Health inspection·October 4, 2024

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to ensure that Significant Change of Status Assessments (SCSA- required when a resident's condition has significantly changed, either improving or declining, and the change is expected to last longer than two weeks) of the Minimum Data Set (MDS- federally mandated assessment tool) were completed within 14 days for one of three residents reviewed for pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)(Resident 39) when Resident 39 had a significant decline in her condition due to severe weight loss and changes in the stage (a system used to classify severity) of her pressure ulcers. Residents Affected - Few This failure resulted in Resident 39's care plan not being updated and revised to reflect her current status, which had the potential to delay the implementation of her care and support needs. Findings: During a review of Resident 39's admission Record (a document that contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses which included protein calorie malnutrition (condition caused by not getting enough protein and calories in the diet, which can lead to weight loss, muscle wasting, and a weakened immune system) and unstageable (wound that we can't see how deep the sore is because it is covered with dead skin or other material) pressure ulcer of sacral (tailbone) region. During a concurrent interview and record review with the Director of Nursing (DON) and Administrator (Admin), on October 4, 2024, at 3:21 PM, the DON and the Admin reviewed Resident 39's clinical record which indicated Resident 39's weight were as follows: July 2, 2024, weight : 133 pounds; August 2, 2024, weight : 125 pounds; September 4, 2024, weight : 116 pounds. The DON and the Admin acknowledged that Resident 39 had a severe weight loss from July 2024 to September 2024 with a total of 17 pounds weight loss which was 12.8% in 3 months period. (7.5 % in three months is the suggested parameter for evaluating significance of unplanned and undesired weight loss.) During further interview and record review with the DON and the Admin, on October 4, 2024, at 3:30 PM, the DON and the Admin reviewed Resident 39's Skin Progress Report, dated July 2, 2024, which indicated . Date first observed 07/02/2024 [July 2, 2024] . site coccyx [tailbone] . length. 2.1. Width 1.2. Stage. Suspected deep tissue injury [is a type of wound happen from pressure on the skin usually looks like a purple or dark red spot, skin not open/break] . weekly progress report date 08/13/2024 [August 13, 2024]. Current stage. UTD [Unstageable] . Wound measurement (cm [unit in measurement centimeter]) 5.4 [length] x 8.5 [width] . The DON and the Admin acknowledged Resident 39's pressure ulcer was bigger in size and worsening in stage. Page 1 of 7 555089 555089 10/04/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0637 Level of Harm - Minimal harm or potential for actual harm During a follow up interview with the DON and the Admin, on October 4, 2024, at 3:40 PM, Resident 39's admission MDS assessment dated [DATE], and Quarterly MDS assessment dated [DATE], were reviewed. The DON stated that instead of Resident 39's Quarterly Assessment, the assessment completed should be SCSA MDS. The DOn further stated We missed it. (After a significant decline in Resident 39's status, of significant weight loss and pressure ulcers, a SCSA was not completed after 14 days) Residents Affected - Few During a concurrent interview and record review with the DON and the Admin, on October 4, 2024, at 3:50 PM, the DON and the Admin reviewed the facility's policy and procedure (P&P) titled Weight Assessment and Intervention, revised March 2022, which indicated .the threshold for significant unplanned and undesirable weight loss will be based on following criteria [where percentage of body weight loss =(usual weight-actual weight)/(usual weight) x 100]: a. 1-month 5% weight loss is significant; greater than 5% is severe. b. 3-month 7.5% weight loss is significant; greater than 7.5% is severe. c. 6-month 10% weight loss is significant; greater than 10% is severe . A review of the facility policy and procedure titled Change in Resident's Condition or Status, revised March 2023, indicated .2. A significant assessment is major decline or improvement in resident status that will: a. Will not normally resolve itself without intervention . b. impact more than one area . c. requires interdisciplinary review and/or revision of the care plan .9. If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [is a federal law that establishes regulations for nursing facilities] regulation governing resident assessment and as MDS RAI [Resident Assessment Instrument. It's a tool used in nursing homes to assess residents' health and needs] instruction manual . A review of the RAI manual, revised October 2023, indicated . The SCSA is a comprehensive assessment for a resident . It can be performed at any time after the completion of an admission assessment .The MDS is the last day of this observation period] (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met 555089 Page 2 of 7 555089 10/04/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of eight residents reviewed for Range of Motion (ROM- full movement potential of a joint) (Resident 39) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM when Resident 39's Restorative Nursing Assistant (RNA- help residents improve and maintain their physical abilities and ADLs, and prevent further decline) orders were not carried out in a timely manner. This failure could have potentially caused a delay of preventing severe contractures (a medical condition characterized by the shortening and hardening of muscles, tendons, or connective tissues, which can lead to stiffness and restricted movement in joints) of all extremities. Findings: During a review of Resident 39's admission Record (a document that contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). A review of Resident 39's physician's orders, dated August 7, 2024, indicated, RNA (Restorative Nursing Assistant) for AAROM (Active Assistive Range of Motion) exercise, left (L) LE (lower extremity), 3x/week as tolerated. RNA for exercise, Right LE 3x/week as tolerated. Physician's orders, dated September 19, 2024, indicated, RNA to perform L UE (upper extremity) AAROM exercise 5x/week or as tolerated. RNA to perform R UE AAROM exercises 5x/week or as tolerated. RNA to apply rolled hand towel to R hand 5x/week or as tolerated, RNA to apply rolled hand towel to L hand 5x/week or as tolerated. (This RNA order was rewritten on September 30, 2024.) During a review of Resident 39's RNA progress notes for the months of August 2024, it indicated Resident 39 started receiving her AAROM exercises on August 14, 2024. (One week after the order was written.) During a concurrent interview and record review with RNA Supervisor and the Director of Nursing (DON), on October 4, 2024, at 3:30 PM, Resident 39's RNA orders and RNA weekly progress notes for the month of August 2024 were reviewed. RNA Supervisor and DON acknowledged that the RNA orders were not carried out timely. During a concurrent interview and record review with RNA Supervisor and the DON, on October 4, 2024, at 3:45 PM, RNA Supervisor and the DON reviewed the facility's policy and procedure, (P&P), titled, Physician Orders and Telephone Orders, dated, January 2004, indicated: .GUIDELINES: 1. A resident shall be admitted or accepted for care on the order of a physician. The admission order is to begin with Admit to and include, but not limited to, the following orders: a. Diet, . c. Treatment (specific treatment, frequency, site), d. Activity limitation. 7. Computer generated physician's order shall be reviewed by a qualified person, preferable by a licensed Nurse, prior to placement of these orders into the resident's health record. RNA Supervisor and the DON acknowledged the policy and stated Resident 39's RNA orders were not carried out timely and was started in a delay. 555089 Page 3 of 7 555089 10/04/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with prescriber's orders and facility policy for one resident reviewed for use of antibiotic (medication used to treat bacterial infections) (Resident 39). This failure had the potential to make the antibiotic less effective and prolong the course of treatment, placing Resident 39's health at risk. Findings: During a review of Resident 39's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 39 was admitted to the facility on [DATE], with the diagnoses of protein-calorie malnutrition, (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). During a review of Resident 39's physician order, dated August 21, 2024, it indicated, Ertapenem Sodium (Ertapenem Sodium-antibiotic used to treat bacterial infections) Injection Solution Reconstituted 1 GM (gram- unit of measurement) Inject 1 gram intramuscularly (IM- a method of delivering medication directly into a muscle) in the evening for infection/UTI (urinary tract infection- infection that can occur in any part of the urinary system) for 10 days. During a review of Resident 39's Medication Administration Record (MAR) for the month of August 2024, it indicated Resident 39 received the first dose of Ertapenem Sodium on August 21, 2024. Further review indicated on August 22, 2024, Resident 39 was not administered the prescribed antibiotic. During a review of Resident 39's nursing progress notes, dated August 22, 2024, for 17:00 PM dose, documented by LVN 2, it indicated, Ertapenem Sodium Injection Solution Reconstituted 1 Waiting delivery from pharmacy. During a concurrent interview and review of Resident 39's clinical records, with a Registered Nurse (RN 1), on October 4, 2024, at 4:48 PM, RN 1 acknowledged that Resident 39 was not administered Ertapenem Sodium on August 22, 2024. RN 1 stated the medication was available in the Emergency Kit (Ekitdesigned to support both staff and residents, ensuring continuity of care and safety during emergencies.) and LVN 2 should called the pharmacy to inform them that she was getting another dose in the Ekit because the antibiotic still has not arrived. During a concurrent interview and record review with RN 1, on October 4, 2024, at 5:06 PM, RN 1 reviewed the facility's policy and procedure (P&P), titled, Administering Medications, revised April 2019, which indicated Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation - .4. Medications are administered in accordance with prescriber orders, including any required time frame. RN 1 stated the policy was not followed. 555089 Page 4 of 7 555089 10/04/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six residents reviewed for nutrition (Resident 39) received a diet prescribed by their physician in a timely manner. This failure had the potential to place Resident 39 at risk for further nutrition and medical decline. Findings: During a review of Resident 39's admission Record (contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). During a review of Resident 39's Outpatient Clinic Prescription from her Primary Care Physician, dated August 8, 2024, it indicated Please d/c [discontinue] current diet and follow recommendations per Barium test result. Small quarter size chopped soft diet w/ [with] thin liquids by teaspoon or small open cup sips . A review of Resident 39's physician orders were reviewed from August 8, 2024 through August 25, 2024, there was no documented evidence to indicate the diet order from Resident 39' s PCP was written and carried out by the facility. During a review of Resident 39's physician order, dated August 26, 2024, it indicated Resident 39 had an order to have a regular diet, mechanical soft texture, thin consistency, small bites and sips, 1:1 supervision, sips need to be slow. This order was carried out 18 days after original diet order was received. During a concurrent interview and record review, on October 4, 2024, at 2:00 PM, with the Director of Nursing (DON), the DON reviewed Resident 39's Outpatient Clinic Prescription, dated August 8, 2024, and Resident 39's current diet order, dated August 26, 2024 and stated the diet order was not carried out timely. During a review of the facility's policy and procedure titled Physician Orders and Telephone Orders, dated January 2004, it indicated . 3. All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Each order shall include the diagnosis/condition to support the order. During a review of a facility document titled Job Description - Registered Nurse (RN), dated January 27, 2022, it indicated, The Registered Nurse is responsible for assuring physician's orders are followed and quality care is provided on each shift in a skilled care facility . Makes actual patient rounds, assessing and observing the following at least three times per day .Hydration/nutritional status/feeding program. 555089 Page 5 of 7 555089 10/04/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety, when: Residents Affected - Some 1. On October 1, 2024, two unopened one-pound bags of mini marshmallows, with an expiration date of August 8, 2024, were found stored on top of a shelf in the dry storage room and was available for use. 2. On October 1, 2024, one 4 oz (ounce- a unit for measuring liquid) cup of apple juice and one 4 oz cup of cranberry juice, with the date September 29, 2024, were found on Resident 51's bedside table and were available for consumption. These failures have the potential to compromise food safety and increase the risk of foodborne illness (caused by the ingestion of contaminated food or beverages) for 84 vulnerable residents receiving food from the facility's kitchen. Findings: 1. During a concurrent observation and interview on October 1, 2024, at 8:19 AM, with the Dietary Supervisor (DSS), in the kitchen, the dry storage room was inspected. Two unopened one-pound bags of mini marshmallows, with an expiration date of August 8, 2024, were found stored on top of a shelf. (54 days expired.) The DSS acknowledged that two bags of mini marshmallows were outdated and stated those bags should be removed. During a concurrent interview and record review on October 3, 2024, at 3:38 PM, the DSS reviewed the facility's undated Policy and Procedure (P&P) titled Storage of Canned and Dry Goods which indicated, .No food item that is expired or beyond the best buy date are in stock. The DSS acknowledged that the policy was not followed. 2. During a concurrent observation and interview on October 1, 2024, at 10:26 AM, with License Vocational Nurse (LVN 1), in Resident 51's room, there were two cups of fruit juices (one apple and one cranberry) on top of Resident 51's bedside table. Both cups were labeled with the date 9/29/24 [September 29, 2024]. LVN 1 acknowledged that the juices were two days old. LVN 1 further stated that the cups were from the meal tray and should not have been left overnight. During an interview, on October 3, 2024, at 10:50 AM, with the Administrator (Admin), the Admin stated the practice for passing the tray was to come back to check if the resident consumed the food and pick up after each meal. The Admin further stated the two fruit juices found on Resident 51's room should have not been left at the bed side overnight. During a concurrent interview and record review, on October 3, 2024, at 11:00 AM, with the Admin, the facility's P&P titled Assistance with Meals revised March 2022, was reviewed. The P&P indicated, .Resident confined to bed: . 4. Nursing services . will pick up resident's food trays after each meal .All residents: . 2. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41°F to 135ºF) will be kept to a minimum. Foods that are left on trays without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded . The Admin stated the facility did not follow the policy. 555089 Page 6 of 7 555089 10/04/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control prevention were implemented among a highly vulnerable population of 86 residents, when an oxygen tubing (thin plastic tube that connects a machine, which makes extra oxygen to a person's nose) and related oxygen supplies were not replaced in accordance with the facility's policy and procedure for one of five residents reviewed for oxygen (Resident 34). Residents Affected - Few This failure has the potential to cause and increased risk of infection to Resident 34 due to prolonged use of respiratory equipment without proper replacement. Findings: During a record review of Resident 34's admission Record (contains demographic and medical information), it indicated Resident 34 was admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (like a stroke, where the blood flow to part of the brain is block), dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function,), and dysphagia (difficulty of swallowing). During a review of Resident 34's Physician Orders, dated October 4, 2024, it indicated Oxygen related supplies, including the humidifier (a small device that adds moisture to the oxygen coming from a machine that helps people breath) were to be changed every night shift every Sun [Sunday.] During an observation on October 1, 2024, at 3:48 PM, in Resident 34's room, Resident 34 was lying in the bed, resting. On the right side of Resident 34's bed, there was an oxygen concentrator (machine that helps people who have trouble breathing), which had a set up bag attached to it. The set-up bag, which contained oxygen tubing and other respiratory supplies, was inspected. The oxygen tubing and setup bag were marked with a date of January 1, 2024 (Nine months ago.) During a concurrent observation and interview on October 1, 2024, at 3:53 PM, with Registered Nurse (RN 1), in Resident 34's room, RN 1 acknowledged the findings and stated it should have been replaced weekly. RN 1 stated the night shift staff was responsible for changing and supplies every Sunday, but this was not done. During a concurrent interview and record review on October 3, 2024, at 4:44 PM, with the Administrator (Admin), the Admin reviewed the facility's undated policy and procedure (P&P) titled, Oxygen Administration, which indicted The oxygen tubing should be changed weekly and as needed, including changing the mask, cannula, nebulizer equipment, etc. When not in use, the oxygen tubing should be stored in a clean bag. The [NAME] acknowledged the policy and stated the staff failed to follow the oxygen administration policy, which mandated the weekly replacement of oxygen tubing and related supplies. 555089 Page 7 of 7