Other·June 21, 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 abbreviated standard survey for the investigation of one complaint. Complaint number CA00632514. Representing the California Department of Public Health: Surveyor 38478, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00632514.

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

F684 06/07/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents received 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: LO7Q11 Facility ID: CA240000148 If continuation sheet 1 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care consistent with professional standards of practice when Licensed Vocational Nurse (LVN) 1 did not administer the medications timely as ordered by the physician, for five of seven sampled residents (Residents A, B, C, D, and E), in a universe of 49 residents in the facility. This failure increased the potential for residents to not receive the intended therapeutic effect of the medications within the desired time, which could possibly affect their overall medical condition. Findings: On April 12, 2019, at 9:12 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to administration/personnel concerns regarding medication administration. A. Resident A's record was reviewed. Resident A was admitted to the facility on September 25, 2018, with diagnoses which included history of cancer of the rectum (the final section of the large intestine, terminating at the anus) with metastasis (spread and growth from primary site of cancer) to the liver. The history and physical, dated September 26, 2018, indicated Resident A had the capacity to understand and make decisions. The recapitulation of physician's orders (a process to verify on a monthly basis that all residents' physician orders are accurate and updated) for April 2019, indicated the following medications were to be administered at 9 a.m.: - "Potassium Chloride (supplement used to treat low blood levels of potassium)...10 mEq (milliequivalent) by mouth one time a day... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 2 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - Furosemide (Lasix- medication used to reduce extra fluid in the body) tablet 20 mg (milligrams)...by mouth two times a day... (ascites- accumulation of fluid, causing abdominal swelling)... - Actigall (medication used to dissolve gallstones) Capsule...300 mg by mouth two times a day... - Cymbalta (medication used to treat depression)...60 mg...by mouth one time a day for depression... - Ondansetron (medication used to treat nausea and vomiting)...8 mg...by mouth three times a day..." A physician's order, dated April 7, 2019, at 1:40 p.m., indicated, "May give now all due medications dated 4/07/2019 at 9 AM. Monitor resident for any undesirable or unintended harmful effect occurring as a result of late medication administration. Notify MD (physician) in a timely manner..." The Medication Administration Record (MAR) for Resident A indicated the above-mentioned medications were administered at 2:43 p.m. (5 hours later than the ordered administration time). B. Resident B's record was reviewed. Resident B was admitted to the facility on July 3, 2017, with diagnoses which included cerebrovascular disease (stroke), diabetes mellitus (disease associated with high blood sugar levels), epilepsy (seizure disorder), and asthma (chronic disease of the airways that makes breathing difficult). The annual history and physical, dated July 29, 2018, indicated Resident B did not have the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 3 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 recapitulation of orders for April 2019, indicated the following medications were to be administered at 7 a.m.: - "Metoprolol (medication used to treat high blood pressure)...25 mg by mouth two times a day... - Metformin (medication used to treat high blood sugar levels)...500 mg by mouth two times a day..." The MAR for Resident B indicated the abovementioned medications were administered at 2:46 p.m. (7 hours later than the ordered administration time). The recapitulation of orders for April 2019, indicated the following medications were to be administered at 9 a.m.: - "Lasix...20 mg by mouth one time a day... - Advair Diskus (medication that is breathed in through the mouth to open up the bronchial tubes [air passages] in the lungs)...100-50 mcg/dose (micrograms per dose) 1 puff inhale orally (by mouth) every 12 hours... - Keppra (medication used to treat seizure)...1500 mg by mouth two times a day... - Klor-Con (Potassium Chloride)...20 mEq...by mouth one time a day... - Amlodipine (medication used to treat high blood pressure)...5 mg by mouth one time a day... - Oxybutynin Chloride (medication used to treat overactive bladder)...10 mg by mouth..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 4 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 MAR for Resident B indicated the abovementioned medications were administered at 2:46 p.m. (5 hours later than the ordered administration time). The progress notes, dated April 7, 2019, at 1:40 p.m., indicated, "Around 1125 am (sic), (the) resident approached (Registered Nurse Supervisor [RNS]) asking for her Charge Nurse (LVN 1) because she wanted her inhaler medication..." A physician's order, dated April 7, 2019, at 1:40 p.m., indicated, "May give now all due medications dated 4/07/2019 at 9 AM. Monitor resident for any undesirable or unintended harmful effect occurring as a result of late medication administration. Notify MD in a timely manner..." C. Resident C's record was reviewed. Resident C was admitted to the facility on March 13, 2013, with diagnoses which included cerebrovascular disease with right hemiplegia (paralysis of one side of the body), major depression, and anxiety disorder. The annual history and physical, dated August 24, 2018, indicated Resident C did not have the capacity to understand and make decisions. The recapitulation of orders for April 2019, indicated the following medication was to be administered at 7 a.m.: - "Potassium Chloride...20 mEq...by mouth two times a day..." The MAR for Resident C indicated the Potassium medication was administered at 2:50 p.m. (7 hours later than the ordered administration time). The recapitulation of orders for April 2019, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 5 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated the following medications were to be administered at 9 a.m.: - "Lexapro (medication used to treat depression)...20 mg...by mouth one time a day... - Klonopin (medication used to treat anxiety)...0.5 mg by mouth every morning and at bedtime... - Lovaza (medication used to treat high cholesterol levels) 1 gm (gram)...2 capsules by mouth two times a day... - Lantus (long-acting insulin) 100 unit/ml...Inject 10 unit(s) subcutaneously (layer of tissue just beneath the skin) in the morning... - Spironolactone (medication used to treat high blood pressure and fluid retention) 25 mg...by mouth one time a day..." A physician's order, dated April 7, 2019, at 1:40 p.m., indicated, "May give now all due medications dated 4/07/2019 at 9 AM. Monitor resident for any undesirable or unintended harmful effect occurring as a result of late medication administration. Notify MD in a timely manner..." The MAR for Resident C indicated the abovementioned medications were administered at 2:50 p.m. (5 hours later than the ordered administration time). The recapitulation of orders for April 2019, indicated the following medication was to be administered at 11:30 a.m.: - "Insulin Regular...inject as per sliding scale (set of instructions for administering insulin dosages based on specific blood glucose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 6 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE readings): if (blood sugar is) 151-200= 2 (unitsu); 201-250= 4 (u); 251-300= 6 (u); 301-350= 8 (u); 351-400= 10 (u)...before meals..." The MAR for Resident C indicated the insulin order was completed at 2:51 p.m. (3 hours later than the ordered administration time). The recapitulation of orders for April 2019, indicated the following medication was to be administered at 12:00 p.m.: - Norco tablet (pain medication) 10/325 mg...by mouth every 6 hours..." The MAR for Resident C indicated the Norco was administered at 2:51 p.m. (2 hours later than the ordered administration time). D. Resident D's record was reviewed. Resident D was admitted to the facility on December 21, 2016, with diagnoses which included heart failure, high blood pressure, and diabetes mellitus. The history and physical, dated December 12, 2018, indicated the resident had the capacity to understand and make decisions. The recapitulation of orders for April 2019, indicated the following medications were to be administered at 9 a.m.: - "Amlodipine...5 mg by mouth one time a day... - Isosorbide Mononitrate (medication used to treat heart failure)...30 mg...by mouth one time a day... - Lasix tablet 40 mg...by mouth one time a day... - Plavix (blood thinner)...75 mg...by mouth one time a day... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 7 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - MS Contin (Morphine Sulfate- pain medication)...30 mg...by mouth two times a day... - Aspirin (blood thinner)...81 mg...by mouth one time a day... - Insulin Glargine...Inject 18 unit(s) subcutaneously in the morning..." A physician's order, dated April 7, 2019, at 1:40 p.m., indicated, "May give now all due medications dated 4/07/2019 at 9 AM. Monitor resident for any undesirable or unintended harmful effect occurring as a result of late medication administration. Notify MD in a timely manner..." The MAR for Resident D indicated the abovementioned medications were administered at 2:53 p.m. (5 hours later than the ordered administration time). E. Resident E's record was reviewed. Resident E was admitted to the facility on July 10, 2017, with diagnoses which included neuralgia (intermittent pain along the course of a nerve), hypertension, diabetes mellitus, and heart failure. The history and physical, dated July 22, 2018, indicated the resident had the capacity to understand and make decisions. The recapitulation of orders for April 2019, indicated the following medication was to be administered at 7 a.m.: - "Potassium Chloride...20 mEq...by mouth two times a day..." The MAR for Resident E indicated the Potassium medication was administered at 2:50 p.m. (7 hours later than the ordered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 8 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 time). The recapitulation of orders for April 2019, indicated the following medications were to be administered at 9 a.m.: - "Lexapro tablet 20 mg...by mouth one time a day... - Klonopin tablet 0.5 mg...by mouth every morning and at bedtime... - Lovaza...1 gram...by mouth two times a day... - Lantus Solution 100 unit/ml...inject 10 unit(s) subcutaneously in the morning... - Spironolactone tablet 25 mg...by mouth one time a day..." The recapitulation of orders for April 2019, indicated the following medications were to be administered at 11:30 a.m.: - "Novolog (insulin)...Inject as per sliding scale: ): if (blood sugar is) 151-200= 2 (units- u); 201250= 4 (u); 251-300= 6 (u); 301-350= 8 (u); 351-400= 10 (u)...before meals and at bedtime..." The progress notes, dated April 7, 2019, at 12:15 p.m., indicated, "At 1215PM (sic) when I was making my RN rounds, resident called my (RNS) attention and reported to me that she didn't got (sic) all her 9 am medications today. All routine medication and pain medications. She felt neglected and she is in pain. Resident stated her blood sugar was not checked before her lunch tray was served. Resident stated that I need(ed) to address her concerns otherwise she will find somebody to help her..." A physician's order, dated April 7, 2019, at 1:40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 9 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m., indicated, "May give now all due medications dated 4/07/2019 at 9 AM. Monitor resident for any undesirable or unintended harmful effect occurring as a result of late medication administration. Notify MD in a timely manner..." The MAR for Resident E indicated the Lexapro, Klonopin, Lovaza, and Lantus medications were administered at 2:50 p.m. (5 hours later than the ordered administration time). The MAR indicated the Spironolactone medication was administered at 2:51 p.m. The MAR indicated the blood sugar check ordered for 11:30 a.m. was completed at 2:51 p.m. with a result of 137 (milligrams per deciliter). The recapitulation of orders for April 2019, indicated the following routine pain medication was to be administered at 12:00 p.m.: - "Norco tablet 10-325 mg...1 tablet by mouth every 6 hours...chronic pain..." The MAR indicated the Norco medication was administered at 2:51 p.m. (2 hours later than the ordered administration time. On April 12, 2019, at 10:31 a.m., LVN 1 was interviewed and stated she worked as a charge nurse on April 7, 2019, during the AM shift (6:30 a.m. to 3:00 p.m.) She stated she came in late at 9 a.m. as she was feeling sick that day. She stated she called LVN 2, who worked the NOC shift (10:30 p.m. to 7 a.m.), and told him that she would come in late. LVN 1 stated she was delayed with her medication pass (the administration of prescribed drugs by licensed nurses to a group of residents). On April 17, 2019, at 8:10 a.m., the RNS was interviewed and stated she was the supervisor on duty on April 7, 2019, during the AM shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 10 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE She stated LVN 2 stayed over to do medication pass while waiting for LVN 1 to arrive in the facility. The RNS stated LVN 1 came in at 9 a.m. to continue the medication pass. She stated at "around 12 noon," Resident E complained to her that she did not receive her 9 a.m. medications. She stated multiple residents were looking for LVN 1 for their medications. She stated Resident A was looking for his charge nurse for his medications, Resident B was asking for her inhaler, and Resident C told her she did not receive her pain medication. She stated she checked the MAR and found out multiple medications were not administered on time by LVN 1. She stated LVN 1 went to lunch at 11:15 a.m. and found out she returned from lunch after more than an hour. She stated she asked LVN 1 where she had been, and LVN 1 responded that she took her lunch and remained quiet. The RNS stated LVN 1 didn't tell her that she was sick that day. The RNS stated she called the physicians and reported the late administration of medications and informed the responsible party of the incident. On April 19, 2019, at 5:13 p.m., LVN 2 was interviewed and stated he received a call from LVN 1 on April 7, 2017, at 7 a.m., that she was "running behind." LVN 2 stated he started the medication pass and waited until LVN 1 came to the facility. He stated LVN 1 continued the medication pass when she came in the facility at 9 a.m. LVN 2 stated he was "halfway" with the 9 a.m. medications when LVN 1 arrived and endorsed the residents for continuity of care. On April 23, 2019, at 10:22 a.m., the Director of Nursing was interviewed regarding the incident on April 7, 2019. She confirmed the late administration of medications for Residents A, B, C, D, and E. When asked about the facility's policy, she stated the medications should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 11 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administered within one hour before and after the ordered scheduled time. The facility's policy and procedure titled, "Medication Administration," dated January 2011, indicated, "Administration Process...Medications are administered in accordance with the written orders of the attending physician...Medications are to be administered within one (1) hour before or one (1) hour after the prescribed time..." According to the "Foundations and Adult Health Nursing, Seventh Edition," authored by Cooper and Gosnell, Copyright 2015, it indicated: "SIX 'RIGHTS' OF MEDICATION ADMINISTRATION ...The nurse must use each step of the nursing process when carrying out responsibilities pertaining to medication administration. Medications are administered in a variety of ways. Regardless of the route by which a drug enters the body, the same practices and principles of medication administration apply. ...The nurse is responsible for administering the medications at the right time. Many health care facilities use a standardized schedule for medication administration. The nurse should refer to the facility's policy regarding the timing of medications that are given routinely...Some long-term care facilities allow administration as long as 60 minutes before or 60 minutes after the scheduled time..."

F835 SS=D Administration CFR(s): 483.70

F835 06/07/2019 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 12 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility administration failed to ensure LVN 1, who was placed on probationary status by the California Board of Vocational Nursing & Psychiatric Technicians (BVNPT), received direct on-site supervision from a registered nurse, as required by the BVNPT probation unit. A previous deficiency citation was issued to the facility on §483.70(f)(1)(2) for failure to implement the probationary requirements for LVN 1 while employed at the facility. This failure resulted in the lack of supervision of LVN 1 and the lack of implementation of LVN 1's active disciplinary action, which had the potential to negatively impact resident care in the facility. Findings: On April 12, 2019, at 9:12 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to administration/personnel concerns. LVN 1's employee file was reviewed. LVN 1's Vocational Nursing (VN) license indicated: - Primary status: Current; - Secondary status: Probation; - Disciplinary actions: Start: April 13, 2018; - Action: Revocation of the license is stayed pending successful completion of probation. The "Stipulated Settlement and Disciplinary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 13 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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," dated March 12, 2018, adopted by the BVNPT, Department of Consumer Affairs, for LVN 1, indicated: "...It is hereby ordered that Vocational Nurse License...issued to Respondent (LVN 1) is revoked. However, the revocation is stayed and Respondent is placed on probation for five (5) years on the following terms and conditions...Respondent shall obey all federal, state and local laws at all times, including all statutes and regulations governing the license...Respondent shall fully comply with the conditions of probation established by the Board and shall cooperate with representatives of the Board in its monitoring and investigation of the Respondent's compliance with the Probation Program...Before commencing or continuing employment in any health care profession, Respondent shall obtain approval from the Board of the supervision provided to the Respondent while employed...Respondent shall not function as a charge nurse...during the period of probation except as approved, in writing, by the Board..." In a previous interview with the Probation Officer (PO) on February 4, 2019, at 2:10 p.m., the PO confirmed LVN 1's vocational nursing license was placed on probation by the BVNPT. She stated LVN 1 "can function as a charge nurse" during the period of probation but that a Registered Nurse (RN) should always be present "on-site" with her. She stated the BVNPT approved LVN 1's probationary status based upon a signed employment authorization and consent form with the attached job description that indicated her job title as an LVN. The facility's Nursing Staffing Assignment and Timesheets for March and April 2019 were reviewed and indicated LVN 1 worked as a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 14 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE licensed vocational nurse without direct on-site supervision from a registered nurse on the following dates and times: - March 31, 2019, from 6:53 a.m. to 1:04 p.m.; and - April 6, 2019, from 4:15 p.m. to 6:36 p.m. On April 18, 2019, at 11:06 a.m., LVN 1's Timesheet Details for March and April 2019 were reviewed with the Administrator (ADM). The ADM confirmed LVN 1 did not receive onsite supervision on March 31, 2019, from 6:53 a.m. to 1:04 p.m., and on April 6, 2019, from 4:15 p.m. to 6:36 p.m. The ADM confirmed he was aware of the supervision requirements for LVN 1 by a registered nurse as the facility was previously cited on §483.70(f)(1)(2) for failure to implement LVN 1's probationary requirements. When asked about the scheduling of the licensed nurses (LVNs and RNs), the ADM stated the Director of Nursing (DON) was responsible for making the schedule of the licensed nurses. On April 23, 2019, at 10:22 a.m., the DON was interviewed regarding LVN 1. She stated she was aware of LVN 1's probationary status and conducted the quarterly evaluation for LVN 1, which was submitted to the BVNPT. She confirmed the facility's failure to provide on-site RN supervision for LVN 1 on the abovementioned dates. It was discussed during the exit conference for complaint intake number CA00622201, on February 25, 2019, regarding the deficient finding on the lack of onsite RN supervision for LVN 1. The DON acknowledged the administration's failure to implement the facility's previous plan of correction, electronically signed and dated March 11, 2019, with a completion date of March 18, 2019, for a deficiency written at §483.70(f)(1) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 15 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555492 (X3) DATE SURVEY COMPLETED 05/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2), in ensuring the proper implementation of the probationary requirements and active disciplinary action for LVN 1 while employed at the facility. The State of California BVNPT's "Disciplinary Guidelines," dated June 2007, indicated, "...protection of the public shall be the highest priority for the Board of Vocational Nursing and Psychiatric Technicians...in exercising its licensing, regulatory, and disciplinary functions. Whenever the protection of the public is inconsistent with other interests sought to be promoted, the protection of the public shall be paramount. To facilitate uniformity of disciplinary orders and to ensure that its disciplinary policies are known, the Board adopted these Disciplinary Guidelines. The guidelines are intended for use by individuals involved in disciplinary proceedings against vocational nurse and psychiatric technician licensees or applicants..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LO7Q11 Facility ID: CA240000148 If continuation sheet 16 of 16