights had been documented after admission. He stated that it should have been taken weekly. During an interview with Director of Staff Development (DSD) on November 21, 2019, at 2:38 PM, the DSD stated that weekly weights should be done for one month after admission. During a concurrent interview and record review with Minimum Data Set Director (MDSD) on November 21, 2019, at 2:43 PM, the MDSD stated that new admissions are weighed weekly for four weeks. RNA's see weights flagged in ecare (electronic system of identifying care tasks needed to be implemented). The MDSD stated, "It would inform us of a decline in resident's health such as electrolyte imbalances, dehydration (a harmful reduction in the amount of water in the body), malnutrition (A condition that results from lack of sufficient nutrients in the body) and potential pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin)." During an interview with the Director of Nursing (DON) on November 21, 2019, at 11:07 AM, the DON stated new admissions are weighed weekly for one month. The DON stated, "They should have been done. If weights are not done, we are placing the resident at risk for dehydration and malnutrition because we are not monitoring. Basically placing the resident's health condition at risk." The facility policy and procedure titled "Weight Assessment and Intervention," dated January 22, 2013, indicated under "Weight Assessment: 1. The nursing staff will measure resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 23 of 47 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 11/25/2019 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 weights on admission, the next day, and weekly for four weeks thereafter. 2. Weights will be recorded in the electronic record immediately after being taken. " 3. During a review of the clinical record, the face sheet (a document which contains basic information about the resident), indicated, Resident 21 was admitted to the facility on February 20, 2017, with diagnoses which included GERD (Gastric Esophageal Reflux Disease- a condition of the stomach that causes heartburn). A review of Resident 21's physician's order dated May 26, 2019, indicated, "Omeprazole 40 mg (milligram- a unit of measurement) capsule Q (every) D (day) via G tube (gastric tube-a (gastric tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) for GERD." A review of Resident 21's Electronic Medication Administration Record (E-MAR) on November 21, 2019 at 10:30 AM, indicated the medication is being given at 9 AM. During a review of the document titled, "Consultant Pharmacist's Medication Regimen Review," dated, October 9, 2019, for Resident 21, indicated, "Omeprazole works best given before meals. Consider changing administration time from 9 AM to 6:30 AM." During a review of the Clinical record for Resident 21 on November 21, 2019, there was no documented evidence the doctor was notified and pharmacy's recommendation was carried out, 43 days after the consultant pharmacist's medication Regimen Review report was given to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 24 of 47 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 11/25/2019 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 Director of Nurses (DON) on November 21, 2019, at 2:45 PM, the DON confirmed there was no documented evidence the doctor was notified and pharmacy's recommendation were carried out. The DON stated, "The doctor should have been notified and the pharmacy's recommendation should have been followed." A review of the facility's policy and procedure titled, "Administering Medications," undated, indicated, "Medications shall be administered in a safe and timely manner ...4. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns."

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 12/25/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require 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 interview and record review, the facility failed to assess one of two Residents' (Resident 77's) pain level each shift and document the effectiveness of the pain medication administered. This had the potential FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 25 of 47 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 11/25/2019 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 for the staff to not be able to determine if the pain medication was adequately controlling Resident 77's pain which could cause unnecessary suffering. Findings: During an interview with Resident 77 on November 20, 2019 at 6:43 AM, he stated that the nurses do not ask his pain level after giving his pain medication. He states his pain isn't controlled sometimes. During review of clinical record for Resident 77 with a Licensed Vocational Nurse (LVN 2), the Medication Administration Record (MAR) and nurses progress notes did not show that Resident 77's pain level before and after receiving Norco (a narcotic pain medication) was effective in relieving his pain. During a concurrent interview and record review of the MAR (Medication Administration Record-record of medications, treatments and assessments) and nursing progress notes with the Minimum Data Set (A computerized assessment tool) Director (MDSD) on November 21, 2019 at 3:26 PM, the MAR for the month of November 2019, and the nurses' progress notes showed that pain levels (from 0no pain to 10-worst pain) were not documented for every shift before and after Norco had been administered. MDSD stated that the order placed for pain level done in electronic medical record on October 24, 2019 was not entered correctly so the LVN was not able to enter pain level in the electronic record. She stated that the LVNs who were not able to enter pain level should have re-entered the order correctly in the electronic record. Also, they could have documented the pain level and effectiveness of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 26 of 47 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 11/25/2019 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 pain medication in the nurses' progress note. During a concurrent interview and record review of the MAR and nurses progress notes with the Director of Staff Development (DSD) on November 22, 2019 at 9:47 AM, the DSD stated that Licensed staff should check for effectiveness of pain medication 30 minutes after it has been given and the pain level should be assessed every shift. They should be documenting the pain level in the MAR. If they can't enter the pain level right away, then they can stop the original order for pain level and put in a new order. "We expect the problem to be dealt with immediately. Pain levels are important. We want to make sure patients are comfortable and pain can increase blood pressure and cause other medical dilemmas. Maybe patient can go into cardiac arrest (Absence of pulse, blood pressure and respirations). There should have been a pain level despite note saying medication effective. " During a review of the MAR notes for November 2019, there was no documentation to show effectiveness of the pain medication (Norco). The MAR for November 2019 showed that Resident 77's pain level was asessed, but there was no documentation of what the pain level was each shift. As well as, prior to and following the administration of the Norco. During an interview with the Director of Nursing (DON) on November 22, 2019, at 10:33 AM, the DON stated. "If [the nurses] were not able to put the pain level in MAR, then they should put it in the nurses' progress note. We assess residents pain every shift. The DON stated Pain level should be documented somewhere and there should be a pre and post pain level done." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 27 of 47 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 11/25/2019 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 The facility policy and procedure titled "Pain Clinical Protocol," undated, indicated under "Assessment and Recognition ... 3.a. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level." Also, under "Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant levels of chronic pain... 4a. The physician will adjust or discontinue medications accordingly, based on effectiveness..."

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

F761 12/25/2019 §483.45(g) Labeling of Drugs and Biologicals 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 28 of 47 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 11/25/2019 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow their policy and procedure for home medication brought to the facility upon admission by leaving the home medications at the bedside for one of eight residents (Resident 297). This failure had the potential to result in over dose of blood pressure medications (lower the blood pressure) and diuretic medication (increase production of urine and lower the blood pressure) and would have caused hypotension, dehydration (loss of body fluids), cardiac arrhythmia (irregular heart beat) and even death. Findings: During an observation on November 18, 2019, at 12:25 PM, Resident 297 was lying semi fowlers position (head of the bed raised at 45degree angle) in her bed. She was awake, alert, and interviewable. There was a medication prescription bottles were observed inside the plastic bag placed on the Resident 297's bed besides the Resident 297. During a concurrent interview with Resident 297, Resident 297 stated she brought those medications from home last Wednesday (November 11, 2019- six days ago) when she was admitted to the facility. A review of Resident 297's clinical record face sheet (demographic data) indicated Resident 297 was admitted to the facility on November 13, 2019, with the diagnoses of plural effusion (water in the lungs), atrial fibrillation (irregular FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 29 of 47 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 11/25/2019 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 heartbeat), and hypertension (high blood pressure). During an interview on November 18, 2019 at 12:40 PM, with the Registered Nurse (RN 2), in Resident 297's room, RN 2 acknowledged and stated residents never allowed to have their home medication at the bedside. RN 2 stated the home medications should be sent back with the family member or has to be locked in the medication room until family comes and pick it up to prevent overdose. During a concurrent interview and medication reconciliation of Resident 297's home medication on November 18, 2019. At 12:43 PM, with the Director of Nursing (DON) in the medication room, the DON acknowledged the following prescription medication bottles were found inside the plastic bag as follows: one bottle of 150 milligrams (mg- a unit of measurement) Propafenone tablets (antiarrhythmic medication), 2 bottles of 1 mg bumetanide tablets (water pill), one bottle of 20 mg Lasix tablets (water pill), and one bottle of losartan 25 mg (lower blood pressure). The DON stated home medications should be locked in the medication room until it was given back to the family or it would be properly discarded. The facility policy and procedure titled "Acceptance of Medications on Admission" undated indicated "Purpose: The purpose of this procedure is to establish for the acceptance of medications brought to the facility by the resident or family upon admission; Preparation: ...7. Medications not accepted by this facility must be returned to the resident's representative (sponsor) or destroyed in accordance with our established procedures governing the destruction of medication. The nurse Supervisor will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 30 of 47 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 11/25/2019 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 responsible for documenting the results of the facility's decision to accept or reject medications brought by the resident upon admission."

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

F802 12/25/2019 §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. 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 kitchen staffs when: 1.A Dietary Aide (DA 1) did not demonstrate appropriate knowledge on the use of the sanitization bucket. 2. A Dishwasher (DW 2) did not demonstrate appropriate knowledge on the use of the sanitization bucket. 3. A Dishwasher (DW 1) did not demonstrate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 31 of 47 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 11/25/2019 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 appropriate knowledge on the use of the sanitization bucket. These failed practices had the potential for food borne illness (disease caused by consumption of contaminated food and drinks) for a medically compromised population of 98 residents who received food from the kitchen out of a facility census of 100. Findings: 1.During an observation and interview with DA 1 on November 18, 2019, at 9:47 AM, DA 1 stated the red sanitization bucket with a sanitizer solution (a sanitizer solution used to sanitize the food contact areas such as counter tops) would be changed every 2 hours and further stated solution would be changed every 5 hours and as needed. DA 1 further demonstrated the strength of sanitization bucket solution by checking the solution. DA 1 collected the sanitization solution in the bucket and was observed testing the water mixed solution with a quaternary ammonia test strip (a test strip used to check the concentration of a quaternary ammonia solution) and the test strip result indicated 100 ppm (parts per million-unit of measurement). DA 1 stated after dipping the test strip in to the solution would wait for a minute and compare the results with the test strip indicator. 2. During an observation on November 18, 2019, at 9:55 AM, a red sanitization bucket solution was labeled as November 17, 2019, at 5:00 AM. During a concurrent observation and interview with DW 2 on November 18, 2019, at 9:55 AM, DW 2 stated the sanitization bucket solution FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 32 of 47 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 11/25/2019 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 was made today (November 18, 2019). DW 2 further stated the sanitization bucket would be changed every 4 hours and as needed. DW 2 further stated he would collect the premixed solution from the multi [quaternary] solution and mixed with hot water and dip the test strip in to the solution and would wait for a minute for the strip's color change. DW 2 stated he would wait for a minute and compare the color change with the color codes on the test strip box and logged in to the record and the test results should be 200ppm. During a concurrent interview and record review with DW 2 on November 18, 2019, at 9:57 AM, DW 2 reviewed facility's document titled "Sanitizer bucket change schedule" for the month of November 2019, indicated, "November 18, at 5:00 AM was 200ppm, 8:00 AM was 200ppm." DW 2 was unable to say when was the sanitizer bucket changed. 3. During an interview with DW 1 on November 18, 2019, at 3:43 PM, DW 1 stated he would change the sanitizer bucket solution as needed and wait for a minute for the color change of the test strip. DW 1 was unable to demonstrate the sanitizer bucket solution change. During an interview with the Dietary Supervisor (DS) on November 18, 2019, at 3:50 PM, the DS stated kitchen staffs are expected to change the red sanitization bucket solutions every 3-4 hours and as needed. Staffs are expected to dip the paper in the sanitizing solution and wait for 10 seconds to compare the results with the test strip box. During a review of the [BRAND NAME] quat-10 test paper instructions indicated, "Dip paper in [quaternary]solution, NOT FOAM SURFACE, for 10 seconds. Compare colors at once ...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 33 of 47 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 11/25/2019 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 facility's undated policy and procedure titled "Sanitization", indicated, " ... sanitizing procedures - 5. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways: ... b. contact with QAC (at approved concentration) per manufacturer's instructions ...."

F804 SS=F Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 12/25/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide hot food within an appropriate temperature for a medically compromised residents in the facility when hot food in the breakfast tray was served cold. This failure had the potential for the growth of harmful bacteria that could lead to food borne illness (food poisoning caused by contaminated food consumption) for a medically compromised population of 98 residents who received food from the kitchen in the universe of 100. Findings: During a resident council meeting conducted in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 34 of 47 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 11/25/2019 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 the facility on November 19, 2019, at 2:30 PM, five of five residents were complained the food was served cold and served late for the past several months. During a review of the facility's document "Resident council" minutes dated September 27, 2019, indicated, "council members requesting for more fruits specially breakfast, sometimes trays are late ... ." During a tray line observation on November 20, 2019, at 6:46 AM, along with the cook 1, in the kitchen temperature(temp) checked by the surveyor after calibrating the thermometer to 34 degrees Fahrenheit (F- unit of measurement), indicated the following: Fried egg - 147.2 F (eggs held for service should be at least 155 degrees F). During an observation of a breakfast test tray (a sample tray of food to test the temp and the palatability) in the food cart was served at the [400's hallway] and the remaining four trays in the cart was served in the dining room, with the Dietary Supervisor(DS), on November 20, 2019, at 7:38 AM, after the thermometer was calibrated by the DS and the surveyor indicated the following: Fried egg- 114. 6 F (surveyor), 114.4 F (DS). During an interview with the DS on November 20, 2019, at 7:45 AM, the DS verified the food temp of the test tray was too low for the hot food, and put the eggs in the unsafe temperature zone. The DS stated the fried eggs should have still been above 120 degrees F when the food was served outside the kitchen A review of the policy and procedures titled "Meal Service" [NAME of company], indicated, " ... Meals that meet the nutritional needs of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 35 of 47 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 11/25/2019 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 will be served in an accurate and efficient manner, and served at the appropriate temperatures ... Recommended temp at delivery to resident-Hot Entrée >= 120F ... ." During a follow up interview and record review with the DS on November 20, 2019, at 8:46 AM, the DS reviewed the policy and procedures titled "Meal Service" and verified the facility did not follow this policy and procedure by serving hot food at a lower than safe temperature to the residents.

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

F812 12/25/2019 §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 safe and sanitary food preparation and storage practices as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 36 of 47 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 11/25/2019 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 1. Uncovered vegetables (celery and cabbage) were found in the walk in refrigerator. 2. Unlabeled bread (five packages) found in the dry storage room. 3. Nine hotel pans of various sizes were stacked and stored wet. 4. Kitchen staff (Dishwasher- DW 4) did not perform hand hygiene when entered in to the kitchen. These failed practices had the potential for the growth of harmful bacteria that could lead to food borne illness (disease caused by consumption of contaminated food and drinks) for a medically compromised population of 98 residents who received food from the kitchen out of a facility census of 100. Findings: 1.During an initial tour of the kitchen on November 18, 2019, at 9:20 AM, an observation was conducted with the facility's Dietary Supervisor (DS). Observed one clear large plastic box of uncovered celery and a large box of cabbage uncovered in the walk -in refrigerator. During a concurrent interview with the DS on November 18, 2019, at 9:21 AM, the DS verified the vegetables (celery and cabbage) box should have been covered and kept in the walk in refrigerator. A review of the facility's undated policy and procedure titled "Food receiving ad storage", indicated, " ... Labeling foods stored in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 37 of 47 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 11/25/2019 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 refrigerator/freezer, 7. All foods stored in the refrigerator will be covered ... ." During a concurrent interview and record review with the DS on November 22,2019, at 11:13 AM, the DS reviewed the facility's undated policy and procedure titled "Food receiving ad storage" and verified the facility did not follow the policy and procedure for the storage of the celery and cabbage. The DS further acknowledged the vegetables should have been covered and kept in the refrigerator. 2. During an initial tour of the kitchen on November 18, 2019, at 9:26 AM, with the facility's DS, an observation was conducted five packets of unlabeled (use by- final day that the product will be at it's optimum freshness) bread in the dry storage room shelves. During an interview with the DS on November 18, 2019, at 9:27 AM, the DS stated the bread packet should have been labeled with the use by date. 3. During an initial tour of the kitchen along with the DS on November 18, 2019, at 9:30 AM, nine (9) hotel pans of various sizes were on the bottom rack of the shelves in the food production area and were stacked and wet on the inside surface. During an interview with the DS on November 18, 2019, at 9:31 AM, the DS confirmed five medium hotel pans, two (2) small serving pans, and two (2) large hotel pans were stored and stacked wet and all these pans were used to serve the food. The DS further stated the pans should be completely dry before stacking. A review of the facility's undated policy and procedure titled "Sanitization", indicated, " ... 10. Air drying, Food preparation equipment and utensils that are manually washed will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 38 of 47 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 11/25/2019 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 allowed to air dry ... ." During a concurrent interview and record review with the DS on November 22, 2019, at 11:42 AM, the DS reviewed the facility's policy and procedure titled "Sanitization" and verified the facility did not follow the policy and procedure when multiple pans were stored and stacked wet. 4.During an observation on November 18, 2019, at 9:40 AM, DW 4 entered in to the kitchen without performing hand hygiene and went in to the walk in refrigerator with a cart. During an interview with DW 4 on November 18, 2019, at 9:42 AM, DW 4 confirmed he did not perform hand hygiene and went in to the walk in refrigerator to collect the juices. A review of facility's undated policy and procedure titled "Food preparation and service", indicated, " ... 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illnesses ... ." During an interview and record review with the DS on November 22, 2019, at 11:54 AM, the DS stated all kitchen staff were expected to perform hand hygiene prior to handling the food. The DS further reviewed the facility's undated policy and procedure titled "Food preparation and service", and verified the facility did not follow this policy and procedure when a DW did not perform hand hygiene.

F814 SS=D Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 12/25/2019 §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 39 of 47 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 11/25/2019 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 by: Based on observation, interview, and record review, the facility failed to ensure one of four (4) dumpsters lids were completely closed and trash was kept on top of the dumpster lid. This failure had the potential for the harborage of insects and pests that could affect the health and safety of a highly vulnerable population of 100 residents. Findings: During an observation with the Dietary Supervisor (DS), on November 18, 2019, at 9:58 AM, of the garbage storage area outside of the kitchen trash dumpsters were inspected. The first dumpster was observed the dumpster was overfilled with trash and the lid was halfway closed, with the top part of the lid was also stored with trash. During a concurrent interview with the DS, the DS stated, the expectation of the trash dumpster lids is that the lids should be completely closed and the trash should not be stored on top of the dumpsters. During an interview with the Director of Environmental Services (DES), on November 21, 2019, at 11:56 AM, the DES, stated the dumpster lids was expected to be covered always. The DES further stated dumpsters were not to be over filled and the trash should be placed inside the dumpster. Facility was unable to provide a policy and procedure for the dumpster maintenance. According to the 2013 "United States Department of Agriculture Food Code", proper storage and disposal of garbage and refuse are necessary to minimize the development of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 40 of 47 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 11/25/2019 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 odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 12/25/2019 §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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 41 of 47 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 11/25/2019 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 (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, 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 ensure infections do not develop and potentially transmit communicable disease to other residents, for four of 22 sampled residents (Residents 72, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 42 of 47 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 11/25/2019 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 347, 92 and 247) when: 1.For Resident 72, Her nasal cannula had not been changed for 11 days. 2.For Resident 247, there was no sign at resident's room entrance stating isolation precautions were in place. 3.Resident 347's Intra Venous access (I V- a cannula inserted in to the vein to administer medicines) dressing was outdated and was not changed per facility's policy and procedure. 4.Resident 92's I V dressing was not dated to indicate when it was inserted or changed per facility's policy and procedure. These failures had the potential to jeopardize the health and safety of these residents (Residents 72, 247, 347 and 92). Findings: 1.During an observation on November 18, 2019 at 12:19 PM, the nasal cannula for Resident 72 was dated November 8, 2019. During an interview with Licensed Vocational Nurse (LVN1) on November 18, 2109 at 12:24 PM, she confirmed that nasal cannula was dated November 8, 2019. She stated that they are changed every week by the Environmental Director (ED). During an interview with the ED on November 18, 2019 at 12:36 PM, she stated that the cannula is changed every Friday and that it should have been changed. During an interview with the Director of Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 43 of 47 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 11/25/2019 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 (DON) on November 18, 2019 at 12:46 PM, he stated that the standard of care was to change the nasal cannula weekly and the cannula should have been changed. The facility policy and procedure titled "SNF Oxygen Services Policy and Procedure," undated, indicated "The nasal cannula should be changed every 5 - 7 days, unless a severe infection requires a more frequent change." 2.During an observation on November 18, 2019, at 10:34 AM, at the entrance of the room for Resident 247, were gloves, gowns and masks hanging from door, but no sign stating the resident was in isolation precautions. During an interview with Treatment Nurse (TN) on November 18, 2019, at 10:35 AM, she stated that there should be a sign at the entrance to resident 247's room. She stated that other residents, staff and visitors could get an infection from Resident 247 if precautions were not taken. During an interview with the DON on November 18, 2019 at 10:55 AM, he stated that there should be a sign on the door or frame of the door for isolation precautions. There would be an issue of transmitting infection to others, if precautions were not taken.. During an interview with Director of Staff Development/Infection Control Preventionist (DSD/ICP) on November 18, 2019, at 11:05 AM, she stated that there should have been a stop sign." We are placing persons at risk to be exposed to an infection with cross contamination. " The facility policy and procedure titled "Isolation-Initiating Transmission-Based Precautions," undated, indicated, " ... 5. When FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 44 of 47 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 11/25/2019 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 Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall ... b. Post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. This facilities process for notification is signage instructing visitors to see nurse before entering." 3.During an observation and interview with Resident 347, on November 18, 2019, at 10:32 AM, Resident 347 was alert awake and was able to communicate her needs. Resident 347 had two I V access lines, one was on her left arm and another one in the antecubital (ACclose to elbow) area. The I V in the left arm was dated November 2, and the left AC I V was dated November 3 and the dressing was visibly slightly moistened. Resident 347 stated she had the I V from the hospital and she was not receiving any medicines through the I V and had requested multiple times to the staff to remove it. During a review of Resident 347's "Admission Record" (contains demographic information) indicated, Resident 347 was admitted on November 6, 2019, with diagnoses which included biliary pancreatitis without necrosis or infection (complications from gall stones leads to inflammation of the pancreas), and diabetes mellitus (elevated blood sugar level). During a concurrent observation and interview with a Registered Nurse (RN 1) on November 18, 2019, at 10:45 AM, RN 1 verified Resident 347 's I V dressing were dated November 2 and November 3 on resident's left arm and AC area respectively. RN 1 stated the dressing would usually be changed every three to five days or the I Vs should have been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 45 of 47 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 11/25/2019 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 discontinued. RN 1 further stated the I V was placed prior to admission and Resident347 was not receiving any I V medicines. A review of facility's undated policy and procedure titled "Peripheral I V dressing changes" indicated, "The purpose of this procedure is to prevent catheter related infections associated with contaminated, loosened or soiled catheter site dressings ... 2. Change the dressing at the time of catheter site rotation (every 72 to 96 hours) or immediately upon observing that he integrity of the dressing has been compromised ... ." During an interview and record review with the Director of Nursing (DON) on November 21, 2019, at 2:43 PM, the DON stated I V dressings should be changed every three to five (5) days and as needed, or if the resident was not on any I V medicines, or the nurse should obtain an order from the physician to discontinue the I V. The DON further stated staffs are expected to check the I V site and document in the progress notes about the site and dressing. The I V dressings being over 2 weeks without being changed was not acceptable. The DON further reviewed facility's undated policy and procedure titled "Peripheral I V dressing changes" and verified the facility did not follow the policy and procedure by not changing the I V dressing in a timely manner. 4. During an observation and interview with Resident 92 on November 18, 2019, at 11:06 AM, Resident 92 was lying in her bed, resident was alert, awake, and able to communicate her needs. Resident 92 was observed with an undated I V access site in her left arm. Resident 92 stated she had received medication through that [I V]. During an observation and interview with RN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 46 of 47 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 11/25/2019 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 at Resident 92's room on November 18, 2019, at 11:14 AM, RN 1 confirmed Resident 92's left hand I V site was unlabeled. RN 1 further stated staff are expected to date and initial the dressing after placing the I V access and document in the resident's progress notes. A review of Resident 92's "admission Record" indicated Resident 92 was admitted on October 23, 2019, with diagnoses included, embolism (blood clot block the blood vessels causes emboli) and thrombosis (blood clots) of arteries of the lower extremities and atrial fibrillation (irregular heart beat). A review of facility's undated policy and procedure titled "Peripheral I V dressing changes" indicated, " ... Steps in the procedure, 7. Label dressing with date, time, and initials ... ." During an interview, and record review, with the DON on November 21, 2109, at 2:53 PM, the DON stated, staff are expected to label the I V dressing with date, time and initials and also document in the resident's progress notes. The DON further reviewed facility's undated policy and procedure titled "Peripheral I V dressing changes" and verified the facility did not follow the policy and procedure by not labeling the I V dressing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CHNI11 Facility ID: CA240000065 If continuation sheet 47 of 47