Other·November 13, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted from August 5, 2019, through August 12, 2019. Representing the California Department of Public Health: Surveyor 40308, HFEN; Surveyor 40000, HFEN; Surveyor 40356, HFEN; Surveyor 40674, HFEN; and Surveyor 25338, HFES. The facility census was 94 residents. Due to the facility's failure to ensure sanitary conditions were maintained in the food and nutrition services, the Administrator, Head Consultant, and Nurse Consultant 1, were notified of an immediate jeopardy situation on August 5, 2019, at 11:41 a.m. The immediate jeopardy was removed on August 7, 2019, at 7:46 p.m., after the facility's removal plan of action was reviewed and verified to have been implemented.

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 09/05/2019 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his 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: IZTI11 Facility ID: CA240000700 If continuation sheet 1 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure informed consent was obtained and/or verified from the resident's representative prior to administering psychotropic medications (medications to control mood and/or behavior) for one of five residents reviewed for unnecessary medications (Resident 50). This had the potential to result in the resident to receive medications not knowing the risks and benefits for the use of the medications. In addition, the resident's representative was not afforded the right to be able to make informed decisions for the resident. Findings: On August 8, 2019, Resident 50's record was reviewed. Resident 50 was admitted to the facility on April 12, 2019, with diagnoses which included dementia (memory loss). The "HISTORY AND PHYSICAL," dated July 14, 2019, indicated, "...resident does NOT have the capacity to understand and make decisions..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 2 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 "Order Summary Report," indicated the following: a. On July 19, 2019, "Olanzapine (medication to treat mental illness) Tablet Give 5 mg (milligrams) for Dementia Psychosis (severe mental disorder) M/B (manifested by) Auditory Hallucinations related to UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE...Informed consent obtained from (Resident 50's name) by (physician's name) ..."; and b. On July 22, 2019,"Ativan (medication to treat anxiety) 1 MG (Lorazepam) Give 1 tablet via (by) G-Tube (gastronomy -feeding tube inserted through the stomach wall used to provide nutrition) every 12 hours as needed (PRN) for anxiety (fear or worry) m/b (manifested by) episodes of inconsolable screaming informed consent obtained by (name of physician) from (Resident 50's name) ..." On August 12, 2019, at 10:21 a.m., a concurrent interview and record review with the Assistant Director of Nursing (ADON) were conducted. The ADON verified that Resident 50 had an order for Olanzapine for dementia. The ADON stated Resident 50 was not capable of understanding and making decisions. The ADON further stated the physician should have obtained the informed consent from the resident's responsible party (RP) for the use of Olanzapine and Ativan. The facility policy and procedure titled, "INFORMED CONSENT," dated June 2019, was reviewed. The policy indicated, "...The Attending Physician determines the capacity of the resident to make decisions and give informed consent on his/her History & (and) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 3 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 Physical. If the resident is determined to not have the capacity to make informed decisions, a surrogate decision-maker is identified...When initiating a new order or an increase in psychotropic drugs, the Attending Physician will...Obtain informed consent from resident or responsible party..."

F578 SS=E Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 09/05/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 4 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents' wishes related to provision of medical care would be followed, for four of eight residents (Residents 22, 31, 85, and 8), when: 1. For Residents 22, 31, and 85, the facility failed to ascertain copies of the residents advance directives (written instructions on the provision of medical care and treatment in the event the person was not able to made the decision); and 2. For Resident 8, the facility failed to provide information to the resident and/or to the resident's representative information on how to formulate and advance directive. These failures had the potential to lead to the provision of care and services not in accordance with the residents' best interest. Findings: 1. a. On August 6, 2019, Resident 22's record was reviewed. Resident 22 was admitted to the facility January 10, 2019, with diagnoses that included, anoxic brain damage (lack of oxygen to the brain), cerebral vascular accident (a lack of blood flow to the brain), unspecified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 5 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 intellectual disabilities, and cerebral edema (swelling in the brain). The resident's BIMS (Brief Interview for Mental Status-assessment for level of cognition) score was 99 (unable to completed the screening). The facility document titled "Advance Directive Acknowledgement," dated January 24, 2019, indicated Resident 22 had an advance directive. The document was signed by the resident's representative. There was no documented evidence of the advance directive in the resident's record and there was no documented evidence the facility followed up to ascertain a copy of Resident 22's advance directive. On August 7, 2019, at 9:18 a.m., a concurrent interview and record review were conducted with the SSD. The SSD stated Resident 22 had an advance directive; however, the advance directive was not in the medical record. The SSD stated the facility did not have documented evidence indicating a follow up was conducted to obtain a copy of Residents 22's advance directive. The SSD stated the facility should have followed up with Resident 22's representative to obtain a copy of the advance directive. b. On August 6, 2019, Resident 31's record was reviewed. Resident 31 was admitted to the facility on August 14, 2017, with diagnoses which included, end stage renal disease (kidney failure), dysphagia (difficulty swallowing), and cerebral infarct (lack of blood supply to the brain). The resident's BIMS score was 3 (severe impairment). The facility document titled "Advance Directive Acknowledgement," dated June 11, 2019, indicated Resident 31 had an advanced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 6 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 directive. The document was signed by the resident's representative. There was no documented evidence of the advance directive in the resident's medical record and there was no documented evidence indicating the facility followed up to ascertain a copy of Resident 31's advance directive. On August 6. 2019, at 3:30 p.m., a concurrent interview and record review were conducted with the SSD. The SSD stated Resident 31 had an advance directive; however, the advance directive was not in the medical record. The SSD stated the facility did not have evidence which would indicate a follow up was conducted to obtain a copy of Residents 31's advance directive. The SSD stated the facility should have followed up with Resident 31's representative to obtain a copy of the advance directive. c. On August 8, 2019, Resident 85's record was reviewed. Resident 85 was admitted to the facility on July 4, 2019, with diagnoses which included Parkinson's disease (deterioration of the nervous system), and heart failure (failure of the heart to pump blood adequately). The resident's BIMS score was 13 (cognitively intact). The facility document titled, "Advance Directive Acknowledgement," dated July 4, 2019, indicated Resident 85 had an advanced directive. The document was signed by the resident's representative. There was no documented evidence of the advance directive in the resident's medical record. There was no documented evidence indicating the facility followed up to ascertain a copy of Resident 31's advance directive. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 7 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 August 8, 2019, at 9 a.m., a concurrent interview and record review were conducted with the SSD. The SSD stated Resident 85 had an advance directive. The SSD stated the advance directive for Resident 85 was not in the medical record. The SSD stated the facility did not have evidence indicating a follow up was conducted to obtain a copy of Residents 31's advance directive. The SSD stated the facility should have followed up with Resident 31's representative to obtain a copy of the advance directive. 2. On August 6, 2019, Resident 8's record was reviewed. Resident 8 was admitted to the facility on July 15, 2018. There was no documented evidence on Resident 8's records a written information on how to formulate an AD was provided to the resident and/or resident representative (RR). On August 7, 2019, at 10:41 a.m., Resident 8's record was reviewed with the Director of Nursing (DON). The DON stated the written information on the AD were to be provided to the resident (if self-responsible) or the RR on admission. The DON stated the SSD was to follow up with the resident or the RR in providing a written information on the AD within seven days after admission and during quarterly care plan meetings. The DON stated there was no documented evidence a written information regarding AD was discussed with the resident and/or the RR. On August 7, 2019, at 10:48 a.m., the SSD was interviewed. The SSD stated there was no documented evidence indicating a written information regarding AD was provided to the resident and/or the RR. The SSD stated the written information on the AD should have been provided to Resident 8 and/or the RR when Resident 8 was admitted to the facility on July 15, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 8 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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, "Advance Directives," revised April 2013, was reviewed. The policy indicated, "...Advance directives will be respected in accordance with state law and facility policy...Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directive...Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives..."

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

F580 09/04/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 9 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 (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 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 interview and record review, the facility failed to notify the physician of the severe weight loss of 10 pounds (lbs.) [8%] in one month for one of five residents reviewed for nutrition (Resident 6). This failure resulted in the delay in care and treatment of the resident's severe weight loss, which increased the risk for further decline in the resident's nutritional condition. Findings: On August 8, 2019, Resident 6's record was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 10 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 reviewed. Resident 6 was admitted to the facility on January 4, 2019, with diagnoses which included severe dementia (decline in mental ability severe enough to interfere with daily life) and debility (being weak). A review of Resident 6's record indicated the following weights: a. On January 5, 2019, 2019, Resident 6 weighed 129 lbs.; and b. February 5, 2019, Resident 6 weighed 119 lbs. (10 lbs. weight loss/ 8% in a month). There was no documented evidence indicating the resident's weight loss on February 5, 2019, was reported to the resident's physician. On August 12, 2019, at 10:50 a.m., Resident 6's record was reviewed with the Assistant Director of Nursing (ADON). The ADON stated there was no documented evidence indicating the 10 lbs. weight loss identified on February 5, 2019, was communicated to the physician. The ADON stated the weight loss should have been communicated to Resident 6's physician.

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 08/26/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 11 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 12 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 13 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 interview and record review, the facility failed to ensure the residents' representative, and/or the ombudsman were provided a written notice of transfer for two of four residents reviewed for hospitalization, (Residents 22 and 31). This failure resulted in the residents' representative inability to be afforded the opportunity to appeal a potential inappropriate transfer or discharge. In addition, this failure posed the risk of the ombudsman not being aware of the circumstances should appeals be filed by the residents or the resident's representative regarding the transfer or discharge. Findings: 1. Resident 22's record was reviewed. Resident 22 was admitted to the facility January 10, 2019, with diagnoses that included, anoxic brain damage (lack of oxygen to the brain), cerebral vascular accident (a lack of blood flow to the brain), unspecified intellectual disabilities, and cerebral edema (swelling in the brain). The resident's BIMS (Brief interview for mental status- assessment for cognition status) score was 99 (unable to complete the screening). Resident 22 was transferred to the acute hospital on May 19, 2019, as a result of a head laceration related to a fall. There was no documented evidence in the record which would indicate Resident 22's representative and the Ombudsman were notified in writing of the reason for the discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 14 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 August 7, 2019, at 2:43 p.m., the Medical Record Assistant (MRA) was interviewed. The MRA stated there was no evidence in the record indicating that the Notice of Transfer/Discharge was provided in writing to the resident's representative or the Ombudsman. On August 7, 2019, at 3 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated that there was no documented evidence in the record that the Notice of Transfer/Discharge was provided in writing to Resident 22's representative or the Ombudsman. 2. Resident 31's record was reviewed. Resident 31 was admitted to the facility August 14, 2017, with diagnoses that included end stage renal disease (kidney failure), dysphagia (difficulty swallowing), and cerebral infarct (lack of blood supply to the brain). Resident 31's BIMS (Brief interview for mental status- assessment of cognition status) score was 3 (severely impaired). Resident 31 was transferred to the acute hospital on the following dates: a. May 5, 2019, Complained of chest pain. Sent to the acute hospital from the facility; b. May 13, 2019, Complained of chest pain. Sent to the acute hospital from the facility; c. May 18, 2019 Complained of chest pain at the dialysis center. Transferred to the acute hospital; and d. June 8, 2019, Resident became unresponsive at the dialysis center. Transferred to the acute hospital There was no documented evidence in the record indicating that the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 15 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 or the ombudsman were provided in writing, of the reason for transfer or discharge. On August 7, 2019, at 3:10 p.m., the MRA was interviewed. The MRA stated there was no documented evidence in the record that the Notice of Transfer/Discharge was provided in writing to the resident's representative or the Ombudsman. On August 7, 2019, at 3:19 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated that there was no evidence in the record that the Notice of Transfer/Discharge was provided in writing to the resident's representative or the Ombudsman. The ADM stated the facility should have provided Resident 31's representative and the Ombudsman written notice that Resident 31 was transferred.

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

F657 09/05/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 16 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: jBased on observation, interview, and record review, the facility failed to ensure the resident's care plan was updated to reflect the use of oxygen for one of 24 residents (Resident 36). This failure had the potential to result in inadequate treatment and management of resident's respiratory issues. Findings: Resident 36's medical record was reviewed. Resident was admitted on March 3, 2019, with diagnoses that included respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) and chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). The physician order dated June 28, 2019, indicated, "...monitor o2 sat (oxygen saturation) every shift may use o2 via nasal cannula at 2L/min if o2 is less than 92%..." Resident 36's Minimum Data Set (MDS - an assessment tool) quarterly review dated June 10, 2019, indicated Resident 36's treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 17 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 included oxygen therapy. On August 12, 2019, at 8:28 a.m., Resident 36 was observed in bed. Resident 36 verbalized she has slight difficulty in breathing. Resident 36 was noted wearing a nasal cannula (oxygen tubing) and the oxygen machine was turned on. On August 12, 2019, at 9:44 a.m., a concurrent observation, interview, and record review were conducted with the Assistant Director of Nursing (ADON). The ADON confirmed Resident 36 was receiving oxygen. The ADON stated Resident 36 had an order for oxygen, and running at 2 liters per minute (LPM) via nasal cannula. In addition, the ADON confirmed Resident 36's listed care plans did not include the use of oxygen as ordered. The ADON stated the care plan should have been updated to reflect the use of oxygen therapy. The facility's policy and procedure titled, "Care Plans - Comprehensive," revised September 2010, was reviewed. The policy indicated, "...Each resident's comprehensive care plan is designed to...Reflect treatment goals...and objectives in measurable outcomes...Aid in preventing or reducing declines in the resident's functional status and/or functional levels...Reflect currently recognized standards of practice for problem areas and conditions..."

F677 SS=E ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 09/05/2019 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 18 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 Based on observation, interview, and record review, the facility failed to ensure the necessary services to maintain personal hygiene were provided, for three of five residents reviewed for Activities of Daily Living (ADL) (Residents 8, 48, and 192), when: 1. For Residents 8 and 48, the facility failed to provide hygiene care for hypertrophied (thick) and/or long nails; and 2. For Resident 192, the facility failed to provide oral hygiene while on tracheostomy (an opening of direct airway through an incision in the trachea that allows a person to breath). These failures resulted in poor personal hygiene which could negatively affect the residents' physical well-being. Findings: 1a. On August 6, 2019, at 2:26 p.m., Resident 8 was observed sitting in the wheelchair with fingernails approximately more than half centimeter long with dark matter underneath the fingernails. Resident 8's fingernails were also observed to be jagged. On August 7, 2019, at 9:53 a.m., Resident 8 continued to have long and jagged fingernails with dark matter underneath the nails. In a concurrent interview with Resident 8, he stated a Certified Nurse Assistant (CNA) cut his fingernails about two months ago. On August 7, 2019, at 10:07 a.m., CNA 1 was interviewed. CNA 1 stated the CNAs provide personal hygiene assistance (such as oral care, denture care, and nail care) to residents. CNA 1 stated the CNAs trim residents' fingernails. CNA 1 stated Resident 8 required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 19 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 extensive assistance in personal hygiene. CNA 1 further stated Resident 8's fingernails were long, "dirty," and needed to be trimmed. On August 7, 2019, at 10:15 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated Resident 8's fingernails were long and "dirty". RN 1 stated the CNAs can trim residents' fingernails. RN 1 further stated the CNA should have cleaned and trimmed Resident 8's fingernails. On August 7, 2019, Resident 8's record was reviewed. Resident 8 was admitted to the facility on July 15, 2018. Resident 8's Minimum Data Set (MDS - an assessment tool), dated July 17, 2019, indicated Resident 8 required extensive assistance in personal hygiene. Resident 8's care plan for ADL, dated April 26, 2019, indicated, "...ADL deficit R/T (related to)...Personal Hygiene Extensive...Assist w/ (with) adl as needed..." b. On August 6, 2019, at 11:05 a.m., Resident 48 was observed to have long thick nails on both of her hands. Resident 48's hands were observed to be dry, cracked and scaly. In a concurrent interview with Resident 48, she stated nobody cuts her nails and the fingernails kept on growing and were already long. On August 7, 2019, at 9:13 a.m., Resident 48 was observed sitting in the wheelchair. Resident 48 was observed to have long and thick nails on the fourth and fifth fingernails of both hands. Resident 48's other fingernails were observed to be long about half centimeter with dark matter underneath the nails. Resident 48 was observed to be scratching her arms and had multiple small open areas with some scabs on both of her arms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 20 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In a concurrent interview with Resident 48, she stated staff did not trim her fingernails. On August 7, 2019, Resident 48's record was reviewed. Resident 48 was admitted to the facility on May 10, 2016. Resident 48's MDS, dated June 10, 2019, indicated Resident 48 required extensive assist in personal hygiene. The care plan for "ADL FUNCTION," dated May 10, 2016, indicated, "...Resident requires assistance with ADL's...Assist or provide for hygiene needs...Provide for nail care PRN (as needed) ..." On August 8, 2019, at 12:20 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated she was not aware of Resident 48's long hypertrophied nails. LVN 2 stated she did not receive any report from the CNAs about Resident 48's long thick nails. LVN 2 stated CNAs should have trimmed and cleaned Resident 48's fingernails. On August 8, 2019, at 12:33 p.m., CNA 3 was interviewed. CNA 3 stated she was assigned to care for Resident 48. CNA 3 stated she was aware Resident 48's fingernails were thick and long, which needed to be trimmed. On August 8, 2019, at 3:46 p.m., the Director of Staff Development (DSD) was interviewed regarding Residents 8 and 48's fingernails. The DSD stated CNAs provide assistance to residents on personal hygiene, which includes fingernail care. The DSD stated nail care was "usually" done every Sunday. The DSD stated she remembered Resident 48's long and thick fingernails were discussed during their meeting couple of times; however, she did not look further into it. She stated Resident 8's fingernails needed to be trimmed. The DSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 21 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 stated Resident 48's long thick fingernails should have been referred to a specialist. The facility policy and procedure titled, "Care of Fingernails/Toenails," revised October 2010, was reviewed. The policy indicated, "...The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections...Nail care includes daily cleaning and regular trimming...Proper nail care can aid in the prevention of skin problems around the nail bed...Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin...Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease..." 2. On August 5, 2019, at 12:15 p.m., Resident 192 was observed lying in bed awake with a tracheostomy in place. Resident 192 was nonverbal, but able to respond to questions by nodding his head or moving it side to side. Resident 192 had his mouth open. Resident 192 was observed with white matter in his mouth/teeth that appeared moistened and thick. Resident 192's representative was at the resident's bedside. In a concurrent interview with the resident's representative, she stated Resident 192 had not received oral care since his admission on August 2, 2019. The representative stated she comes in daily, and would stay at the facility from morning to about 8 p.m. On August 5, 2019, at 3:30 p.m., Resident 192's mouth/teeth were observed with white matter that appeared moistened and thick. The resident was asked if staff had come in to provide oral care, and the resident nodded, side to side (meant "No"). In a concurrent interview with the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 22 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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, she stated Resident 192 had not received oral care since 12:15 p.m. On August 6, 2019, at 10:15 a.m., Resident 192 was observed in his room. Resident 192 was observed with white matter in his mouth/teeth that appeared thicker, but less moistened. Resident 192 move his head side to side (meant "No"), when asked if he had received oral care that morning. In a concurrent interview with the resident's representative, she stated she was not allowed to stay with the resident at night. She stated she came in early that morning and since she came in, the resident had not received oral care. On August 7, 2019, Resident 192's record was reviewed. Resident 192 was admitted on August 2, 2019, with diagnoses that include cerebral vascular accident (stroke), tracheostomy dependence, quadriparesis (paralysis of the four limbs and torso). Resident 192's "History and Physical," dated August 5, 2019, indicated, "This resident has fluctuating capacity to understand and make decisions." On August 7, 2019, at 1:01 p.m., Resident 192's was observed with white matter in his mouth/teeth. The white matter was thicker (cottage-cheese like looking) and less moist. The resident was asked if he got oral care that day, and the resident moved his head side to side, (meant "No.") In a concurrent interview with the resident's representative, she stated she had not seen anyone performing oral care for the resident since she came in that morning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 23 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 August 8, 2019, at 11:09 a.m., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated the facility's protocol was for residents to get oral care at least twice a day. The CNAs were responsible for providing oral care. On August 8, 2019, at 3:25 p.m., Resident 192 was interviewed. Resident nodded his head "Yes" when asked if he had received oral care that day. The resident's mouth/teeth were clean without any signs of white matter. In a concurrent interview with the resident's representative, she stated the resident "finally" received oral care from staff that morning. The facility policy and procedure titled, "Mouth Care," revised October 2010, was reviewed. The policy indicated, "Purpose: The purposes of this procedure are...to cleanse and freshen the resident's mouth, and to prevent infections of the mouth..." The facility policy and procedure titled, "Teeth, Brushing," revised October 2010, was reviewed. The policy indicated, "...The purposes of this procedure are to clean and freshen the resident's mouth, to prevent infections of the mouth, to maintain the teeth and gums in a healthy condition, to stimulate the gums, and to remove food particles from between the teeth..."

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

F679 08/13/2019 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 24 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide activities that meet the interest and preferences for one two residents reviewed for activities (Resident 85). This failure had the potential to cause boredom, loneliness, and frustration for Resident 85. Findings: On August 5, 2019, at 9:43 a.m., Resident 85 was interviewed. Resident 85 stated that she does not like to get out of bed, except for physical therapy. Resident 85 stated she enjoyed doing activities in her room. Resident 85 stated she enjoyed listening to music and doing puzzles. Resident 85's record was reviewed. Resident 85 was admitted to the facility on July 4, 2019, with diagnoses that included Parkinson's disease (deterioration of the nervous system), and heart failure (failure of the heart to pump blood adequately). Resident 85's BIMS (Brief interview for mental status) score was 13 (cognitively intact). Resident 85 was observed on the following days: a. On August 5, 2019, at 3 p.m., Resident 85 was awake and in bed. The resident stated she did not attend group activities. Resident 85 stated she was not provided activities in her room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 25 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. On August 6, 2019, at 4 p.m., Resident 85 was in her room awake and in bed. The resident stated she did not attend group activities. Resident 85 said activities were not provided in her room. c. On August 7, 2019, at 4 p.m., Resident 85 was in her room sleeping in bed. Resident 85's care giver stated the resident did not attend group activities and no one came in to see her. d. On August 8, 2019, at 3:30 p.m., Resident 85 was in her room in bed and an awake. The resident stated she did not attend activities and no one brought activities to her. A review of the document titled, "ActivitiesInitial Review," with an effective date of July 9, 2019, indicated the resident enjoys listening to music and doing puzzles. A review of the document titled, "Resident Care Conference Review," dated July 24, 2019, indicated the resident enjoys listening to music. A review of the document titled "Activity Daily Participation Log, " for the month of July 2019, indicated that music and puzzles were not provided to Resident 85. From August 1-8, 2019, Resident 85 was provided music once on August 5, 2019. Resident 85 was not provided music or puzzles for seven days during the month of August 2019. On August 8, 2019, at 5:11 p.m., a concurrent interview and record review were conducted with the Director of Activities (DOA). The documents titled "Activities-Initial Review" and "Activity Daily Participation Log" were reviewed. The DOA stated that music and doing puzzles were the preferred activities for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 26 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 85. The DOA stated Resident 85 did not receive music activity or puzzles during the month of July, and music activity was offered once for the month of August 2019.

F684 SS=G Quality of Care CFR(s): 483.25

F684 09/04/2019 § 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: 2. On August 7, 2019, at 8:22 a.m., Licensed Vocational Nurse (LVN) 4 was observed during medication administration for Resident 45. LVN 4 took Resident 45's blood pressure prior to administering the routine medications, with Resident 4 blood pressure reading was 128/80 mmHg (millimeters of mercury). LVN 4 administered medications that included Midodrine 10 mg (milligrams) one tablet. On August 7, 2019, at 10:13 a.m., Resident 45's record was reviewed. Resident 45 was admitted on May 3, 2019, with diagnoses that included hypotension (low blood pressure). Resident 45's physician's orders dated July 10, 2019, indicated, "Midodrine HCL Tablet 10 MG Give 10 mg by mouth three times a day for SBP less than 90 (SBP means systolic blood pressure - the top number in a blood pressure reading, which measures the pressure when the heart beats and pumps blood) Hold for SBP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 27 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 greater than 100. During an interview with LVN 4 on August 7, 2019, at 10:50 a.m., LVN 4 stated she gave the Midodrine thinking the medication would lower the resident's blood pressure. The LVN stated "I should have held it. The order says to hold it if SBP is greater than 100." Resident 45's medication administration record (MAR) from July to August 2019 was reviewed. The MAR indicated, "Midodrine HCL Tablet 10 MG Give 10 mg by mouth three times a day for SBP less than 90. Hold for SBP greater than 100." The MAR indicated the Midodrine was given 54 out of 63 doses in July 2019, and 19 of 19 doses in August 2019, when the medication should have been held. The MAR indicated Resident 45's SBP readings were between 110 to 153 mmHg for the times when the medication should have been held. According to the Centers for Diseases Control and Prevention (CDC), a blood pressure less than 120/80 mmHg is normal. People with levels from 120/80 mmHg to 139/89 mmHg have a condition called prehypertension, which means they are at high risk for high blood pressure. A blood pressure of 140/90 mmHg or more is too high. On August 7, 2019, at 10:25 a.m., Resident 45's record was reviewed with the Assistant Director of Nursing (ADON). The ADON stated the Midodrine order indicated to hold the medication if SBP was greater than 100 mmHg. The ADON stated the Midodrine should have not been given to the resident when her SBPs were greater than 100 mmHg for the months of July and August 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 28 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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, "Administering Medications," revised December 2012, was reviewed. The policy indicated, "...Medications must be administered in accordance with the orders..." Based on observation, interview, and record review, the facility failed to ensure the needed care and treatment were provided for two of 24 residents (Residents 48 and 45), when: 1. For Resident 48, the itchiness and rashes on the arms, back, and legs were not provided treatment that relieved and/or improved the resident's skin condition. In addition, the dermatology (branch of medicine concerned with the diagnosis and treatment of skin disorders) consult was not completed timely. These failures resulted for Resident 48 to experience continuous itchiness and rash in the arms, back, and legs, causing for the resident to sustain multiple open lesions and scabs on the body from scratching; and 2. For Resident 45, the physician's order to hold Midodrine (medication to treat low blood pressure), was not followed when Resident 45's systolic blood pressure (pressure of the blood in the arteries when the heart pumps) was above 100 mmHg (millimeter per mercury; unit of pressure). This failure increased the risk for heart complications which could negatively impact the resident's health condition. Findings: 1. On August 6, 2019, at 11:05 a.m., Resident 48 was observed sitting in the wheelchair. Resident 48 have long nails on both hands, with the fourth and fifth fingernails appearing to be hypertrophied (thick). Resident 48's palms FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 29 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 both hands were dry and scaly. In addition, Resident 48 have multiple small open skin areas with scabs on both of her arms and face, and multiple pink raised rashes on both arms. In a concurrent interview, Resident 48 stated her hands and arms were itchy. Resident 48 stated she had been applying cream on her arms and hands and the itchiness was not improving. Resident 48 was observed to be scratching her arms with her fingernails and rubbing her legs together throughout the conversation. On August 7, 2019, at 9:13 a.m., Resident 48 was observed rubbing her legs together and scratching her arms. Resident 48's fingernails on both hands were observed to be long (about more than half centimeter [cm]), jagged, and had dark matter under the nails. In a concurrent interview, Resident 48 stated her arms and legs had been itching for months. Resident 48 stated she felt there were bugs biting her. She stated they were putting cream before. Resident 48 stated she thought the rashes had gotten worst. On August 7, 2019, at 12:03 p.m., Resident 48 was observed in the dining room, scratching her right arm with her left hand. On August 7, 2019, at 3:49 p.m., Resident 48 was observed in the dining room, sitting in the wheelchair and rubbing her legs together. In a concurrent interview, Resident 48 stated, "It's itchy." On August 7, 2019, Resident 48's record was reviewed. Resident 48 was admitted to the facility on May 10, 2016, with diagnoses which included anemia (low blood count) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 30 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 dementia (memory loss). The facility document titled, "...Admission Nursing Evaluation," dated May 10, 2016, indicated Resident 48 did not have skin problems on admission. A review of Resident 48's Minimum Data Set (MDS- an assessment tool) dated June 10, 2019, indicated the resident's Brief Interview for Mental Status (BIMS-assessment tool for cognition status) score was five (0-7 means severe impairment). The facility document titled, "BEHAVIOR/SIDE EFFECTS MONITORING," for the months of January 2019 to July 2019, was reviewed. The document indicated Resident 48 was monitored for behavior of scratching herself every shift with the following episodes: - January 21, 2019 to January 31, 2019 (4 episodes); - February 2019 (33 episodes); - March 2019 (26 episodes); - April 2019 (26 episodes); - May 2019 (28 episodes); - June 2019 (43 episodes); and - July 2019 (38 episodes). The physician's "Progress Notes," dated April 2, 2019 and May 1, 2019, for Resident 48, indicated, "...Scattered erythematous (redness) lesions to the left cheek, abdomen, and BLE (both lower extremities), and bilateral wrists..." The "Treatment Administration Record," for the month of May 2019, indicated Resident 48's itchiness on the back and arms were treated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 31 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 with Hydrocortisone (a topical drug used the relief of itching and inflammation associated with a wide variety of skin conditions) cream three times a day from May 3 to May 15, 2019. There was no documented evidence Resident 48 had any other skin treatment after May 15, 2019. The care plan titled, "PURITUS [sic; should read pruritus - severe itching of the skin], CHRONIC RASH," dated May 2, 2019, indicated, "...@ (At) Risk for altered skin integrity R/T (related to) puritus [sic]...Keep nails trim/clean...encourage not to scratch...monitor for altered skin integrity & notify MD (physician)/RP (responsible party) ..." The physician's "Progress Notes," dated June 2, 2019, indicated, "...Diffused rash...Patient's digits and toes are extremely dry and cracked with multiple dry fissures (crack or split) ..." The document indicated the physician recommended to obtain dermatology (specialty that deals with the skin, nails, hair and its diseases) consult. The "Physician's Telephone Order," dated June 3, 2019, indicated, "...Dermatology consult for fingers & toes." The care plan titled, "RISK FOR SKIN BREAKDOWN," dated June 3, 2019, indicated, "...At risk for skin breakdown r/t... ASE (adverse side effects) to meds (medications)...Derma (dermatology) consult as ordered..." The physician's "Progress Notes," dated July 10, 2019, indicated Resident 48 had diagnosis of, "...Impaired skin integrity...Diffuse papular (raised) rash..." The "Order Summary Report," dated July 10, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 32 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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, indicated, "...Urgent Dermatology Consult for Fingers and Toes and diffuse rash..." The facility document titled, "SHOWER DAY SKIN INSPECTION," dated July 8, 2019 to August 3, 2019, was reviewed. The document indicated Resident 48 had generalized red raised rashes (skin reaction or eruption that occurs throughout the body). On August 7, 2019, at 4:04 p.m., a concurrent interview and record review was conducted with Treatment Nurse (TN) 1. TN 1 stated Resident 48 complained of itching and had observed Resident 48 to be scratching her arms since last month. TN 1 stated there was currently no treatment being applied to Resident 48's rashes. TN 1 stated there was no documentation of a reassessment of Resident 48's generalized rash after the treatment order was completed on May 15, 2019, to re-evaluate whether the treatment needed to be continued or changed. On August 7, 2019, at 4:32 p.m., Resident 48 was observed with TN 1. Resident 48 was observed sitting in the wheelchair and scratching her arms. Resident 48 was transferred to bed and was talking fast about her itching and rashes. Resident 48 was observed rubbing her back against the bed repeatedly. In a concurrent interview with Resident 48, she stated she cannot sleep at night because of the itching and felt like something was inside her skin. Resident 48 was observed to be teary eyed as she was saying she had been itching for a long time and nothing was being done. Concurrently, TN 1 was observed to check Resident 48's skin. TN 1 stated Resident 48 had multiple scattered open lesions with scabs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 33 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 both arms. TN 1 stated Resident 48 had raised rashes on both arms, back, and lower extremities. On August 7, 2019, at 5:20 p.m., Case Manager (CM) 1 was interviewed. She stated she was not aware of the dermatology consult ordered on June 3, 2019. CM 1 stated Resident 48 had an order for urgent dermatology consult on July 10, 2019. CM 1 stated the Nurse Practitioner (NP) notified her on July 11, 2019, of an order for dermatology consult for the generalized rash for Resident 48. CM 1 stated the NP told her the doctor's office will process the referral for dermatology consult. CM 1 stated she followed up with the doctor's office on August 1, 2019 (21 days from the order for an urgent dermatology consult on July 10, 2019 and 59 days after the initial order for a dermatology consult on June 3, 2019) about the referral for dermatology consult for Resident 48. CM 1 stated she expected the urgent referral for dermatology consult to be processed within at least four days to two weeks. CM 1 further stated the dermatology consult referral should have been followed up in a timely manner. On August 8, 2019, at 9:53 a.m., Resident 48's Responsible Party (RP) was interviewed. Resident 48's RP stated Resident 48 had the itchiness and rashes in her body since last year. The RP stated the family had tried different bath soaps and lotion, but were not effective. On August 12, 2019, at 4:41 p.m., a policy was requested from the Infection Preventionist (IP) and stated the facility did not have a specific policy on non-pressure or rashes management. The IP provided a policy on pressure sore/skin breakdown. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 34 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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, "Referrals, Social Services," revised December 2008, was reviewed. The policy indicated, "...Social services personnel shall coordinate most resident referrals with outside agencies...Referrals for medical services must be based on physician evaluation of resident need and a related physician order...Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician..."

F688 SS=D Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 09/04/2019 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide range of motion (ROM-the full movement potential of a joint) exercises for one of four sampled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 35 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 reviewed for ROM care issues (Resident 193). This failure had the potential to result in Resident 193 developing a contracture (abnormal shortening of the muscle tissue, rendering the muscle highly resistant to stretching leading to permanent disability) of his upper and lower limbs. Findings: On August 6, 2019, at 11:08 a.m., a visit to Resident 193's room was conducted. Resident 193 was lying in bed, unable to move. A family member was observed feeding the resident. The resident was able to verbalized his needs. Resident 193 stated he was concerned of getting contractures since he had not received any kind of physical therapy (exercises) since his admission on July 23, 2019. Resident 193's record was reviewed on August 7, 2019. Resident 193 was admitted to the facility on July 23, 2019, with diagnoses that included quadriplegia (paralysis of all four limbs and torso.) The "History and Physical," dated August 5, 2019, indicated Resident 193's had the capacity to understand and make decisions. Resident 193's physician's order, dated July 23, 2019, included Physical Therapy (PT) evaluation and treatment. The "Physical Therapy PT Evaluation & Plan of Treatment," dated July 25, 2019, document indicated: "...Patient will safely perform bed mobility tasks...in order to reduce risk for falls and enhance safe functional mobility. (Target: 8/20/19)...Frequency: 5 time(s)/week...Clinical impressions...skill rehab (rehabilitation) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 36 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 recommended to facilitate functional gains and/or established program for RNA (Restorative Nursing Assistant) to maintain functional mobility and develop exercise program for caregiver and staff prior d/c (discharge)...Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: compromised general health, falls and pressure sores..." Resident 193's physician order dated on August 1, 2019, (seven days after PT had recommended to place the resident on RNA exercises), for RNA (Restorative Nursing Assistant)/CNA (Certified Nursing Assistant) for passive range of motion to bilateral lower extremities and upper extremities, five times weekly as tolerated, every day shift, every Monday, Tuesday, Wednesday, Thursday, and Friday. On August 7, 2019, at 4:45 p.m., a concurrent interview and record review were conducted with RNA 2. RNA 2 stated Resident 193 was not receiving RNA exercises. RNA 2 stated the RNA treatment record did not include Resident 193 as one of the residents that received RNA treatment. RNA 2 stated she did not receive any order to provide services to Resident 193. On August 8, 2019, at 4:47 p.m. the RNA treatment record was reviewed with the Assistant Director of Nursing (ADON). The record did not contain documented evidence indicating Resident 193 received RNA services since it had been ordered (on August 1, 2019). The ADON stated Resident 193's order for RNA services should have been started from the day it had been ordered. In addition, the ADON was not able to explain the reason for the delay on obtaining the RNA treatment order after the PT had recommended it on July 25, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 37 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 (seven-days delay). The facility policy and procedure titled, "Functional Impairment," revised September 2012, indicated, "...In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes efficiently using available resources...the staff will monitor and discuss with the physician the resident's functional progress, both while receiving therapy and in general while on the unit..."

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 09/05/2019 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 38 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 Based on interview and record review, the facility failed to recognize, assess, and address the significant weight loss for one of three residents (Resident 6) reviewed for nutrition care. This failure had resulted in the delay of treatment for the weight loss which increased the risk for further decline in nutritional status for Resident 6. Findings: On August 8, 2019, Resident 6's record was reviewed. Resident 6 was admitted to the facility on January 4, 2019, with diagnoses including severe dementia (decline in mental ability severe enough to interfere with daily life) and debility (being weak). A review of the facility document titled," Weight and Vital Summary," indicated the following: a. On January 5, 2019, Resident 6's weight was 129 pounds (lbs.); and b. On February 5, 2019, 119 lbs. (10-lbs weight loss [8 percent] in one month). There was no documented evidence in Resident 6's record indicating the physician was notified of the significant weight loss after identifying the 10-lbs weight loss in February 5, 2019. In addition, there was no documented evidence an assessment was conducted and/or any interventions taken for the weight loss. On August 12, 2019, at 10:50 a.m., a concurrent interview and record review were conducted with the Assistant Director of Nursing (ADON). The ADON stated there was no documented evidence the 10-lbs identified weight loss was communicated with the physician. The ADON stated the facility should have assessed and provided intervention for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 39 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 significant weight loss. The facility policy and procedure titled, "Weight Assessment and Intervention," revised September, 2008, was reviewed and indicated, "...Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing...The Dietitian will respond within 24 hours of receipt of written notification. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time...The threshold for significant unplanned and undesired weight loss will be based on the following criteria...1 month - 5% weight loss is significant; greater than 5% is severe...The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss...Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the residents; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals..."

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 09/04/2019 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a residentFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 40 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a resident who receives nutrition by enteral means, was provided the appropriate treatment and services, when one of the two residents reviewed for tube feeding (Resident 238), did not receive the amount of enteral feeding formula in accordance with the physician order. This failure placed the resident at risk for significant weight changes and/or fluid imbalance. Findings: On August 6, 2019, at 8:32 a.m., Resident 238 was observed lying in bed in a semi-upright position, with a tube feeding (TF-medical device used to provide nutrition to people who cannot obtain nutrition by mouth) formula of Nepro with Carbsteady (type of formula) 1.8 calories bottle, running at 42ml/hr. The formula bottle was labeled with a date of August 4, 2019, started at 2 p.m., at a rate of 60 milliliters per hour (ml/hr.). There was approximately 100 ml left in the bottle. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 41 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 238's record was reviewed. Resident 238 was admitted on July 11, 2019, with diagnoses that included gastrostomy (creation of an artificial external opening into the stomach for nutritional support) tube dependent and quadriplegia (total loss of use of all four limbs). The facility document titled, "Order Summary Report," indicated the following: a. On July 11, 2019, "Nepro 1.8 @ (at) 42ml/hrs. x (to run for) 20 hours..."; and b. On July 19, 2019, "...Nepro 1.8 @ 60ml/hrs. x 20 hours..." On August 6, 2019, at 8:36 a.m., a concurrent observation and interview was conducted with Registered Nurse (RN) 2 at Resident 238's bedside. RN 2 confirmed the rate on the label was 60 ml/hr.; however, the rate on the feeding pump was running at 42 ml/hr. RN 2 stated the feeding pump should be set and running to deliver the enteral feeding formula at 60 ml/hr. The facility's policy and procedure titled, "...Tube Feeding via Continuous Pump," revised March 2015, was reviewed and indicated, "...Check...nutrition label against the order before administration...Check the following information...Type of formula...Rate of administration (ml/hour) ...Check the label on the enteral feeding formula against the physician order..."

F695 SS=E Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 09/04/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 42 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care and treatment for five of six residents (Residents 238, 188, 24, 21 and 36) when: 1. Resident 238's oxygen saturation (O2 Sat an acceptable level of oxygen in the body) was not monitored while suctioning (a method of removing mucous from the lungs) the resident. This failure had the potential for Resident 238 to experience complications from suctioning such as hypoxemia (below-normal level of oxygen in your blood) and cardiac dysrhythmias (abnormal heartbeat) resulting from hypoxemia; 2. Resident 188's nasal cannula (a tube used to deliver oxygen through the nose) was not labeled and replaced after seven days in accordance with facility policy. In addition, Resident 188's oxygen mask was not stored to prevent contamination of the equipment. These failures had the potential to result in deterioration of the respiratory equipment and allow bacteria or mold to grow, potentially causing an infection to 188; 3. Resident 24's suction tubing and Yankauer (oral suctioning equipment) was not labeled and replaced in accordance with the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 43 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 policy. In addition, Resident 24's suction tubing and Yankauer were not stored to prevent contamination. These failures had the potential to result in deterioration of the respiratory equipment and allow bacteria or mold to grow, causing an infection to Resident 24; and 4. Residents 21 and 36's physician's orders for oxygen administration was not followed. This failure had the potential to result in improper oxygen therapy and potentially missed opportunities to identify the residents' significant change in condition. Findings: 1. Resident 238's records were reviewed. Resident 238 was admitted on July 11, 2019, with diagnoses that included chronic respiratory failure (serious illness that affects breathing), oxygen dependence, and tracheostomy dependence (tracheostomy - surgical opening on the neck area to provide either temporary or permanent airway). Resident 238's physician's orders included, "...Suction Tracheal secretions for excessive secretion..." On August 7, 2019, at 9:34 a.m., Respiratory Therapist (RT) 1 was observed performing tracheal suctioning on Resident 238. On August 7, 2019, at 9:50 a.m., RT 1 was interviewed. RT 1 stated he did not check Resident 238's O2 Sat during suctioning. RT 1 further stated it was not required to check the resident's O2 Sat during suctioning. On August 7, 2019, at 4:42 p.m., The RT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 44 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 Director (RTD) was interviewed. The RTD stated the O2 Sat should be monitored during suctioning of a resident. The facility's policy and procedure titled, "...Suctioning the Lower Airway..., "revised October 2010, indicated, "...General Guidelines...Monitor the resident's pulse and oxygen saturation during suctioning...oxygen saturation drops below 90 percent...discontinue suctioning..." 2. On August 5, 2019, at 9:15 a.m., Resident 188 was observed in bed, with a nasal cannula for oxygen. The nasal cannula was not labeled. In addition, an oxygen mask was observed on top of Resident 188's bed headboard, uncovered and was not labeled. In a concurrent interview with Licensed Vocational Nurse (LVN) 5, she stated the nasal cannula and the oxygen mask should be labeled in order to indicate when were these appliances changed. LVN 5 further stated the oxygen mask should be stored inside a set-up bag. LVN 5 stated the oxygen cannula and oxygen mask should be changed every week. Resident 188's record was reviewed. Resident 188 was admitted on July 20, 2019, with diagnoses that included dependence on supplemental oxygen and chronic respiratory failure (long-term condition that happens when lungs cannot get enough oxygen into the blood). The physician's order dated July 23, 2019, indicated, "Oxygen @ (at) 2 l/min (liters per minute) via nasal cannula or face mask continuously for shortness of breath..." On August 7, 2019, at 8:06 a.m., the RTD was interviewed. RTD stated the nasal cannula should be changed every seven days. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 45 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 RTD further stated Resident 188's oxygen mask should have been stored inside a set-up bag and should have been labeled. 3. On August 6, 2019, at 9:31 a.m., a suction machine attached to a Yankauer was observed at Resident 24's bedside table. The suction equipment was stored inside a set-up bag dated June 18, 2019. There was a brown colored residue noted inside the suction canister. In addition, white sediments were also noted in the Yankauer. On August 6, 2019, at 9:48 a.m., LVN 2 was interviewed. LVN 2 confirmed there was no label when the Yankauer and suction equipment were initially used or opened. LVN 2 stated the suction equipment should have been labeled with the date it was first set up. LVN 2 further stated the tubing should be changed every week and the suction canister should be changed every Tuesday. Resident 24's record was reviewed. Resident 24 was admitted on August 10, 2017, with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke). The physician's order dated May 12, 2019, indicated, "...May suction orally for excessive secretions..." The facility's policy and procedure titled, "Changing/Cleaning of Disposable and NonDisposable Equipment (revised December 1, 2018)" was reviewed and indicated, "...Disposal equipment must be labeled with date..." The policy further indicated: "...Thursday...suction canister... ...Twice a week and PRN...Yankauer... ...Saturday and PRN...oxygen mask...nasal cannula..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 46 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Centers for Disease Control (CDC) infection control guidelines titled, "...Recommendations for Environmental Infection Control in Health-Care Facilities...Guidelines for Environmental Infection Control in Health-Care Facilities (2003)," indicated: "...Use barrier protective coverings as appropriate for noncritical equipment surfaces that are...touched frequently with gloved hands during the delivery of patient care...likely to become contaminated with blood or body substances..." 4a. On August 6, 2019, at 10:19 a.m. and 1:59 p.m., Resident 21 was observed in bed using oxygen via nasal cannula (NC) at 5 liters per minute. On August 7, 2019, at 9:58 a.m., Resident 21 was observed in bed using oxygen via NC at 5 l/min. Resident 21's record was reviewed. Resident 21 was admitted on March 3, 2018, with diagnoses that included cerebral infarction (stroke) and muscle weakness. The physician's order dated July 31, 2018, indicated, "...Oxygen @ 2l/min via nasal cannula continuously..." There was no physician's order allowing to titrate the oxygen therapy rate. On August 7, 2019, at 10:15 a.m., a concurrent observation, interview, and record review was conducted with RN 1. RN 1 confirmed that Resident 21's oxygen flow rate was set and running at 5 l/min. RN 1 stated Resident 21's oxygen should be at 2 l/min as ordered by the physician. RN 1 further stated there was no documented evidence Resident 21 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 47 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 assessed justifying the need for the resident to receive more than 2 l/min of oxygen therapy. b. On August 6, 2019, at 8:53 a.m., a concurrent observation and interview was conducted with Resident 36. Resident 36 was observed wearing a nasal cannula attached to a portable oxygen machine. The oxygen machine was turned off. At 11:53 a.m, Resident 36's oxygen machine was turned on and set at 2 L/min. Resident 36's record was reviewed. Resident 36 was admitted on March 3, 2019, with diagnoses that included respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing). The physician order dated June 28, 2019, indicated, "...monitor o2 sat (oxygen saturation) every shift may use o2 via nasal cannula at 2L/min if o2 is less than 92%..." On August 12, 2019 at 8:28 a.m., Resident 36 was observed in bed. The resident was observed coughing, but unable to cough out phlegm. Resident 36 verbalized she has slight difficulty in breathing. Resident 36 was noted wearing a nasal cannula and the oxygen machine was set at 1 L/min. On August 12, 2019 at 9:44 a.m., a concurrent observation and interview was conducted with the Assistant Director of Nursing (ADON) in Resident 36's room. The ADON confirmed Resident 36's oxygen was flowing at a rate of 1 L/min. The ADON stated the resident's respiratory status should be assessed prior to administering oxygen, and if needed, the oxygen flow rate should be set at 2 L/min as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 48 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 ordered by the physician. The facility's policy and procedure titled, "Oxygen Administration," revised October 2010," was reviewed and indicated, "...Verify that there is a physician's order...Adjust the oxygen delivery device...the proper flow of oxygen is being administered..."

F725 SS=E Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2)

F725 09/05/2019 §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 49 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure sufficient number of Certified Nursing Assistants (CNAs) were available to provide the residents' treatment/s and care (such as personal hygiene), in a timely manner, for two of 24 residents (Residents 44 and one confidential interview) reviewed. These failures resulted in the delay of care and treatment/s of the residents, subsequently affecting the residents' well-being. Findings: 1. On August 6, 2019, at 2:51 p.m., Resident 44's representative (RR) was interviewed. The RR stated she stayed in the facility from 11 a.m. to about 12 a.m. every day. The RR stated there were times when the facility only had one CNA working on night shift (11 p.m. to 7 a.m. shift- night/ NOC shift) for the entire building (the facility had a 99-bed capacity). The RR stated she hired a sitter for Resident 44 for a couple of hours in the morning to ensure Resident 44 got repositioned while lying in bed and kept clean by facility staff. On August 8, 2019, Resident 44's record was reviewed. Resident 44 was admitted on April 13, 2019, with diagnoses that included quadriplegia (paralysis of all extremities) and aphasia (inability to express speech). The "Minimum Data Set (MDS - an assessment tool)," dated June 20, 2019, indicated Resident 44 required total assistance in all activities of daily living (ADL, such as bathing and toileting). On August 12, 2019, the "Census and Direct Care Service Hours Per Patient Day (DHPPD," dated July 12, 2019, was reviewed. The document indicated the facility had a resident census of 89 residents on July 12, 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 50 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 August 12, 2019 at 2:57 p.m., the "NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET," for July 12, 2019, was reviewed with the Director of Staff Development (DSD). Two CNAs signed onto the document (approximately 44 to 45 residents per CNA) for the 11 p.m. to 7 a.m. shift. (Note: The facility had subacute [SA] residents residing in the facility, which should have their own staff - not comingled with the non-SA residents.) In a concurrent interview, the DSD stated on July 12, 2019, 11 p.m. to 7 a.m. shift, there were five CNAs scheduled to work. The DSD stated only two CNAs showed up to work. The DSD stated the assignment sheet was missing. The DSD further stated the CNAs' staffing was "way too short (not enough staff)" for July 12, 2019, NOC shift. 2. On August 6, 2019, at 4:25 p.m., a resident (that wished not to be identified for fear of retaliation) was observed to be awake in bed. In a concurrent interview, the resident stated she waited for about six hours to get changed and was soiled in her incontinent brief as the facility had insufficient staff most of the time usually in the afternoon (3 p.m. to 11 p.m., PM shift) and the night shift (NOC, 11 p.m. to 7 a.m.). The resident stated she did not receive exercises from the Restorative Nurse Assistant (RNA - CNAs trained to provide exercises) at times as the RNA would get pulled out to work as CNAs, or there were not enough CNAs to get her dressed and ready for exercises. The resident stated she developed redness on her buttocks because she was left soiled for six hours before she was cleaned and changed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 51 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 August 8, 2019, the confidential resident's record was reviewed. The resident was admitted to the facility in 2016 (not specifying the date for anonymity). The MDS, dated May 27, 2019, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15 (cognitively intact). The MDS indicated the resident had moisture associated skin damage (skin problem related to moisture). The MDS also indicated the resident was incontinent and required extensive assistance in toileting. On August 12, 2019, at 2:57 p.m., a concurrent interview and record review was conducted with the DSD. The "CNA Assignment Sheet," for August 12, 2019 (for the 7 a.m. to 3 p.m., AM shift), indicated the nursing skilled unit had a census of 80 residents. The document indicated there were six CNAs assigned. Each CNA was assigned 13 to 14 residents. In a concurrent interview, the DSD stated for a census of 80 residents there should have been at least eight CNAs working. Each CNA should have had about nine to ten residents assigned. The DSD stated six CNAs assigned for 80 residents were not enough to provide care for 13 to 14 residents assigned to each CNA. Furthermore, the DSD stated for a census of 80 residents, the AM shift should have at least eight CNAs, the PM shift should have at least six CNAs, and the NOC shift should have at least five CNAs. A random review of the assignment sheets for the month of July were reviewed with the DSD. *July 1, 2019, census of 83 residents: - AM shift: projected nine CNAs, actual six CNAs worked (three less); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 52 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - PM shift: projected seven CNAs, actual five CNAs worked (two less); - NOC shift: projected four CNAs, actual three CNAs worked (one less); *July 2, 2019, census of 82 residents: - AM shift: projected eight CNAs (one less than their usual staffing), actual six CNAs worked (two less); - PM shift: projected seven CNAs, actual five CNAs worked (two less); - NOC shift: projected four CNAs, actual four CNAs worked; *July 6, 2019, census of 87 residents: - AM shift: projected ten CNAs, actual six CNAs worked (four less); - PM shift: projected seven CNAs, actual five CNAs worked (two less); - NOC shift: projected five CNAs, actual three CNAs worked (two less); *July 7, 2019, census of 89 residents: - AM shift: projected nine CNAs (two residents more compared to July 6, 2019, but projected one less CNA), actual six CNAs worked (three less); - PM shift: projected ten CNAs, actual five CNAs worked (five less); - NOC shift: projected four CNAs, actual three CNAs worked (one less); *July 13, 2019, census of 85 residents (morning), then 86 residents (afternoon): - AM shift: projected ten CNAs, actual seven CNAs worked (three less); and - PM shift: projected eight CNAs, actual five CNAs worked (three less). On August 12, 2019, at 2:57 p.m., the DSD was interviewed. The DSD stated they did not have the adequate number of CNAs in July 2019. The DSD further stated, when CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 53 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 staffing was inadequate, the quality of the residents' care could be diminished. CNA staff interviews were conducted: On August 12, 2019, at 2:49 p.m., CNA 2 (AM shift) was interviewed. CNA 2 stated she was not able to provide personal hygiene to the residents when she was assigned more than 13 residents during her shift. CNA 2 stated upon starting her shift, she would find her residents soiled from NOC shift. On August 12, 2019, at 2:56 p.m., CNA 4 (AM shift) was interviewed. CNA 4 stated she had 13 residents assigned to her. CNA 4 stated "usually" she was assigned 9 to 10 residents for each CNA. CNA 4 stated if more residents were assigned, it would require more time to finish the residents' care. CNA 4 stated the facility should provide more CNAs to be able to deliver quality care for the residents. The facility policy and procedure titled, "Staffing," revised April 2007, was reviewed. The policy indicated, "...Our facility provides adequate staffing to meet needed care and services for our resident population...Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met...Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident..."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 09/05/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 54 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure routine medications were available and administered as ordered for Residents 45 and 81. Resident 45 did not receive doxepin (nerve pain medication). Resident 81 did not receive digoxin (heart medication). These failures resulted in the residents not receiving the routine medications ordered to meet their medical needs, subsequently potentially affecting the residents' well-being. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 55 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 1a. On August 7, 2019, at 8:22 a.m., Licensed Vocational Nurse (LVN) 4 was observed during medication administration for Resident 45. LVN 4 was observed to administer the following medications scheduled for 9 a.m. to Resident 45: - Aspirin (blood thinner) 81 milligrams (mg, unit of measurement), one tablet; - Buspirone (anti-anxiety- mood disorder) 30 mg, one tablet; - Duloxetine (for mood improvement) 30 mg, one tablet; - Midodrine (for low blood pressure when standing) 10 mg, one tablet; - Folic Acid 400 mg (supplement), one tablet; - Venlafaxine ( an antidepressant- mood disorder) 75 mg, one tablet; - Xarelto (a blood thinner) 2.5 mg, one tablet; - Multivitamins (supplement), one tablet; - Senna (a laxative) 8.6 mg, one tablet; and - Claritin (anti-allergy medication) 10 mg, one tablet. On August 7, 2019, at 10:13 a.m., Resident 45's record was reviewed. Resident 45 was admitted on May 3, 2019, with diagnoses that included cellulitis (bacterial infection of the skin and fat tissue under the skin) and amputation (surgical removal) of the right foot. The facility document titled, "Order Details," indicated Resident 45 had a physician's order, dated July 3, 2019, for "Doxepin HCL Capsule 25 MG (milligrams)...by mouth...one time a day for nerve pain...everyday...09:00 (9 a.m.)..." LVN 4 was not observed to administer doxepin to Resident 45 during the medication administration observation on August 7, 2019 at 8:22 a.m. On August 7, 2019, at 10:50 a.m., Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 56 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 45's record was reviewed with LVN 4. During a concurrent interview, LVN 4 stated the doxepin medication was not given because it was not available. LVN 4 stated she had not notified the pharmacy and the physician of the unavailability of the doxepin. b. On August 7, 2019, at 8:50 a.m., LVN 7 was observed during medication administration for Resident 81. LVN 7 was observed to prepare Resident 81's medications scheduled for 9 a.m. During a concurrent interview, LVN 7 stated she could not find the digoxin medication (medication for heart failure, a heart condition, and hearth rhythm irregularity) in the medication cart. LVN 7 stated the medication was not in the cart and she needed to notify the pharmacy and the physician of the unavailability of the medication. On August 7, 2019, at 10:02 a.m., Resident 81's record was reviewed. Resident 81 was admitted on April 16, 2019, with diagnoses that included cerebral infarction (stroke) and atrial fibrillation (a heart rhythm disorder). A review of Resident 81's "Medication Administration Record (MAR)" was conducted. The MAR, dated August 2019, included a physician order, dated April 19, 2019, which indicated, "Digoxin Tablet Give 0.125 mg via PEG-tube (percutaneous endoscopic gastrostomy- a tube passed into a patient's stomach through the abdominal wall) one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) related to CHRONIC ATRIAL FIBRILLATION...0900 (9 a.m.)." Resident 81's MAR indicated Resident 81 did not receive digoxin on August 2 and 7, 2019. The "Progress Note," dated August 2, 2019, at 8:45 a.m. indicated, "...will send again to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 57 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 pharmacy and confirm they are sending. This will be the 3rd attempt..." On August 7, 2019, at 3:34 p.m., Resident 81's record was reviewed with LVN 8. In a concurrent interview, LVN 8 was asked if the pharmacy had delivered Resident 81 digoxin. LVN 8 stated the digoxin had not yet been delivered. LVN 8 verified in the MAR that Resident 81 had not received the digoxin for that morning. LVN 8 was not able to find documented evidence Resident 81's physician was notified Resident 81 had not received the digoxin scheduled for 9 a.m. on August 7, 2019. On August 7, 2019, at 4:12 p.m., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated every resident should receive medications as ordered by the physician. The ADON stated licensed nurses should call the pharmacy when they were running out of medication/s and ask the pharmacy to send the medications. The undated policy and procedure titled, "Medication Orders and Receipt Record," was reviewed. The policy indicated, "...Medications should be ordered in advance, based on the dispensing pharmacy's required lead time..." The facility policy and procedure titled, "Administering Medications," revised December 2012, was reviewed. The policy indicated, "...Medications must be administered in accordance with the orders, including any required time frame..."

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 09/05/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 58 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 59 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure unnecessary medications were not given, for two of five residents reviewed for unnecessary medications (Residents 45 and 50). 1. For Residents 45, the hypnotic medication (Ambien; a sleeping aid) and the anti-anxiety medication (Xanax; medication used to treat anxiety), ordered in an as needed basis, did not have a duration of 14 days or justification for its continued use; and 2. For Resident 50, the anti-anxiety medication (Ativan; medication used to treat anxiety), ordered in an as needed basis (PRN), did not have a duration of 14 days or justification for its continued use. These failures had the potential to result in the residents receiving unnecessary medications and/or sustaining medication-related side effects. Findings: 1. On August 7, 2019, Resident 45's record was reviewed. Resident 45 was admitted to the facility on May 3, 2019, with diagnoses that included generalized anxiety disorder (mood disorder). The "Medication Administration Record," for July and August 2019 included a physician's order, dated May 7, 2019, which indicated, "Ambien Tablet 5 MG (milligram, a unit of measurement)...Give 1 (one) tablet by mouth every 24 hours as needed for Inability to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 60 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 sleep..." (the order did not indicate a stop date). The documents indicated Resident 45 received the medication on July 4, 7, 9, 10, 11, 17, 22, 23, 25, 28, and 29, 2019, and on August 1 and 3, 2019 (up to 88 days from the date Ambien was ordered for Resident 45). The documents included a physician's order, dated July 10, 2019, which indicated, "...Xanax Tablet 0.25 MG... Give 1 tablet by mouth every 12 hours as needed for anxiety m/b restlessness..." (the order did not indicate a stop date). The documents indicated Resident 45 received the Xanax on July 10, 12, 14, 15, 19, 20, 21, 26, and 30, and on August 2, 2019 (up to 23 days from the date Xanax was ordered for Resident 45). The "Progress Note," by the physician, dated July 5, 2019, indicated, "Ok extend Ambien x 14 days..." There was no documented evidence the physician progress note was transcribed as a physician's order nor clarified from the practitioner. On August 12, 2019, at 11:50 a.m., Resident 45's record was reviewed with the Assistant Director of Nursing (ADON). In a concurrent interview, ADON stated the order for Ambien should have been transcribed as a physician's order, which would have ended the use of Ambien on July 19, 2019. The ADON confirmed the current physician's orders for Xanax and Ambien had no stop date. The ADON stated there should have been stop dates of 14 days for both medications. The ADON further stated if the resident needed the medication beyond 14 days, there should be a medical justification for the continued use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 61 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 both Xanax and Ambien, of which the physician should be notified, and a new order should be obtained from the physician. 2. On August 8, 2019, Resident 50's record was reviewed. Resident 50 was admitted to the facility on April 12, 2019. The "Order Summary Report," included a physician's order, dated July 22, 2019, which indicated, "Ativan 1 MG (milligram) (LORazepam) Give 1 tablet via G-Tube (a feeding tube inserted through the stomach) every 12 hours as needed for anxiety m/b (manifested by) episodes of inconsolable screaming..." The "Medication Administration Record (MAR)," for the month of July 2019 and August 2019, were reviewed. The MAR indicated Resident 50 received Ativan daily from July 22, 2019 to August 11, 2019 (for 21 days). On August 12, 2019, at 10:21 a.m., a concurrent interview and record review with the ADON was conducted. The ADON confirmed the current physician's orders for Ativan had no stop date. The ADON stated there should have been a stop date for the medication of 14 days. The ADON further stated if the resident needed the medication beyond 14 days, there should be a medical justification for the continued use of Ativan, which the physician should be notified and a new order should be obtained. The policy and procedure titled, "Administering Medications," revised December 2012, was reviewed. The policy indicated, "...If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 62 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 consider whether a standing dose of medication is clinically indicated..."

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 09/04/2019 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater when, for two of seven residents observed during medication administration (Residents 45 and 81), four of 35 opportunities observed (11 percent) resulted in medication errors. The medication errors were as follow: 1a. Resident 45 was not given Doxepin (medication for nerve pain) as ordered by the physician. This failure had the potential to result in causing undesired pain to the resident; b. Resident 45 received Midodrine (medication to increase blood pressure) when the physician's order indicated to hold the medication. This failure had the potential to result in undesired high blood pressure; 2a. Resident 81 was not given digoxin as ordered by the physician (Digoxin - medication to stabilize heart rate). This failure had the potential to result in causing irregular heart beat rhythm to the resident; and b. For Resident 81, the licensed nurse failed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 63 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 provide water flushing in between each medication administered through the gastrostomy tube (GT - tube inserted through the abdomen that delivers nutrition and medication directly to the stomach). This failure had the potential to result in sub-therapeutic effects of the medications. Findings: 1. On August 7, 2019, at 8:22 a.m., Licensed Vocational Nurse (LVN) 4 was observed during medication administration for Resident 45. LVN 4 was observed to administer the following medications scheduled for 9 a.m. to Resident 45: - Aspirin (blood thinner) 81 milligrams (mg, unit of measurement), one tablet; - Buspirone (anti-anxiety- mood disorder)30 mg, one tablet; - Duloxetine (for mood improvement) 30 mg, one tablet; - Midodrine (for low blood pressure) 10 mg, one tablet; - Folic Acid 400 mg (supplement), one tablet; - Venlafaxine ( an antidepressant- mood disorder) 75 mg, one tablet; - Xarelto (a blood thinner) 2.5 mg, one tablet; - Multivitamins (supplement), one tablet; - Senna (a laxative) 8.6 mg, one tablet; and - Claritin (anti-allergy medication) 10 mg, one tablet. a. On August 7, 2019, at 10:13 a.m., Resident 45's record was reviewed. Resident 45 was admitted on May 3, 2019, with diagnoses that included cellulitis (bacterial infection of the skin and fat tissue under the skin) and amputation (surgical removal) of the right foot. The facility document titled, "Order Details," indicated Resident 45 had a physician's order, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 64 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 dated July 3, 2019, for "Doxepin HCL Capsule 25 MG (milligrams)...by mouth...one time a day for nerve pain...everyday...09:00 (9 a.m.)..." LVN 4 was not observed administering doxepin to Resident 45 during the medication administration observation on August 7, 2019. On August 7, 2019, at 10:50 a.m., Resident 45's record was reviewed with LVN 4. During a concurrent interview, LVN 4 stated the doxepin medication was not given because it was not available. LVN 4 stated she had not notified the pharmacy and the physician of the unavailability of the doxepin. LVN 4 stated she did not administer Doxepin to Resident 45 during the medication administration observation conducted on August 7, 2019. b. On August 7, 2019, at 8:22 a.m., LVN 4 was observed during medication administration for Resident 45. LVN 4 was observed to take Resident 45's blood pressure prior to administering the routine medications, which the blood pressure reading was 128/80 mmHg (millimeters of mercury, a unit of measurement). LVN 4 was observed to administer the medications to Resident 45 (the medications included one tablet of midodrine 10 mg). On August 7, 2019, at 10:13 a.m., Resident 45's record was reviewed. Resident 45 was admitted on May 3, 2019, with diagnoses that included hypotension (low blood pressure). Resident 45's "Medication Administration Record (MAR)," included a physician's order, dated July 10, 2019, which indicated, "Midodrine HCL (hydrochloride) Tablet 10 MG Give 10 mg by mouth three times a day for SBP (systolic blood pressure- the top number in a blood pressure reading, which measured the pressure when the heart beat and pumped FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 65 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 blood) less than 90 Hold for SBP greater than 100..." On August 7, 2019, at 10:25 a.m., Resident 45's record was reviewed with the Assistant Director of Nursing (ADON). The ADON stated the midodrine order indicated to hold the medication if SBP was greater than 100 mmHg. The ADON stated the midodrine should have not been given to the resident when her SBP was greater than 100 mmHg. During an interview with LVN 4 on August 7, 2019, at 10:50 a.m., LVN 4 stated she gave the midodrine thinking the medication would lower Resident 45's blood pressure. LVN 4 stated, "I should have held it. The order says to hold it if SBP is greater than 100." According to the web article titled, "High Blood Pressure Fact Sheet," dated June 16, 2016, published by the Centers for Diseases Control and Prevention, "...A blood pressure less than 120/80 mmHg is normal. A blood pressure of 140/90 mmHg or more is too high. People with levels from 120/80 mmHg to 139/89 mmHg have a condition called prehypertension, which means they are at high risk for high blood pressure..." The facility policy and procedure titled, "Administering Medications," revised December 2012, was reviewed. The policy indicated, "...Medications must be administered in accordance with the orders..." 2. On August 7, 2019, at 8:50 a.m., LVN 7 was observed during medication administration for Resident 81. LVN 7 was observed to administer the following medications to Resident 81: - Vitamin C 250 mg two tablets; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 66 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 - Keflex (an antibiotic) 500 mg one capsule; - Amlodipine Besylate (medication for high blood pressure) 10 mg one tablet; - Aspirin (a blood thinner) 81 mg one tablet; - Prostat (a protein supplement) 30 ml; and - Brimonidine (medication to decrease pressure in the eye) eye drops, one drop administered to each eye (not included in the GT administration). a. LVN 7 was observed to prepare Resident 81's medications scheduled for 9 a.m. During a concurrent interview, LVN 4 stated she could not find the digoxin medication (medication for heart failure, a heart condition, and hearth rhythm irregularity) in the medication cart. LVN 4 stated the medication was not in the cart and she needed to notify the pharmacy and the physician of the unavailability of the medication. On August 7, 2019, at 10:02 a.m., Resident 81's record was reviewed. Resident 81 was admitted on April 16, 2019, with diagnoses that included cerebral infarction (stroke) and atrial fibrillation (a heart rhythm disorder). A review of Resident 81's "Medication Administration Record (MAR)" was conducted. The MAR, dated August 2019, included a physician's order, dated April 19, 2019, which indicated, "Digoxin Tablet Give 0.125 mg via PEG-tube (percutaneous endoscopic gastrostomy- a tube passed into a patient's stomach through the abdominal wall) one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) related to CHRONIC ATRIAL FIBRILLATION..." Resident 81's MAR indicated Resident 81 did not receive digoxin on August 2 and 7, 2019. The "Progress Note," dated August 2, 2019, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 67 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 8:45 a.m., indicated, "...will send again to pharmacy and confirm they are sending. This will be the 3rd attempt..." On August 7, 2019, at 3:34 p.m., Resident 81's record was reviewed with LVN 8. In a concurrent interview, LVN 8 was asked if the pharmacy had delivered Resident 81 digoxin. LVN 8 stated the digoxin had not yet been delivered. LVN 8 verified in the MAR that Resident 81 had not received the digoxin for that morning. LVN 8 was not able to find documented evidence Resident 81's physician was notified the medication scheduled for 9 a.m. had not received the digoxin. On August 7, 2019, at 4:12 p.m., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated every resident should receive medications as ordered by the physician. The licensed nurses were responsible for contacting the pharmacy to ensure medications were ordered and delivered when the supply was running low to prevent doses being missed. The undated policy and procedure titled, "Medication Orders and Receipt Record," was reviewed. The policy indicated, "...Medications should be ordered in advance, based on the dispensing pharmacy's required lead time..." The facility policy and procedure titled, "Administering Medications," revised December 2012, was reviewed. The policy indicated, "...Medications must be administered in accordance with the orders, including any required time frame..." b. LVN 7 was observed to crush the tablet medications and put each in separate cups. LVN 7 was observed to release the contents of the capsule (Keflex) in another medication cup. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 68 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 LVN 7 was observed to dissolve the medications in the cups in 10 ml of water separately. The LVN was observed pouring each medication through Resident 81's GT one medication cup after another. LVN 7 was not observed to administer water flushes in between administration of each medication. Immediately after the medication administration, a concurrent interview with LVN 7 was conducted. LVN 7 stated she did not need to flush the medications in between because the medications had been dissolved individually in water already. On August 7, 2019, at 9:29 a.m., an interview was conducted with the Registered Nurse Supervisor (RNS) 1. RNS 1 stated it was the facility policy to flush each medication with 15 ml of water after each medication or as specified by the physician wehn administering through a GT. On August 7, 2019, Resident 81's record was reviewed. The record did not indicate Resident 81 was on fluid restriction (a limit in fluid intake). The facility policy and procedure titled, "Administering Medications through an Enteral Tube (administration through the gastrointestinal tract [espohagus/stomach/interstines])," revised March 2015, was reviewed. The policy indicated, "...The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube...If administering more than one medication, flush with 15 mL (or prescribed amount) warm sterile or purified water between medications..." The facility policy and procedure titled, "Administering Medications," revised December FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 69 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 2012, was reviewed. The policy indicated, "...Medications must be administered in accordance with the orders..."

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

F803 09/09/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for five randomly observed meal trays (for Residents 2, 7, 15, 31, and 65), to ensure: 1. The small portion diet was observed in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 70 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 accordance with the production/diet spreadsheet (for Residents 2, 7, 15), potentially affecting all residents on small portions diet; 2. The renal diet (diet for individuals with kidney disease) was served in accordance with the production/diet spreadsheet (Resident 31); and 3. The calorie and salt restricted diets were served as ordered by the physician (Resident 65). These failures resulted in residents not being served their meals in accordance with the physician's orders or the production/diet spreadsheet, which could lead to health complications related to nutrition. Findings: 1. On August 7, 2019, at 12:05 p.m., an observation of the tray line was conducted with the Dietary Supervisor (DS) and Cook 2. Resident 15's meal tray was observed prepared by Cook 2. Cook 2 prepared Resident 15's plate by: - Using a 6-ounce (oz, a unit of measurement) ladel for the beef stroganoff; - Using a 4-oz ladel for the egg noodle; and - Using a 4-oz ladel for the baby carrots. Cook 2 was observed to pour out (by estimating) some portions of the food items during the preparation of Resident 15's meal tray. Subsequently, Cook 2 was interviewed. Cook 2 stated she served half of the serving portion of regular diet. Cook 2 was not able to say how many ounces were needed for small portion diet for each of the food items. Cook 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 71 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she just estimated the portion sizes for Resident 15's beef stroganoff, egg noodles, and baby carrots. On August 7, 2019, at 12:50 p.m., Cook 2 was observed preparing Resident 2's meal tray. Cook 2 was observed to place 6 oz ground beef, 4 oz egg noodles, and 4 oz baby carrots on Resident 2's plate. On August 7, 2019, at 1:08 p.m., Cook 2 was observed preparing Resident 7's meal tray. Cook 2 was observed to place 6 oz ground beef, 4 oz egg noodles, and 4 oz baby carrots on Resident 7's plate. Subsequently, a dietary staff was observed to place Residents 15, 2, and 7's meal trays in the meal cart indicating the meal tray was prepared completely and ready to go out to the nursing unit/s. a. On August 7, 2019, Resident 15's record was reviewed. Resident 15 was admitted to the facility on December 25, 2018. The "Order Summary Report," dated February 12, 2019, indicated, "...Regular diet...Regular consistency, SMALL PORTION..." The "Diet Type Report" was reviewed. The document indicated Resident 15's diet was "Regular...Small Portion..." b. On August 7, 2019, Resident 2's record was reviewed. Resident 2 was admitted to the facility on January 16, 2018. The "Order Summary Report," dated April 19, 2019, indicated, "...Regular diet Mechanical Soft texture...small portion..." The "Diet Type Report," provided by the DS on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 72 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 August 6, 2019, was reviewed. The document indicated Resident 2's diet was "Regular...small portion- mechanical (blended, pureed, ground, or finely chopped)." c. On August 7, 2019, resident 7's record was reviewed. Resident 7 was admitted to the facility on June 29, 2011, with diagnoses which included cerebral infarction (stroke). The "Order Summary Report," dated January 15, 2019, indicated, "...Mechanical Soft Texture, SMALL PORTIONS..." The "Diet Type Report" was reviewed. The document indicated Resident 7's diet was "Regular...Mechanical Soft...Small Portions." The facility document titled, "Diet Spreadsheet," was reviewed. The document indicated the following menu and portion size for small portion diet: - Beef Stroganoff Over Egg Noodles (4 oz beef/3 oz noodles); and - Baby Carrots (3 oz). On August 7, 2019, at 1:14 p.m., a concurrent interview and record review was conducted with the DS. The facility document titled, "Diet Type Report," indicated Residents 15, 2, and 7, had small portions diet. The DS stated Residents 15, 2, and 7 should have received small portions on their meal trays in accordance to the diet spreadsheet. 2. On August 7, 2019, at 1:03 p.m., Cook 1 was observed preparing Resident 31's meal tray. The resident's tray was observed to have 6 oz of regular diet beef stroganoff over 4 oz egg noodles, 4 oz regular baby carrots, and a slice of cream puff cake. Resident 31's diet sheet was reviewed and indicated Resident 31 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 73 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 renal diet. The facility document titled, "Diet Spreadsheet," indicated the following menu and portion size for a renal diet as follow: - Low sodium (LS) Beef & Egg Noodles (2 oz beef & 1/3 cup noodles); - LS Carrots (4 oz); and - Cookie (1 each). The "Diet Type Report," provided by the DS on August 6, 2019, was reviewed. The document indicated Resident 31 had a diet of controlled carbohydrate and renal diet. Resident 31's record was reviewed. The "Order Summary Report," dated June 20, 2019, indicated, "...Controlled carbohydrate...RENAL..." On August 7, 2019, at 1:14 p.m., a concurrent interview and record review with the DS was conducted. The DS stated Resident 31 had a diet order of renal diet. The DS stated the diet spreadsheet for renal diet indicated LS beef and egg noodles, LS carrots, and cookie. The DS stated she did not know what LS meant in the diet spreadsheet. On August 8, 2019, at 8:34 a.m., the DS was interviewed. The DS stated the LS diet for renal meant low sodium. The DS stated they did not serve low sodium diet. Requested for the recipe for LS Beef and LS carrots from the DS. On August 8, 2019, the recipe for regular beef stroganoff and carrots, LS beef and LS carrots were reviewed. The recipe for LS beef was compared with the recipe of regular beef stroganoff. The recipes indicated regular beef FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 74 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 stroganoff contained the following ingredients not included in LS beef: salt, mushrooms, half & half cream, Worcestershire sauce, bay leaf, sour cream, and mustard. The LS baby carrots' recipe did not contain salt as compared to the regular baby carrots. On August 8, 2019, at 10:58 a.m., the facility's Registered Dietician/Nutrition Consultant (RNC) was interviewed. The RNC stated the diet order for Resident 31 was controlled carbohydrate with renal diet. The NC stated the cook should have followed the diet spreadsheet for renal diet, which included LS beef, LS carrots, and cookie. 3. On August 7, 2019, at 1:03 p.m., Cook 1 was observed preparing Resident 65's meal tray. The facility document titled, "Diet Type Report," was concurrently reviewed. Cook 1 was observed to prepare regular chicken, mashed potatoes, baby carrots, and cake for Resident 65. The document indicated Resident 65 was on a "NAS (No Added Salt)/CCHO (Controlled Carbohydrate)" diet with additional instructions of "Calorie restriction 2000 cal/day (calories per day) and Salt restriction to 2 (two) g (grams)/day..." The facility document titled, "Diet Spreadsheet," was also concurrently reviewed. The document did not indicate a menu for 2000 cal/day and two grams salt/day. On August 7, 2019, at 1:14 p.m., the DS was interviewed. The DS stated they did not prepare a 2000 cal/day and two grams salt/day food as they did not have it in the spreadsheet. On August 8, 2019, at 10:58 a.m., the RNC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 75 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 interviewed. The RNC stated Resident 65 had a diet order of NAS/CCHO diet and additional instructions of the 2000 calorie/day and two grams salt restricted diet. The RNC stated the diet order was not clear because NAS/CCHO diet was different from 2000 cal/day when compared with two grams/day restricted diet. The RNC stated NAS diet had less than four grams salt and CCHO diet had 2000 calories to 2300 calories/day. The RNC stated Resident 65's diet order was confusing. The RNC stated the cook should have followed Resident 65's diet order. The RNC stated if the diet order was unclear, it needed to be clarified. The facility policy and procedure titled, "Therapeutic Diets," revised November 2015, was reviewed. The policy indicated, "...Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possible dietary restrictions...Mechanical altered diets, as well as diets modified for medical and nuritional needs, will be considered "therapeutic diets"...The physician's diet order should match the terminology used by Food Services..."

F805 SS=D Food in Form to Meet Individual Needs CFR(s): 483.60(d)(3)

F805 09/05/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(3) Food prepared in a form designed to meet individual needs. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 76 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 received the honey-thick fluids during meals as ordered by the physician for one resident (Resident 142). This failure had the potential for Resident 142 to aspirate (inhale fluids into the lungs). Findings: On August 5, 2019, at 12:15 p.m., lunch meal observation was conducted. The Restorative Nursing Assistant (RNA) 1 was observed preparing to feed Resident 142. The food items in the meal tray were observed to include two 4-ounce cartons of health shake (drink with extra protein and vitamins). RNA was observed to pour out the contents of the two cartons into a cup. RNA 1 started to feed Resident 142. A concurrent review of the health shake carton label was conducted. The label indicated the health shake had a nectar thick consistency (less thick compared to honey-thick consistency). On August 5, 2019, at 12:25 p.m., RNA1 was interviewed. RNA1 stated she knew Resident 142 was on a honey thick diet. RNA 1 stated she did not notice the nectar thick imprint on the health shake carton. On August 5, 2019, at 12:45, p.m., the Dietary Supervisor (DS) was interviewed regarding the serving of the nectar-thick health shake to Resident 142. The DS stated Resident 142 received nectar thickened shakes instead of honey thickened shakes. The DS stated Resident 142 received "the wrong shake." Resident 142 record was reviewed. Resident 142 was admitted on July 23, 2019, with diagnoses that included cerebrovascular accident (stroke). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 77 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 physician orders, dated July 30, 2019, indicated, "Regular Fortified diet Full Liquid texture Honey consistency...Full Assist With Meal for Dysphagia (difficulty in swallowing)."

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

F812 09/05/2019 §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 food storage was maintained in the walk-in refrigerator when inadequate temperature control (a temperature of greater than 41 degrees fahrenheit greater) occurred for 3 days (from August 3 to 5, 2019). In addition, the facility served food items after being stored outside the safe temperature for three days. This had the potential to result in affecting a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 78 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 vulnerable population of 64 residents that received oral diets. In addition, this failure had the potential for residents to sustain serious gastro-intestinal illnesses resulting from consumption of food items unsafely stored. Due to this failure, the Administrator (ADM), Head Consultant (HC), and Nurse Consultant (NC), were verbally notified of an immediate jeopardy (IJ) situation, on August 5, 2019, at 11:41 a.m. This was determined due to potentially hazardous foods being served after being stored outside the safe temperatures. The written removal plan for the IJ was accepted on August 5, 2019, at 4:05 p.m. The IJ was removed in the presence of the ADM at the facility on August 7, 2019, at 7:46 p.m., after the facility's removal plan of action to remove the IJ was verified to have been implemented. Findings: On August 5, 2019, at 9:05 a.m., an initial kitchen tour was conducted with the Dietary Supervisor (DS). The walk-in refrigerator was inspected and observed. The refrigerator thermometer reading was at 46 degrees Fahrenheit (F). The walk-in freezer was inside the walk-in refrigerator. The following food items were found inside the walk-in refrigerator: - One unopened two-gallon milk; - One 64 ounces (oz) opened carton of liquid creamer; - One 64 oz opened lactose free milk labeled with the date August 4, 2019; - Multiple unopened four oz carton of milk (about 300 cartons); - Four plates of tuna sandwiches labeled with the date August 2, 2019 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 79 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 - Three fruit plates with cottage cheese labeled with the date August 2, 2019; - Two plates of egg sandwich labeled with the date August 2, 2019; - Two cartons of two pounds (lbs) liquid eggs (one labeled as opened on August 4, 2019); - 12 unopened cartons of two lbs liquid eggs; - An opened box of shelled eggs with two trays of 30 eggs each tray; and - An unopened box of shelled eggs with six trays of 30 eggs each tray. In a concurrent interview, the DS stated the walk-in refrigerator temperature was checked by the cook on August 5, 2019, at around 5 a.m., and was at 48 degrees F. The DS stated the temperature of the refrigerator should be at 41 degrees F or below. The DS stated the walk-in refrigerator temperature had been above 41 degrees F since August 3, 2019. The DS stated she was notified by dietary staff on the morning of August 3, 2019, about the refrigerator temperature issue. The DS stated she notified the Maintenance Supervisor (MS) and ADM of the refrigerator not maintaining appropriate temperatures on August 3, 2019. On August 5, 2019, at 9:29 a.m., Cook 1 was interviewed. Cook 1 stated she was the staff member that checked the refrigerator temperature of the walk-in refrigerator on August 3, 2019, at around 5 a.m. She stated she checked the refrigerator temperature before dietary staff starts taking food items out from the refrigerator (first thing in the morning). Cook 1 stated the temperature was at 45 degrees F. She stated the DS was notified on August 3, 2019, at around 6 a.m. about the refrigerator being out of acceptable temperature range. Cook 1 stated she was instructed by the DS on August 3, 2019, to open the walk-in freezer in order to keep the walk-in refrigerator temperature at 41 degrees FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 80 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE F or below. Cook 1 stated there was no way of knowing how long the refrigerator temperature had been above 41 degrees F since dietary staff does not come in until 5 a.m. Cook 1 stated she worked the first shift on August 4 and 5, 2019. She checked the walk-in refrigerator temperature at around 5 a.m., and the temperature was 45 degrees F on August 4, 2019; and on August 5, 2019, the temperature was at 48 degrees F. Cook 1 stated the walk-in refrigerator temperature should have been under 40 degrees F. Cook 1 stated the food items found in the refrigerator on August 5, 2019, (initial kitchen inspections) had been in the refrigerator since August 3, 2019. On August 5, 2019, at 9:33 a.m., a concurrent interview and record review with the DS was conducted. The DS stated the MS informed her that he defrosted the walk-in refrigerator unit by disconnecting the unit's compressor on August 3, 2019. The DS stated she got instructions from the MS to leave the walk-in freezer door open for about two hours to keep the refrigerator cool, and then to close the walk-in freezer door to avoid the frozen foods to melt. The dietary staff was instructed to continuously do this process, until the refrigerator temperature was serviced. The DS was unable to provide documented evidence indicating monitoring of ensuring the food items did not have temperature above 41 degrees Fahrenheit from August 3 to 5, 2019. The facility document titled, "Refrigerator/Freezer Temperature Log," for August 2019, was reviewed with the DS. The log indicated refrigerator temperature should be within 34 to 41 degrees F. The DS stated the walk-in refrigerator temperature was checked by the cook daily at 5 a.m. and 8 p.m. The document indicated the following temperatures FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 81 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 of the walk-in refrigerator: - 45 degrees F on August 3, 2019, at 5 a.m. and 8 p.m.; - 46 degrees F on August 4,2019, at 5 a.m. and 50 degrees F at 8 p.m.; and - 48 degrees F on August 5, 2019, at 5 a.m. In a concurrent interview with the DS, she stated the walk-in refrigerator temperature was not maintained at 41 degrees F or below since August 3, 2019. The DS further stated the food items in the walk-in refrigerator were compromised and should have been transferred to a working refrigerator or discarded. The DS stated they did not have other refrigerators in the facility to store the food items. On August 5, 2019, at 10:02 a.m., the MS was interviewed. The MS stated he was notified by the DS on August 3, 2019, at around 6 a.m., that the walk-in refrigerator was not maintaining the temperature of 41 degrees F or below. The MS stated he came to the facility on August 3, 2019, after 6 p.m., and defrosted the unit. The DS stated he contacted the refrigerator technician on August 3, 2019, and the technician was not able to come to the facility on August 3 or 4, 2019. The MS stated he did not come to the facility on August 4, 2019 to check on the refrigerator. The MS stated he connected the unit of the walk-in refrigerator on August 5, 2019, at around 10 a.m. The MS stated he was still waiting for the technician to check the walk-in refrigerator. On August 5, 2019, at 10:28 a.m., random food items' temperature (currently stored in the refrigerator) were checked with the DS: - One 4-oz carton milk (temperature was 52.6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 82 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 degrees F); - The lactose free milk (temperature was 46.2 degrees F); and - One tuna sandwich (temperature was 44.6 degrees F). In a concurrent interview with the DS, she stated the food items in the refrigerator were there since August 3, 2019, and were not removed from the refrigerator. The DS stated the food items were exposed to unsafe storage temperature since August 3, 2019. She stated the facility used the food items in the walk-in refrigerator from August 3 to August 5, 2019. The stated the food items should have been discarded and not served to residents. On August 5, 2019, at 4:29 p.m., the Nutrition Consultant (NC) was interviewed. The NC stated he was notified by the DS that the walkin refrigerator was not maintaining a safe temperature of 41 degrees F or below on August 5, 2019, at around 10 a.m. He stated the walk-in refrigerator should have had a temperature of 41 degrees F or below. The NC stated the food items in the walk-in refrigerator should have been transferred to a working refrigerator or discarded four hours after the walk-in refrigerator stopped working properly. In review of the Food Code 2017, "...Frozen TIME/TEMPERATURE CONTROL FOR SAFETY FOOD...shall be held...Under refrigeration that maintains the FOOD temperature at 5 C (degrees Celsius) (41 F) or less..." ...Holding Cold Food Without Temperature Control It is important to note that time/temperature FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 83 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 control for safety foods held without cold holding temperature control for a period of 4 hours do not have any temperature control or monitoring. These foods can reach any temperature when held at ambient air temperatures as long as they are discarded or consumed within the four hours..." The facility policy and procedure titled, "Policy and Procedure...Freezer and Refrigerator Temperatures," revised January 1, 2018, was reviewed. The policy indicated, "...A potential cause of food borne illness is improper storage of TCS/PHF (Time/Temperature Control for Safety/Potentially Hazardous Food) food. The refrigerator must be in good repair and keep foods at or below 41 degrees F...All time/temperature control (TCS/PHF) refrigerated foods shall be held at or below 41 degrees F..." The facility policy and procedure titled, "Policy and Procedure...Freezer/Refrigeration Outage," revised January 1, 2017, was reviewed. The policy indicated, "...Policy: To serve safe foods...In the event of a freezer and/or refrigerator outage - foods will be transferred to a working unit...The facility has a 4-hour time frame when the unit is determined to be nonworking, in which to transfer foods..." Due to these failures, the Administrator (ADM), Head Consultant (HC), and Nurse Consultant (NC), were verbally notified of an IJ situation, on August 5, 2019, at 11:41 a.m. This was determined due to potentially hazardous foods being served after being stored outside safe temperatures. The facility submitted a written removal plan to correct the IJ situation and was accepted on August 5, 2019, at 4:05 p.m. The removal plan included the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 84 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 - All potentially hazardous food that were outside the safe temperature in the walk-in refrigerator were thrown out on August 5, 2019 (after the facility had been notified of the IJ); - All residents on oral diet were monitored for signs and symptoms of gastrointestinal (GI) distress for 72 hours and to notify the physician when GI symptoms occur; - All dietary department staff were educated by the ADM on the policy and procedure for freezer and refrigerator temperatures and freezer/refrigerator outages on August 5, 2019; - All staff were in-serviced by the Director of Nursing on the signs and symptoms of GI distress by August 7, 2019; and - The DS, MS, and ADM received disciplinary action for failure to follow protocol. The IJ was removed in the presence of the ADM at the facility on August 7, 2019, at 7:46 p.m., after the facility's removal plan of action for the IJ was reviewed and was verified to have been implemented.

F838 SS=E Facility Assessment CFR(s): 483.70(e)(1)-(3)

F838 09/02/2019 §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 85 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 86 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a facilitywide assessment (an assessment to determine what resources were necessary to competently provide quality care for residents) was conducted and documented accurately. The facility-wide assessment did not include/address the distribution of staffing for subacute and non-subacute residents. This failure resulted in the lack of nursing staff to provide the necessary care and treatment for all residents (subacute and non-subacute) (Cross-refer to F 725). Findings: Cross-refer to F 725 regarding adequate staffing requirements (included observation, interviews, and record reviews). The facility document titled, "Facility Assessment Plan," completed March 29, 2019, was reviewed with the Facility Marketing Staff (FM). The document did not indicate the nursing staffing requirements for subacute and non-subacute residents. In addition, the facility assessment did not include the respiratory staffing requirements for the subacute residents. On August 12, 2019, at 5:40 p.m., a concurrent interview and record review was conducted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 87 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 with the FM. The facility assessment did not indicate the staffing plan for the Subacute care unit (inpatient care unit for those individuals needing services that are more intensive than those typically received in skilled nursing facilities but less intensive than acute care). FM stated the subacute unit opened on June 2019. FM stated, as of August 5, 2019, there were currently 11 residents in the Subacute unit. FM further stated the facility assessment should be updated to include the current staffing plan for the subacute unit, which subsequently affected the nurse staffing for the non-subacute residents.

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

F880 09/04/2019 §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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 88 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 89 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 implement infection prevention procedures when the pulse oximeter (a device that clips onto a resident's finger to measure oxygen levels in the blood) was not disinfected in between resident use for two of two residents (Residents 238 and 45). This failure had the potential to result in crosscontamination and the spread of infectious diseases amongst the residents. Findings: On August 8, 2019, at 8:23 a.m., Respiratory Therapist (RT) 2 was observed placing a pulse oximeter on Resident 238's finger. During a concurrent interview, RT 2 stated Resident 238's oxygen saturation (O2 Sat measurement of the blood oxygen) was 92%. RT 2 was observed to remove the pulse oximeter. Then, RT 2 was observed to place the same pulse oximeter inside the medication cart. RT 2 was observed to not disinfect the pulse oximeter prior to putting it inside the medication cart. On August 8, 2019, at 9:05 a.m., RT 2 was observed using the same pulse oximeter on Resident 45. During a concurrent interview, RT 2 stated Resident 45's O2 Sat was at 94%. RT 2 was observed to remove the pulse oximeter off Resident 45. Then, RT 2 was observed to place the same pulse oximeter inside the medication cart. RT 2 was observed to not disinfect the pulse oximeter prior to putting it inside the medication cart. On August 8, 2019, at 9:25 a.m., RT 2 was interviewed. RT 2 stated he did not disinfect the pulse oximeter after using the equipment on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 90 of 91 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: _______________ 555379 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASISTENCIA VILLA HEALTHCARE CENTER 1875 Barton Rd Redlands, CA 92373 (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 238, and before and after using the same pulse oximeter on Resident 45. Resident 238's records were reviewed. Resident 238 was admitted on July 11, 2019. The "History and Physical," dated July 14, 2019, indicated Resident 238 had diagnoses which included chronic respiratory failure (a breathing disorder) and oxygen dependence. The "Order Summary Report," dated July 11, 2019, indicated, "Monitor oxygen saturation q (every) shift..." Resident 45's record was reviewed. Resident 45 was admitted on May 3, 2019. The "History and Physical," dated May 6, 2019, indicated Re sident 45 had diagnoses which included chronic obstructive pulmonary disease (lung disease that caused obstructed airflow from the lungs). The "Medication Administration Record," included a physician's order, dated June 29, 2019, which indicated, "Monitor O2 Saturation via Pulse Oximeter Q (every) shift..." On August 12, 2019, at 5:18 p.m., the Infection Preventionist (IP) was interviewed. The IP stated the pulse oximeter should have been disinfected prior and after using the equipment for every resident. The facility's policy and procedure titled, "Cleaning and Disinfection of Resident-Care Items and Equipment (revised July 2014)," was reviewed. The policy indicated, "...Reusable items are cleaned and disinfected...between residents..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IZTI11 Facility ID: CA240000700 If continuation sheet 91 of 91