Other·June 14, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual Re-certification Survey conducted March 11th, through 14th, 2019. Representing the California Department of Public Health: Surveyor 40356, HFEN Surveyor 37536, HFEN Surveyor 25338, HFES Surveyor 39920, HFEN Surveyor 40308, HFEN Surveyor 40674, HFEN Surveyor 40988, HFEN and; Surveyor 41422, HFEN The facility census was 56 residents.

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

F580 04/14/2019 §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 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: QINN11 Facility ID: CA240000016 If continuation sheet 1 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident 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, record review, the facility failed to notify the physician when the resident's blood pressure (BP) readings were below normal range for one of 16 residents (Resident 403). This failure resulted in the resident's physician not being able to act upon the resident's low BP. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 2 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 Findings: On March 11, 2019, at 11 a.m., Resident 403 was interviewed. Resident 403 stated she was in a motor vehicle accident and had fractured her right ankle. She stated she is currently undergoing physical therapy, however; her blood pressure drops whenever she attempts to stand. Resident 403 stated her continuously low blood pressure was holding her back from doing physical therapy. Resident 403's record was reviewed. The resident was admitted on March 2, 2019, with diagnoses that included fracture (a break in bone or cartilage) of lower leg. Occupational Therapy (OT) and Physical Therapy (PT) Notes indicated BP readings of: a. March 6, 2019: 95/62 mmHg (nursing notified); b. March 7, 2019: 82/56 mmHg (nursing notified); c. March 8, 2019: 90/65 mmHg (nursing notified); d. March 11, 2019: 95/52 mmHg (nursing notified); and e. March 12, 2019: 98/54 mmHg (nursing notified). On March 13, 2019, at 11:06 a.m., Resident 403's record was reviewed with Registered Nurse Supervisor (RNS) 1. The blood pressure readings dated March 6, 2019, to March 12, 2019, were discussed with RNS1. RNS1 stated the BP readings were below normal range. RNS 1 stated this was considered a change of condition. The blood pressures documented by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 3 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 nursing, and the nursing progress notes in the resident's (Resident 403) electronic health record, were reviewed with RNS1. RNS1 was unable to find documented evidence Resident 403's physician was notified of the abnormally low BP readings. RNS1 stated the physician should have been notified according to the facility policy and procedure. On March 13, 2019 at 11:40 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 403's low BP levels should have been reported to the resident's physician. A review of the undated policy and procedure titled, "Change in Resident's Condition and Status," was reviewed. The policy and procedures indicated, "POLICY: Facility shall promptly notify the resident, his or her attending physician and resident's legal representative of changes in resident's condition or status...PROCEDURES: 1. The charge nurse will promptly notify the residents attending physician when...There is a significant change in the resident's physical, mental, or psychosocial status..."

F636 SS=D Comprehensive Assessments & Timing CFR(s): 483.20(b)(1)(2)(i)(iii)

F636 04/14/2019 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 4 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 5 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS - an assessment tool) assessments were completed timely for two of 13 residents, reviewed for MDS assessments (Residents 10 and 12). This failure had the potential for the facility not to be able to identify and plan for the care and treatment of the residents' medical problems. Findings: 1. Resident 10's record was reviewed. Resident 10 was admitted on January 22, 2015. Resident 10 was due to have an annual comprehensive assessment on January 25, 2019. There was no documented evidence the comprehensive assessment was completed. 2. Resident 12's record was reviewed. Resident 12 was admitted on January 23, 2018. Resident 12 was due to have an annual comprehensive assessment on January 31, 2018. There was no documented evidence the comprehensive assessment was completed. On March 14, 2019, at 2:42 p.m., the MDS data base was reviewed with the Director of Nursing (DON), . The DON was unable to provide documented evidence indicating the comprehensive MDS assessments were completed within one year of the due date. The DON stated there was no regular scheduled time to transmit the MDS. The DON further stated the annual assessment for Residents 10 and 12 should have been completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 6 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 undated policy and procedure titled "Nursing Assessment," was reviewed. The policy and procedure indicated,"...Time frame for completing the assessment will be based on the type of assessment ...Annual assessment, required by 366 days from previous comprehensive assessment..."

F638 SS=E Qrtly Assessment at Least Every 3 Months CFR(s): 483.20(c)

F638 04/14/2019 §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS - an assessment tool) Assessments for 9 of 13 Residents (Residents 2, 3, 4, 5, 6, 8, 9, 13, and 22). This failure had the potential for the facility not to monitor residents' health status or capture critical indicators of gradual changes in the residents' condition between assessments. Findings: On March 14, 2019, Residents 2, 3, 4, 5, 6, 8, 9, 13, and 22, records were reviewed: 1. Resident 2 was admitted to the facility on October 16, 2018. Resident 2's last MDS was dated October 26, 2018. The quarterly MDS assessment due on January 26, 2019, had not been completed. 2. Resident 3 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 7 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 October 20, 2018. Resident 3's last MDS was dated October 27, 2018. The quarterly assessment for January 27, 2019, had not been completed. 3. Resident 4 was admitted to the facility on March, 28 2017. Resident 4's last MDS was dated October 27, 2018. The quarterly assessment for January 18, 2019, had not been completed. 4. Resident 5 was admitted to the facility on April 22, 2011. Resident 5's last MDS was dated October 21, 2018. The quarterly assessment for January 21, 2019, had not been completed. 5. Resident 6 was admitted to the facility on October 19, 2018. Resident 6's last MDS was dated October 29, 2018. Resident expired on March 1, 2019. The discharge assessment had not been completed. 6. Resident 8 was admitted to the facility on October 22, 2018. Resident 8's last MDS assessment was dated February 1, 2019, had not been completed. 7. Resident 9 was admitted to the facility on October 20, 2014. Resident 9's last MDS was dated October 24, 2018. The quarterly assessment dated January 24, 2019, and the discharge assessment dated February 4, 2019, had not been completed. 8. Resident 13 was admitted to the facility on October 28, 2014. Resident 13's last MDS assessment was dated November 3, 2018. The quarterly assessment for February 3, 2019, had not been completed. 9. Resident 22 was admitted to the facility on March 15, 2018. Resident 22's last MDS was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 8 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 October 23, 2018. The quarterly assessment for January, 23, 2019, had not been completed. On March 14, 2019, at 2:42 p.m., the MDS data base was reviewed with the Director of Nursing (DON). The DON was unable to provide documented evidence which indicated the quarterly MDS assessments were completed. The DON stated there was no regular scheduled time to transmit the MDS. The DON further stated the quarterly assessments for Residents 2, 3, 4, 5, 6, 8, 9, 13, and 22 should have been completed. The facility undated policy and procedure titled "Nursing Assessment," was reviewed. The policy indicated,"...Time frame for completing the assessment will be based on the type of assessment ...Quarterly Review, required within 92 days of prior assessment whether comprehensive or non-comprehensive..."

F640 SS=D Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 04/14/2019 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 9 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - an assessment tool) Discharge Assessments were completed for 4 of 4 residents (Residents 1,3, 6, and 9). This failure resulted in the facilities non-compliance with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 10 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 Center for Medicare and Medicaid Services (CMS) MDS requirements. Findings: 1. Resident 1's record was reviewed. Resident 1 was admitted to the facility on September 24, 2018, with diagnoses which included muscle weakness. Resident 1 was discharged on November 6, 2018. Review of Resident 1's MDS discharge assessment indicated the assessment was not completed. 2. Resident 3's record was reviewed. Resident 3 was admitted to the facility on October 20, 2018, with diagnoses which included essential hypertension (high blood pressure). Resident 3 was discharged on January 31, 2019. Review of Resident 3's MDS discharge assessment indicated the assessment was not completed. 3. Resident 6's record was reviewed. Resident 6 was admitted to the facility on October 19, 2018, with diagnoses which included dementia (memory loss that gets worse overtime). Resident 6 expired on March 1, 2019. Review of Resident 6's MDS discharge assessment indicated the assessment was not completed. 4. Resident 9's record was reviewed. Resident 9 was admitted to the facility on October 20, 2014, with diagnoses which included dementia (memory loss which gets worse overtime). Resident 9 was discharged on February 2, 2019. Review of Resident 9's MDS discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 11 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 assessment indicated the assessment was not completed for Resident 9. On March 14, 2019, at 2:42 p.m., the MDS data base was reviewed with the Director of Nursing (DON). The DON was unable to provide documented evidence the discharge MDS assessments were completed. The DON stated there was no regular scheduled time to transmit the MDS. The DON stated the discharge assessments for Residents 1, 3, 6, and 9, should have been completed. A review of "Resident Assessment Manual Version 3.0, "indicated,"...Completion timing...For all non-admission OBRA (Omnibus Budget Reconciliation Act)...assessments, the MDS completion date (Z0500B) must be no later than14 days after the ARD (Assessment Reference Date)...Submission Time Frame for MDS records...Discharge Assessment...Submit by Z055B+14 days (14 days from the completion date)..."

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 04/14/2019 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 12 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure an indwelling catheter (a tube that is inserted into the bladder to drain urine) was used appropriately for one of one resident (Resident 302). The resident continued to have an indwelling catheter without a medical condition necessitating its use. This failure had the potential for the resident to acquire an avoidable urinary tract infection. Findings: On March 11, 2019, at 8:30 a.m., Resident 302 was observed in bed. An indwelling catheter bag was observed hanging on the right side of the bed with approximate 100 milliliters (ml) of yellow fluid. On March 11, 2019, at 10:52 a.m., an interview with Resident 302 and his family member was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 13 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 conducted. Both stated they did not know the reason for the use of the indwelling catheter. On March 12, 2019, Resident 302's record was reviewed. He was admitted to the facility on February 2, 2019, with diagnoses that included sepsis (a life-threatening complication of an infection) and benign prostatic hyperplasia (prostate gland enlargement). The History and Physical, dated March 3, 2019, indicated, "This resident has the capacity to understand and make decisions." The physician's order dated March 1, 2019, indicated, "bladder retraining x (for) 72 hours and then remove Foley catheter (indwelling catheter)..." There was no documented evidence of urinary catheter medical justification to keep indwelling catheter in use for over the 72 hours ordered by the physician. On March 13, 2019, at 10:15 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated Resident 302's indwelling catheter should have been removed after the bladder retraining was done on March 4, 2019. The undated facility policy and procedure titled, "FOLEY/INDWELLING CATHETER CARE," was reviewed. The policy indicated: "...It shall be this facility's policy to provide necessary services relating to use of foley / indwelling catheter to prevent resident from developing related infection..." The undated facility policy and procedure titled, "FOLEY/INDWELLING CATHETER," was reviewed. The policy indicated: "... Foley catheter shall only be used upon FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 14 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 order from a resident's physician. For those residents admitted to the facility with indwelling catheter, licensed nurse shall assess the resident for medical necessity of use of an indwelling catheter... "

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

F693 04/14/2019 §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 resident§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 the tip of the feeding tube (a tube inserted into the stomach to provide nutrition) was covered while not in use for one of one residents (Resident 38) on tube feeding formula (TF). This failure had the potential for Resident 38 to experience FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 15 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 complications from tube feeding, such as infection. Findings: On March 11, 2019, at 10:55 a.m., Resident 38 was observed in bed. Resident 38's TF was observed not infusing and the tip of the feeding tube was hanging down from the TF pump, uncovered. On March 11, 2019, at 10:58 a.m., during an interview with Registered Nurse Supervisor (RNS) 3, RNS 3 stated she disconnected Resident 38 from the TF. RNS 3 further stated the tip of the tubing should be covered (capped), but she forgot to do it. Resident 38's record was reviewed. Resident 38 was admitted to the facility on September 4, 2018, with diagnoses which included dysphagia (difficulty swallowing), adult failure to thrive (general decline in growth and physical activity), and enterocolitis (inflammation of the digestive tract caused by an infection). Resident 38's physician orders dated January 9, 2019, indicated, "...Glucerna 1.2 at 85 ml (milliliters)/hr (hour) via G-Tube (gastrostomy tube - a flexible feeding tube placed through the abdominal wall and into the stomach)...off at 10 a.m. and on at 2 p.m..." A review of the facility policy titled, "Enteral Tube Feeding via Continuous Pump," revised date March, 2015, indicated, "...Use aseptic technique (practices and procedures used to minimize the risk of infection) when preparing or administering enteral feedings..."

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 04/14/2019 Facility ID: CA240000016 If continuation sheet 16 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who 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, for one of two residents (Resident 44), ensure a "No Smoking" sign was posted outside the resident's room. This failure had the potential to affect the safety and well-being of the resident receiving respiratory therapy. Findings: On March 11, 2019, at 8:35 a.m., Resident 44 was observed in his room sitting in a wheelchair. Resident 44 was receiving oxygen (O2) through a nasal cannula (NC-device placed in the nostrils used to deliver O2 to a person) attached to a portable tank (a pressurized storage cylinder for oxygen). Resident's 44 room did not have a "No Smoking" sign outside his door. On March 11, 2019, at 1:00 p.m., an interview with Registered Nurse Supervisor (RNS) 1 was conducted. RNS 1 acknowledged Resident 44's room did not have a "No smoking" sign posted outside the door. He stated all residents with oxygen should have a "No Smoking" sign posted outside their doors. Resident 44's record was reviewed. Resident 44 was admitted on January 24, 2019, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 17 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 diagnoses that included heart failure (disease that affects pumping action of the heart muscles) and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe). On March 12, 2019, Resident 44's physician order dated March 6, 2019, indicated, "O2 (oxygen) 2-4 L/min of via NC PRN (as needed)." On March 13, 2019, at 2:27 p.m., an interview with Licensed Vocational Nurse (LVN) 3 was conducted. LVN 3 stated a sign should be placed on the resident's door to alert staff and visitor of the use of O2 as a "prevention of a fire hazard" and as an alert in case of an emergency. She stated the licensed nurse is responsible in placing the sign outside the door. On March 13, 2019, at 3:27 p.m. the Director of Nursing (DON) was interviewed. The DON stated there should have been a "No smoking" sign outside the resident's door as a precautionary measure since the resident (Resident 44) is on O2 therapy. A review of the undated facility policy and procedure titled, "OXYGEN THERAPY," was reviewed. The policy stated "...Residents using and/or receiving oxygen therapy shall have visible signs on their rooms of Oxygen in Use/No Smoking Allowed..."

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 04/14/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 18 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the Medication Regimen Review (MRR) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 19 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 recommendations were acted upon for one of eight residents (Resident 47), reviewed for unnecessary medications. This failure resulted in Resident 47 to receive multiple psychotropic medications and experience adverse side effects. Findings: 1. During the recertification survey from March 11 to 14, 2019, Resident 47 was observed: *On March 11, 2019, at 9:25 a.m. - The resident was sleeping on the couch in the activity room, during activities; *On March 11, 2019, at 11:16 a.m. - The resident was sleeping on the couch in the activity room, during activities; and *On March 12, 2019, at 1:34 p.m. - The resident was sleeping and slumped-over in her wheelchair, being wheeled around by staff. *On March 14, 2019, at 9:39 a.m., - The resident was sitting in her wheelchair at the activity room, head down with her eyes closed. On March 14, 2019, at 9:41 a.m., Resident 47's sitter (provided by hospice) was interviewed. The sitter stated since coming intermittently, she only recalled Resident 47 having one episode of psychotic behavior "difficult with staff" since January 2019. She also stated the facility had just administered medications that made the resident "a little off (sleepy during the time of interview)." On March 12, 2019, Resident 47's record was reviewed. Resident 47 was admitted to the facility under hospice care on January 4, 2019, with diagnoses that included dementia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 20 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 (memory loss) with behavioral disturbance, restlessness, and agitation. The physician's orders were reviewed. Resident 47's medication regimen included the following: a. Geodon (an antipsychotic): *On January 4, 2019 - 20 milligrams (mg) by mouth at bedtime for anxiety manifested by (m/b) agitation, restlessness, and combative behavior. (Note: Geodon's drug classification is an antipsychotic. Lexi comp [a reputable drug reference] does not include the use of Geodon as an anti-anxiety.) The Medication Administration Record (MAR) indicated the resident received Geodon: *For January 4 to January 31, 2019 - 27 days [24 doses given, 2 doses held]; *For February 1 to February 28, 2019 - 18 days [16 doses given, 2 doses held]; and *For March 1 to 12, 2019 - 12 days [11 doses given, 2 held]. There was no documented evidence of an assessment on admission providing an explanation and/or history for the use of Geodon. b. Seroquel (an antipsychotic): *On January 7, 2019 - 25 mg by mouth twice daily for hallucinations (false sensory experiences); *On January 17, 2019 - increased to 50 mg twice daily; and *On January 29, 2019 - increased to 50 mg three times daily. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 21 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 Medication Administration Record (MAR) indicated the resident received Seroquel: *For January 7 to January 31, 2019 - 22 days [50 doses given, 1 dose held]; *For February 1 to February 28, 2019 - 28 days [79 doses given, 3 doses held]; and *For March 1 to March 13, 2019 - 13 days [35 doses given, 4 doses held]. There was no documented evidence indicating the necessity of starting Seroquel and subsequently increasing the dosage. c. "ABHR cream" - [Ativan (an anti-anxiety), Benadryl (antihistamine - used for itching/allergy), Haldol (an antipsychotic), Reglan (used for stomach reflux); all four medications compounded (mixed) together as one medication]: *On January 21, 2019 - Apply 1 milliliter (ml) to inner wrist every four hours for anxiety (m/b) fidgeting. The Medication Administration Record (MAR) indicated the resident received ABHR: *For January 21 to January 31, 2019 - 10 days [64 doses given, 15 held]; *For February 1 to February 28, 2019 - 28 days [160 doses given, 8 held]; and *For March 1 to March -- 2019 - 14 days [65 doses given, 12 dosed held]. There was no documented evidence indicating the necessity of starting the ABHR cream. d. Haldol (an antipsychotic): *On January 28, 2019 - Inject 1 mg intramuscularly (IM) every 12 hours for schizoaffective disorder (psychotic diagnosis) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 22 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 m/b mood swings, agitation striking out, hitting, yelling, and incoherent speech. There was no documented evidence indicating the necessity of starting Haldol and subsequently increasing the dosage. The Medication Administration Record (MAR) indicated the resident received Haldol: *For January 28 to January 31, 2019 - 4 days [7 doses given, 2 doses held]; *For February 1 to February 28, 2019 - 28 days [42 doses given, 14 held]; and *For March 1 to March 12, 2019 - 12 days [16 doses given, 7 held] - On February 4, 2019 at 9 a.m., Haldol 1 mg was coded 9 (Other/ See Progress Notes). The Progress Notes Order - Administration Note indicated "hold to prevent over sedation..." - On February 12, 2019 at 9 a.m., Haldol 1 mg was coded 9. The Progress Notes Order Administration Note indicated "resident is in deep sleep at this time. medication held to prevent oversedastion (sic)..." - On February 20, 2019 at 9 a.m., Haldol 1 mg was coded 9. The Progress Notes Order Administration Note indicated "resident is in deep sleep at this time. medication held to prevent over sedation..." - On March 11, 2019 at 9 a.m., Haldol 1 mg was coded 9. The Progress Notes Order Administration Note indicated "held due to increase lethargy and to prevent over sedation" - On March 11, 2019 at 9 a.m., Seroquel 50 mg was coded 9. The Progress Notes Order Administration Note indicated "held due to increase lethargy and to prevent over sedation" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 23 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 Upon starting the recertification survey on March 11, 2019, Resident 47 was on Geodon, Seroquel, ABHR, and Haldol routinely. On March 14, 2019 at 1:28 p.m., the facility document titled, "Note to Attending Physician/Prescriber" (consultant pharmacist recommendation) printed January 15, 2019, was reviewed with Licensed Vocational Nurse (LVN) 2. The document indicated, "...the treatment of behavioral disorders in the elderly patients with dementia with antipsychotic medications is associated with increased mortality...Please review therapeutic benefits vs potential risks for this individual resident who is receiving Seroquel 25 mg BID and Geodon 20mg qhs (every night) (Possible duplicate therapy) ..." LVN 2 stated she was not familiar with the document. LVN 2 further stated she could not find any documented evidence the recommendation for January 15, 2019, was acted upon. On March 14, 2019 at 11:33 a.m., the "Consultant Pharmacist's Medication Regimen Review" (MRR) dated February 27, 2019, was reviewed with Registered Nurse Supervisor (RNS) 1. The MRR indicated, "This resident is currently receiving the following antipsychotic meds (medications): Haldol IM, Geodon and Seroquel...there is the concern of increased side effects with 2 or more antipsychotic agents being used for the same condition...a gradual reduction of one and eventually DC (discontinue) if clinically indicated and psychiatry consult to evaluate..." There was no documented evidence in Resident 47's record indicating the MRR dated February 27, 2019, was addressed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 24 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 RNS 1, RNS 1 stated he is currently working on the February recommendations and the MRR was not done.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 04/14/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to adequately monitor sign and symptoms of adverse consequences of pain medication use for one of 16 residents (Resident 403). This failure had the potential for the resident to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 25 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 continue receiving narcotic (substances affecting mood or behavior) medication despite of having an adverse consequences of high dose narcotic use. Findings: On March 11, 2019, at 11 a.m., Resident 403 was interviewed. Resident 403 stated she in a motor vehicle accident and had fractured her right ankle. She stated she had been undergoing physical therapy, however; her blood pressure (BP-force that heart exerts to circulate the blood around the body) drops whenever she attempts to stand. Resident 403 stated her usual systolic blood pressure readings were 115 to 120 mm/Hg (millimeters mercury- pressure measurement unit). She stated she had no medical history that would cause her BP to be lower that her normal. She stated her continuously low blood pressure reading was holding her back from doing physical therapy. On March 13, 2019, at 11:06 a.m., a concurrent interview and record review was conducted with Registered Nurse Supervisor (RNS) 1. RNS1 verified the following: a. Resident 403 came in with Oxycodone HCl (hydrochloride) orders, and would ask the medication frequently; b. On March 4, 2019, RNS1 spoke with the resident's physician and obtained an order for routine OxyContin ER (extended release), and the physician was aware that the resident already had two existing Oxycodone HCl order on an as needed (PRN) basis. c. Resident 403's blood pressure readings, as reported by Occupational Therapy (OT) and Physical Therapy (PT) to nursing, were below FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 26 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 normal range. Resident 403's record was reviewed. The resident was admitted on March 2, 2019, with diagnoses that included fracture (a break in bone or cartilage) of lower leg. Review of Physician orders dated March 2, 2019, indicated the following: a. "OXYCODONE HCI IR (immediate release) 10 MG (milligrams) PO (by mouth) I TABLET every 04 hours as needed for SEVERE PAIN,"; b. "Oxycodone HCl Capsule 5 MG Give 1 tablet by mouth every 4 hours as needed for Moderate pain."; and c. "OxyContin Tablet ER 12 Hour AbuseDeterrent 20 MG (Oxycodone HCl ER) Give 20 mg by mouth every 12 hours for Severe Pain. " According to Lexi comp (a CMS approved pharmaceutical resource), Oxycodone hydrochloride tablets are indicated for the management of pain severe enough to require an opioid (substances that produce morphinelike effects) analgesic (pain reliever) and for which alternative treatments are inadequate. According to the manufacturer's medication package insert, OxyContin Tablets are a controlled-release oral formulation of oxycodone hydrochloride indicated for the management of moderate to severe pain when a continuous, around-the-clock analgesic is needed for an extended period of time. Review of the Medication Administration Record (MAR) indicated the following: a. On March 3, 2019: Resident received three doses of Oxycodone HCl capsule 5mg, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 27 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 Oxycodone HCl IR 10mg (total of 45 mg).; b. On March 4, 2019: Resident received two doses of Oxycodone HCl capsule 5mg, one dose of Oxycodone HCl IR 10mg, and one dose of OxyContin Tablet ER 20mg (total of 40 mg).; c. On March 5, 2019: Resident received two doses of Oxycodone HCl IR 10mg, and two doses of OxyContin Tablet ER 20mg (total of 60 mg).; d. On March 6, 2019: Resident received one dose of Oxycodone HCl capsule 5mg, one dose of Oxycodone HCl IR 10mg, and two doses of OxyContin Tablet ER 20mg (total of 55mg).; e. On March 7, 2019: Resident received one dose of Oxycodone HCl capsule 5mg, one dose of Oxycodone HCL IR 10mg, and two doses of OxyContin Tablet ER 20mg (total of 55mg).; f. On March 8, 2019: Resident received one dose of Oxycodone HCl capsule 5mg, and two doses of OxyContin Tablet ER 20mg (total of 45mg).; g. On March 9, 2019: Resident received one dose of Oxycodone HCl capsule 5mg, and two doses of OxyContin Tablet ER 20mg (total of 45mg); and h. On March 10, 2019: Resident received one dose of Oxycodone HCl IR 10mg, and two doses of OxyContin Tablet ER 20mg (total of 50 mg). Review of OT (Occupational Therapy)/PT (Physical Therapy) Notes, indicated the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 28 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 OT Notes: a. "3/5/2019 ... has to be put back to bed due to c/o (complaint of) dizziness..."; b. "3/6/2019 ...started to c/o dizziness ...Toileting: ...unable to use BSC (bedside commode) yet at this time due to increasing c/o pain when out of bed and increase dizziness when up..."; c. "3/7/2019 ...pt. (patient) c/o of increasing dizziness, BP dropped to 82/56 with HR (heart rate) of 112...nsg (nursing) made aware ...Toileting...unable to use BSC yet at this time due to increasing c/o pain when out of bed and increase dizziness when up..."; d. "3/8/2019: ...BP initially 120/70 in bed but dropped to 90/65...nsg made aware...Toileting: ...unable to use BSC yet at this time due to increasing c/o pain when out of bed and increase dizziness when up..."; and e. "3/11/2019: Toileting...increasing c/o dizziness when up..." PT Notes: a. "3/6/2019...Returned BTB (back to bed) secondary to c/o dizziness BP 95/62. NSG (nursing) notified."; b. "3/7/2019: ...not able to tolerate sitting on w/c (wheelchair) due to c/o dizziness... BP 82/56mmhg, HR 112bpm ..."; c. "3/11/2019: ...C/o dizziness after gait training...HR 71bpm, BP 119/68mmhg dropped to 95/52mmhg. Nursing aware..."; and d. "3/12/2019: ...C/o light headedness after gait FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 29 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 training... HR 65bpm, BP 102/65mmhg dropped to 98/54mmhg. Nursing notified..." During a phone interview on March 13, 2019, at 3:50 p.m. with the Medical Director (MD), the MD stated he continued medication orders for patient from the acute hospital, including PRN pain medications. The MD verified he was notified by RNS1 about Resident 403's complaints of pain despite the Oxycodone PRN orders, but not the continuously low blood pressure readings. The MD further stated that the goal was to keep the resident pain free in order to do rehabilitation therapy. The resident should not have more than required to produce adverse effects. The MD stated that monitoring for adverse consequences is within the scope of nursing practice. He agreed that hold parameters can also originate from him as a prescriber, and if needed, he would have written it as part of the orders. According to Lexi comp, the Oxycodone medication has a Warnings/Precautions heading which included concerns related to adverse effects and included: "...Hypotension (low blood pressure) ...including orthostatic hypotension (blood pressure falls when suddenly standing up from a lying or sitting position, or a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position) and syncope (dizziness)... Monitor for hypotension following initiation or dose titration..."

F758 SS=G Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 04/14/2019 Facility ID: CA240000016 If continuation sheet 30 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 31 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to, for two of five residents (Resident 47 and 253) : 1. Ensure Resident 47 was free from use of multiple unnecessary psychotropic ( medication capable of affecting the mind, emotions, and behavior) medications, when: a. Geodon, Haldol, and Seroquel, all antipsychotic medications, were being used to treat the same behavior of psychosis (mental disorder) for Resident 47; and b. Seroquel, an antipsychotic medication, was increased in dose without a documented rationale for necessity. These failures resulted in Resident 47's being oversedated while on multiple pyschotropic medications. 2. Ensure Resident 253 was appropriately assessed on admission for adequate indication on Depakote (an antiseizure medication) use. This failure resulted in the lack of monitoring for the effectiveness of Depakote. Furthermore this failure had the potential to result in behavior worsening without being detected and/or treated for Resident 253. Findings: 1. On March 11 to 14, 2019, Resident 47 was observed: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 32 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 March 11, 2019, at 9:25 a.m. - The resident was sleeping on the couch in the activity room, during activities; *On March 11, 2019, at 11:16 a.m. - The resident was sleeping on the couch in the activity room, during activities; and *On March 12, 2019, at 1:34 p.m. - The resident was sleeping and slumped-over in her wheelchair, being wheeled around by staff. *On March 14, 2019, at 9:39 a.m. - The resident was sitting in her wheelchair at the activity room, head down with her eyes closed. On March 14, 2019, at 9:41 a.m., Resident 47's sitter (provided by hospice-care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms) was interviewed. The sitter stated she could only recall Resident 47 having one episode of psychotic behavior "aggresive with staff" since January 2019. She also stated the facility had just administered medications that made the resident "a little off (sleepy during the time of interview)." Resident 47's record was reviewed. Resident 47 was admitted to the facility under hospice care on January 4, 2019, with diagnoses that included dementia (memory loss) with behavioral disturbance, restlessness, and agitation. Review of Resident 47's medication regimen included the following: a. Geodon (an antipsychotic): Physician order: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 33 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 January 4, 2019- "Geodon capsule 20 milligrams (mg) by mouth at bedtime for anxiety manifested by (m/b) agitation, restlessness, and combative behavior." Review of Lexicomp (a nationally recognized drug reference) indicated that Geodon's drug classification is an antipsychotic, and did not include the use of Geodon as an anti-anxiety. The Medication Administration Record (MAR) indicated Resident 47 received Geodon: *For January 4 to January 31, 2019 - 28 days [26 doses given, 2 doses held]; *For February 1 to February 28, 2019 - 18 days [16 doses given, 2 doses held]; *For March 1 to 12, 2019 - 13 days [11 doses given, 2 held]. There was no documented evidence of an assessment on admission providing an explanation and/or history for the use of Geodon. b. Seroquel (an antipsychotic): Physician orders: *On January 7, 2019 - " Seroquel 25 mg by mouth twice daily for hallucinations (false sensory experiences)"; *On January 17, 2019 - Seroquel was increased to 50 mg twice daily; and *On January 29, 2019 - Seroquel was increased to 50 mg three times daily. The Medication Administration Record (MAR) indicated Resident 47 received Seroquel: *For January 7 to January 31, 2019 - 22 days [50 doses given, 1 dose held]; *For February 1 to February 28, 2019 - 28 days FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 34 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 [79 doses given, 5 doses held];and *For March 1 to March 13, 2019 - 13 days [35 doses given, 4 doses held]. There was no documented evidence indicating the necessity of starting Seroquel and subsequently increasing the dosage. c. "ABHR cream" - [Ativan (an anti-anxiety), Benadryl (antihistamine - used for itching/allergy), Haldol (an antipsychotic), Reglan (used for stomach reflux); all four medications compounded (mixed) together as one medication]: Physician order: *On January 21, 2019 - Apply 1 milliliter (ml) to inner wrist every four hours for anxiety (m/b) fidgeting. The Medication Administration Record (MAR) indicated Resident 47 received ABHR: *For January 21 to January 31, 2019 - 10 days [64 doses given, 15 held]; *For February 1 to February 28, 2019 - 28 days [160 doses given, 8 held]; and *For March 1 to March 14, 2019 - 14 days [65 doses given, 12 dosed held]. There was no documented evidence indicating the necessity of starting the ABHR cream. d. Haldol (an antipsychotic): Physician order: *On January 28, 2019 - Inject 1 mg intramuscularly (IM-directly into the muscle) every 12 hours for schizoaffective disorder (psychotic diagnosis) m/b (manifested by) mood swings, agitation striking out, hitting, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 35 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 yelling, and incoherent speech. The Medication Administration Record (MAR) indicated the resident received Haldol: *For January 28 to January 31, 2019 - 4 days [7 doses given, 2 doses held]; *For February 1 to February 28, 2019 - 28 days [42 doses given, 14 held]; and *For March 1 to March 12, 2019 - 12 days [16 doses given, 7 held] . There was no documented evidence indicating the necessity of starting Haldol and subsequently increasing the dosage. Review of Resident 47's Progress notes indicated the following: - On February 4, 2019 at 9 a.m, Haldol 1 mg was coded 9 (Other/ See Progress Notes). The Progress Notes Order - Administration Note indicated "hold to prevent over sedation..." - On February 12, 2019 at 9 a.m., Haldol 1 mg was coded 9. The Progress Notes Order Administration Note indicated "resident is in deep sleep at this time. medication held to prevent oversedastion (sic)..." - On February 20, 2019 at 9 a.m., Haldol 1 mg was coded 9. The Progress Notes Order Administration Note indicated "resident is in deep sleep at this time. medication held to prevent oversedation..." - On March 11, 2019 at 9 a.m., Haldol 1 mg was coded 9. The Progress Notes Order Administration Note indicated "held due to increase lethargy and to prevent oversedation" - On March 11, 2019 at 9 a.m., Seroquel 50 mg was coded 9. The Progress Notes Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 36 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 Administration Note indicated "held due to increase lethargy and to prevent oversedation" Review of the above documentations indicated Resident 47 was on Geodon, Seroquel, ABHR, and Haldol routinely, since March 11, 2019. Review of Resident 47's Psychotropic Summary Record provided by the facility, indicated the following: a. Medications: Geodon/Haldol/Seroquel; b. Diagnosis: Schizoaffective disorder (mental disorder)/psychosis (mental disorder) c. Behavioral Manifestation: mood swings, agitation. angry outburst, striking out, hitting, yelling. d. Behavior data: January 1-31, 2019- total of 11, and for February 1 to 28, 2019- total of 7. The Psychotropic summary record did not fully reflect the behavior manifestation for each medication, but rather the combination of the three medications (Geodon, Haldol/Seroquel) The facility "Medication Review Report (MRR)" for Resident 47, was reviewed and indicated: *January 15, 2019 - "Resident is currently on multiple psych meds (medications)...Caution for excess sedation, lethargy, drowsiness, respiratory depression and fall...Seroquel and Geodon: Recommend...a psychiatry consult to evaluate for possible duplicate therapy, evaluate for behaviors...Geodon for anxiety M/B agitation, restlessness: Not acceptable DX (diagnosis) behaviors. This order may possibly be an unacceptable med..." *February 27, 2019 - "This resident is currently FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 37 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 receiving the following antipsychotic meds (medications): Haldol IM, Geodon, and Seroquel...there is a concern of increased side effects with 2 or more antipsychotic agents being used for the same condition...may I suggest the following changes: A gradual reduction of one and eventually DC (discontinue) if clinically indicated and psychiatry consult to evaluate?..." There was no documented evidence the facility acted upon these recommendations provided by the facility's Pharmacy Consultant. On March 14, 2019, at 11:33 a.m., the "Consultant Pharmacist's Medication Regimen Review (MRR)" for Resident 47 dated February 27, 2019, was reviewed with Registered Nurse Supervisor (RNS) 1. The MRR indicated, "This resident is currently receiving the following antipsychotic meds (medications): Haldol IM, Geodon and Seroquel...there is the concern of increased side effects with 2 or more antipsychotic agents being used for the same condition...a gradual reduction of one and eventually DC (discontinue) if clinically indicated and psychiatry consult to evaluate..." There was no documented evidence in Resident 47's record indicating the MRR dated February 27, 2019, was addressed. In a concurrent interview with RNS 1, RNS 1 stated he is currently working on the February recommendations and the MRR was not done. On March 14, 2019, at 3:20 p.m., Resident 47's record was reviewed with the Director of Nursing (DON). The DON was not able to provide justification for the use of multiple psychotropic medications (Geodon, Haldol, ABHR, and Seroquel), specifically having multiple antipsychotic medications. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 38 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 there should have been an assessment justifying the need for the medications. The DON stated there should also be documented evidence of non-pharmacological interventions being provided and that had failed prior to initiating psychotropic medications while Resident 47 was already in the facility. According to a CMS (Centers for Medicare and Medicaid) document titled, "Atypical Antipsychotic Medications: Use in Adults,"(August 2013), it indicated, "...atypical antipsychotics have been associated with increased mortality when used to treat behavioral disorders in elderly patients with dementia...quetiapine (Seroquel...) in elderly demented patients with behavioral disorders...None of the atypical antipsychotic medications are FDA (Food and Drug Authority) approved for this indication..." According to Lexicomp, a nationally recognized drug reference, haloperidol (generic name for Haldol) had the following US (United States) boxed warning: "Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients...Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 39 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis." Seroquel contains the following US Boxed Warning: "Increased Mortality in Elderly Patients with Dementia-Related Psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death...SEROQUEL is not approved for the treatment of patients with dementia-related psychosis..." According to "Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition," Copyright 2010, by American Psychiatric Association (APA): "... Antipsychotics ...The absence of evidence for combinations of antipsychotics does not mean that there are no patients who are best treated with such a combination. However, their use should be justified by strong documentation that the patient is not equally benefited by monotherapy with either component of the combination. Practitioners should be aware of the problems inherent in combination therapies, including increased side effects and drug interactions as well as increased costs and decreased adherence..." According to "The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition," Copyright 2016, by APA: "...More detailed consideration and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 40 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 documentation of the risks and benefits of treatment options may also be needed in the following circumstances: when the planned treatment is a relatively costly, nonstandard treatment approach (e.g., multiple antipsychotic medications, "off-label" use of a medication)..." 2. On March 13, 2019 Resident 253's records were reviewed. Resident 253 was admitted on March 6, 2019. The acute hospital history and physical dated February 27, 2019 was reviewed. The record indicated Depakote was used for Resident 253's bipolar disorder (mental illness) The admitting physician order dated March 6, 2019 included: "...Depakote ER Tablet Extended Release...Give 1500 mg (milligrams) orally at bedtime for SEIZURE..." On March 13, 2019, at 3:31 p.m., a concurrent interview and record review was conducted with Registered Nurse Supervisor (RNS) 2. RNS 2 stated she transcribed the order for Depakote with an indication for seizure on admission. RNS 2 stated she was not aware Depakote was being used for Resident 253's bipolar disorder. RNS 2 further stated there was no documented evidence of behavior monitoring for the use of Depakote. On March 14, 2019, at 10:57 a.m., the Director Of Nursing (DON) was interviewed. The DON stated, on admission licensed nurses should check the indication of each medication prior to calling the physician to ensure all the information were accurate. The DON stated RNS 2 should have verified and confirmed the use of Depakote was for bipolar disorder. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 41 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 DON further stated, for psychotropic medications, there should be a behavior assessment prior to giving the medication. The DON stated there was no documented evidence an assessment was done on admission and prior to the use of Depakote. The facility policy titled, "ANTIPSYCHOTIC DRUG USE "dated 2013, was reviewed. The policy indicated, "...The indication for each medication used shall be documented in the physician's orders: The indication will be a specific behevior description..."

F770 SS=D Laboratory Services CFR(s): 483.50(a)(1)(i)

F770 04/14/2019 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to complete the physician order for UA (Urinalysis-urine test) with C&S (culture and sensitivity- test to find out what bacteria was causing the infection and to find out the best medication to treat it) for one of one resident (Resident 252), reviewed for laboratory services. This failure had the potential to result in a delay in providing treatment for Resident 252. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 42 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 March 11, 2019, at 12:29 p.m., Resident 252 was observed in bed, appeared sleepy and weak. Resident 252 was noted with an IV (intravenous into the vein access) on the left hand and had a urinary catheter (a hollow flexible tube inserted into the bladder to collect urine). On March 12, 2019, at 3:04 p.m., Resident 252's records were reviewed. Resident 252 was admitted to the facility on February 10, 2019, with diagnoses of muscle weakness and sepsis (blood infection). The physician order dated March 7, 2019, was reviewed. The order indicated, "...UA with C&S related to elevated temperature..." On March 12, 2019, at 3:58 p.m., Resident 252's electronic health record was reviewed with Registered Nurse Supervisor (RNS) 1. RNS 1 stated the results for the UA with C&S done on March 7, 2019, were still pending. During the interview, RNS 1 called the laboratory and he verified that there was no urine specimen collected for Resident 252. On March 14, 2019, at 10:17 a.m., the Director of Nursing (DON) was interviewed. The DON stated the licensed nurses have a 24-hour logbook to document what needs to be followed up. The DON further stated the licensed nurse upon collection of the urine specimen for Resident 252, should have documented and followed up with the results.

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

F812 04/14/2019 §483.60(i) Food safety requirements. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 43 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must §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 expired food items were not stored in the refrigerator, readily available for use. This failure could allow the use of unsafe food, which had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On March 11, 2019, at 8:40 a.m., an initial tour of the kitchen was conducted with Dietary Cook (DC) 1, and the following were observed: a. The facility refrigerator # 2 stored one prepared vanilla pudding with a labeled date of March 5, 2019; In a concurrent interview with DC 1, DC 1 verified the vanilla pudding was old. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 44 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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. The facility refrigerator # 2 stored one clear plastic jar of cranberry sauce (gelatin consistency) with a labeled date of February 16, 2019; In a concurrent interview with DC 1, DC 1 verified the cranberry sauce was expired. c. The facility refrigerator # 3 stored one plastic bag of leftover cooked ham with a labeled date of February 23, 2019; In a concurrent interview with DC 1, DC 1 verified the leftover cooked ham was expired. DC 1 further stated she should have discarded the food items after the maximum refrigeration time indicated in the "Refrigerated Storage Guide." On March 13, 2019, at 12:55 p.m., in an interview with the Dietary Supervisor (DS), the DS stated the food items are considered expired after the maximum refrigeration time provided in the "Refrigerated Storage Guide" and the dietary staff should follow the guidelines. The facility policy and procedure, titled, "Procedure for Refrigerated Storage," dated 2018, was reviewed. The policy and procedure indicated, "...All refrigerated foods are to be kept the amount of time per "Refrigerated Storage Guidelines," pages 6.13..." The facility document titled, "Refrigerated Storage Guide," page 6.13, dated 2018, indicated, "... Leftover cooked meats...Maximum Refrigeration Time 3 days...Desserts, prepared, including pudding ...Maximum Refrigeration Time 3 days...Gelatin, prepared...Maximum Refrigeration Time 5 days." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 45 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

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

F880 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/14/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 46 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed, when a syringe used to administer an oral liquid medication was not cleaned in accordance with the facility policy and procedure. This failure had the potential for the resident to be exposed to infection. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 47 of 48 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: _______________ 555319 (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNRISE POST ACUTE 3476 W Wilson St Banning, CA 92220 (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 March 12, 2019, at 3:10 p.m., during medication administration observation with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed administering liquid morphine sulfate (medication for pain) through an oral syringe. The resident (Resident 17) put the syringe in her mouth and returned it to LVN 1. LVN 1 put the syringe back in the zip lock plastic bag without being washed. On March 13, 2019, at 2:31 p.m., LVN 1 was interviewed. LVN 1 stated when giving medications with a syringe, the syringe should be rinsed with water and dried after each used. LVN 1 stated the syringe had to be changed once a week. Furthermore, LVN 1 stated this action placed the resident at risk for contamination. LVN 1 stated, "I should have washed the syringe before putting it back in the plastic bag." A review of the undated facility policy and procedure titled, "ADMINISTRATION OF LIQUID MEDICATION BY ORAL," was reviewed. The policy stated, "... Pharmacy will provide oral syringes...Rinse oral syringe thoroughly with water after each use...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QINN11 Facility ID: CA240000016 If continuation sheet 48 of 48