Health inspection·February 18, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 observed reaching for the call light. Resident 1 stated she felt agitated with the facility staff when they would not let her talk. Resident 1 was observed calm and answering all questions during the interview. During a record review of Resident 1 ' s, Antipsychotic medication Care Plan (CP), dated 2/18/25, the CP indicated, . admitted with antipsychotic medication related to medical diagnosis Dementia as evidenced by (AEB) psychosis . During a review of Resident 1 ' s acute care hospital, Discharge Instruction Document, dated 2/11/25, the document indicated, . New Quetiapine [Brand Name] 25 mg (unit of measure) oral tablet 0.5 tab by mouth every bedtime . next dose 2/11/25 . The document indicated there was no documented diagnosis or indication of use for this medication. During an interview on 2/18/25 at 11:43 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated Resident 1 had not exhibited any behaviors while CNA 1 provided care. CNA 1 stated she had provided care for Resident 1 on numerous occasions and was familiar with Resident 1. CNA 1 stated, Resident 1 ' s behaviors of yelling, kicking doors and accusation happened in the late afternoon and had not observed behaviors during the day. During a record review of Resident 1 ' s, Order Summary, dated 2/11/25, the order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . black box 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. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . The order summary indicated medication (Quetiapine) was initiated on 2/11/25 for indefinite time of use. During a review of Resident 1 ' s, Facility Verification of Informed Consent-Psychotropic Drug, dated 2/11/25, the form indicated, . [medication brand name] 25 mg (unit of measure) 0.5 tablet bedtime . medical symptom/target behavior to monitor dementia, verbal aggression, drug classification anti-psychotic . medication order status: newly started (started at skilled nursing facility) . indicate severe dementia upon emergency room visit . antipsychotic drugs: purpose treatment of individuals who have been diagnosed with one or more of the following: schizophrenia (disorder affecting a person ' s ability to think, feel, behave clearly), Schizo-affective disorder (mental health disorder that includes mood changes and hallucinations), schizophreniform (mental disorder that impacts reality) disorder, delusional disorder, mood disorder (example bipolar disorder, severe depression refractory to other therapies and or with psychotic features, psychosis (disconnection from reality) in the absence of dementia, medical illness with psychotic symptoms, treatment related to psychosis or mania . During a review of a professional reference from the National library of Medicine titled, Quetiapine Drug information, dated 6/15/2020, the professional reference indicated, . Important warning for older adults with dementia, studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly and perform daily activities and that may cause changes in mood and personality) who take antipsychotics such as quetiapine have an increased risk for death during treatment. Quetiapine is not approved by the Food and Drug Administration (FDA) for the treatment of behavioral problems in older adults with dementia . During a review of Resident 1 ' s, Medication Administration Record (MAR), dated 12/1/24-12/31/24, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the MAR indicated, . Monitor for episodes of Anxiety as evidenced by (AEB) restlessness, every evening shift for 14 days . Monitor of depression AEB voiced sadness every shift . The MAR indicated Resident 1 was not being monitored for hallucinations, delirium or symptoms of psychosis. During a review of Resident 1 ' s, MAR, dated 1/1/25-1/31/25, the MAR indicated, . Monitor of depression as evidenced by (AEB) voiced sadness every shift . The MAR indicated Resident 1 was not being monitored for hallucinations, delirium or symptoms of psychosis. During a review of Resident 1 ' s, MAR, dated 2/1/25-2/28/25, the MAR indicated, . Monitor of depression as evidenced by (AEB) inability to sleep every evening and night shift . Monitor of episodes of Anxiety AEB restlessness . every shift . Quetiapine Give 0.5 tablet by mouth at bed time related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . The MAR indicated Resident 1 received medication every evening beginning on 2/11/25 and indicated Resident 1 was not being monitored for hallucinations, delirium or symptoms of psychosis. During a concurrent interview and record review on 2/18/25 at 11:55 a.m. with licensed vocational nurse (LVN) 1, Resident 1 ' s Order Summary, dated 2/11/25 was reviewed. The order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . 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. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . LVN 1 reviewed and read the order for medication [brand name] with the black box warning. LVN 1 stated Resident 1 ' s diagnosis of dementia was not a proper diagnosis for the use of medication [brand name] because of the increased risk for death in elderly residents according to the black box warning. LVN 1 stated, Resident 1 ' s behaviors had improved since 2/11/25 but was unsure if behaviors had improved due to medication [brand name] use or because Resident 1 had been recently treated for a urinary tract infection which could have caused increased behaviors. During a concurrent interview and record review on 2/18/25 at 12:39 p.m. with the social services director (SSD), Resident 1 ' s Order Summary, dated 2/11/25 was reviewed. The order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . black box 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. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . The SSD stated it was the facility process to monitor the use of psychotropic medications prescribed in the facility and monitor Resident ' s behaviors to establish if medications were effective. The SSD stated with the use of medication [brand name] for dementia, was not an appropriate diagnosis unless there were behaviors exhibited. The SSD stated, Resident 1 exhibited behaviors and was currently prescribed a psychotropic but had not been evaluated or treated by the facility psychologists. The SSD stated the use of medication [brand name] was a recommendation to the facility and Resident 1 ' s physician from Resident 1 ' s family. During a concurrent interview and record review on 2/18/25 at 1:15 p.m. with the director of nursing (DON), Resident 1 ' s Order Summary, dated 2/11/25 was reviewed. The order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few black box 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. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . The DON reviewed and read the order with the black box warning. The DON stated the diagnosis of Dementia was not an appropriate indication of use for this medication [brand name]. The DON stated it was not a usual diagnosis seen for the use of this psychotropic medication in the facility and the black box warning indicated not to use on elderly residents. The DON stated, the facility would clarify diagnosis and reason for medication use with psychotropics in the future. During an interview on 2/18/25 at 1:55 p.m. with the administrator (ADM), the ADM stated the expectation was for the facility nurses to clarify physician orders with the physician or DON when unsure of physician orders. The ADM stated, the facility nursing staff should have called the DON or physician when something did not feel right. During a telephone interview on 2/25/25 at 2:28 p.m. with Resident 1 ' s physician, the physician stated Resident was admitted to the facility for rehabilitation from an injury. The physician stated, during Resident 1 ' s stay in the facility, Resident 1 needed more care than usual and began behaviors of staying up all night and possible hallucinations. The physician stated Resident 1 was admitted to the hospital for a fall, while in the hospital Resident 1 was prescribed the antipsychotic medication. The physician stated the medication (Quetiapine) was used for a diagnosis of schizophrenia and bipolar disorder but Resident 1 did not have those diagnosis. The physician stated the medication was used off label for behaviors and believed it was a good idea to continue Resident 1 with medication following the hospital discharge orders for the diagnosis of Dementia. The physician stated it was for the treatment of behaviors of yelling and pointing at CNAs and staff. The physician stated the medication was discontinued from Resident 1 ' s use solely on his assessment of Resident 1 on 2/18/25. During a record review of the facility ' s policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2001, the P&P indicated, . Residents will not receive medications that are not clinically indicated to treat a specific condition . a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior . Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record . use of psychotropic medications may be considered appropriate in specific circumstances . acute or emergency situations, enduring conditions, and/or new admissions where the resident is already on psychotropic medication . non-pharmacological approaches are used to minimize the need for medications . when determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether other causes for symptoms including symptoms that mimic a psychiatric disorder have been ruled out, signs and symptoms are clinically significant enough to warrant medication therapy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 4 of 4