Health inspection·April 25, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on observation, interview, and record review, the facility failed to discuss and provide information on advanced directives (a written statement of a person's wishes regarding medical treatment, should the person is unable to communicate with the doctor) for two of 49 sampled residents (Residents 139 and 141). This failure had the potential to cause Residents 139 and 141's values and desires related to end-of-life care not to be carried out. Findings: 1. A review of Resident 139's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of February 27, 2021, with a diagnosis of unspecified dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance (such as: sleep disturbances and agitation (physical or verbal aggression, general emotional distress, restlessness, pacing, shredding paper or tissues and/or yelling). A review of Resident 139's Physician Orders for Life-Sustaining Treatment (POLST) dated February 27, 2021, was conducted. Under section D: Information and Signatures, the POLST indicated it had been discussed with Resident 139, who had the capacity to understand. Under Additional Contact, the name and phone number of Resident 139's spouse was included. The POLST indicated Resident 139 had signed the document, however there was no Advance Directives. A review of Resident 139's MDS (The Minimum Data Set-a process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Cognitive Patterns, dated December 11, 2021, indicated a BIMS (Brief Interview for Mental Status) score of three (score of zero to seven indicated severe impairment). A review of Resident 139's physician's history and physical, dated March 1, 2021, indicated Resident 139 did not have the capacity to understand and make decisions. During an observation and interview with Resident 139 on April 20, 2022, at 10:12 AM, Resident 139 was lying quietly in bed watching television. The Surveyor introduced herself. Resident smiled and looked at the surveyor. The Surveyor attempted a conversation with Resident 139, but the resident's attention turned back to the TV. Resident 139 appeared to be talking to herself, but the Surveyor could not hear the words. During an observation and interview with Resident 139 on April 22, 2022, at 10:30 AM, Resident 139 was lying flat in the bed and looking at the ceiling. Resident 139 appeared to be quietly talking to Page 1 of 21 555350 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few herself. The Surveyor could not make out the words. The Surveyor introduced herself. Resident 139 turned her head and looked at the Surveyor and smiled. The Surveyor attempted a conversation with Resident 139. Resident 139 continued to stare at the ceiling and talk to herself. During an interview and record review with a Social Services Director (SSD 1) on April 20, 2022, at 2:55 PM, SSD 1 stated she was the social worker for Resident 139. SSD 1 stated the process for discussing and providing advanced directive information to residents was during the resident's care planning meeting. SSD 1 stated if the resident was unable to attend the meeting, she would reach out to the responsible party to attend the care planning meeting. SSD 1 stated Resident 139 did not have a responsible party or family. SSD 1 stated at the care planning meeting she would ask if the resident had an advanced directive. SSD 1 stated if the resident did not have an advanced directive, she would offer to help in creating an advanced directive. SSD 1 stated no advanced directive discussion was documented in Resident 139's care planning meeting. SSD 1 stated no discussion had occurred for an advanced directive with Resident 139 because Resident 139 did not have the capacity to understand and there was no family. SSD 1 stated the physician, and the interdisciplinary team (IDT) were to assist with consents (such as an advanced directive) for Resident 139 since there was no responsible party and Resident 139 was not self-responsible. SSD 1 stated there was no documentation to show the physician and/or the IDT addressed the advanced directive issue. During an interview with a Medical Records Director (MRD) on April 20, 2022, at 3:13 PM, the MRD stated Resident 139 did not have an advance directive on file in her clinical record. During an interview and record review with the Director of Nursing (DON) on April 21, 2022, at 6:53 AM, the DON stated the POLST should not have been discussed with Resident 139 because she did not have the capacity to understand. The DON stated the POLST should not have been signed by Resident 139 because she could not make her own medical decisions. The DON stated a discussion about advanced directives should have occurred with Resident 139's spouse but the facility had not been able to get in contact with her husband. 2. A review of Resident 141's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of November 30, 2021, with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). The face sheet indicated Resident 141's brother was the Responsible Party (RP) for Resident 141's healthcare. A review of Resident 141's physician's order dated December 2, 2021, indicated, Admit patient to [name and phone number of hospice agency] at [name of skilled nursing facility]. DX [diagnosis]: COPD, Cerebral palsy [a disorder of movement, muscle tone, and posture], Hypertensive heart disease [heart disease caused by high blood pressure]. Admitting MD [medical doctor]: [name of hospice physician] . A review of Resident 141's Physician Orders for Life-Sustaining Treatment (POLST) dated November 30, 2021, was conducted. Under section D: Information and Signatures, the area where the POLST and advanced directives were supposed to be discussed was blank. The Section Additional Contact, was blank. The POLST indicated Resident 141 had signed the document. During an observation and interview with Resident 141 on April 20, 2022, at 10:43 AM, Resident 141 was in his room in bed and watching TV. Resident 141 stated he did not know if he had an advanced directive. The Resident stated he did not remember talking to anyone about an advanced directive or a 555350 Page 2 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0578 POLST. Level of Harm - Minimal harm or potential for actual harm During an interview with a Medical Records Director (MRD) on April 20, 2022, at 3:13 PM, the MRD stated Resident 141 did not have an advance directive on file in his clinical record. Residents Affected - Few During an interview and record review with a Social Services Director (SSD 1) on April 20, 2022, at 3:15 PM, SSD 1 stated she was the social worker for Resident 141. SSD 1 stated the process for discussing and providing advanced directive information to residents was during the resident's care planning meeting. SSD 1 stated if the resident was unable to attend the meeting, she would reach out to the responsible party to attend the care planning meeting. SSD 1 stated at the care planning meeting she would ask if the resident had an advanced directive. SSD 1 stated if the resident did not have an advanced directive, she would offer to help in creating an advanced directive. SSD 1 stated no advanced directive discussion was documented in Resident 141's care planning meeting. SSD 1 stated there was no documented evidence to show an advanced directive discussion had occurred with Resident 141 or Resident 141's brother. During an interview and record review with the Director of Nursing (DON) on April 21, 2022, at 7:12 AM, the DON stated the section on the POLST which indicated a discussion of the POLST, and an advanced directive should have been filled out by the nurse who did the admission, and it was not. The DON stated she had no documented evidence to show an advanced directive discussion occurred with Resident 141 or Resident 141's brother. A review of the facility's policy and procedure titled, Advanced Directives, dated December 2016, indicated the following: Policy Statement: Advanced directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advanced directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's legal representative. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. 7. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advanced directives, the facility 555350 Page 3 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0578 staff will offer assistance in establishing advanced directives. Level of Harm - Minimal harm or potential for actual harm a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Residents Affected - Few b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 555350 Page 4 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for one of four residents reviewed for PASRR (Resident 61). This failure had the potential for Resident 61 not to receive the care and services most appropriate for his needs. Findings: During a review of Resident 61's clinical record, the face sheet (contains demographic and medical information), undated, indicated Resident 61 was admitted to the facility on [DATE], with diagnoses that included myasthenia gravis (a disease that causes weakness of muscles, and difficulties with speech and chewing), major depressive disorder (mental disorder characterized by depressed mood or loss of interest in activities), and schizoaffective disorder (a chronic mental health condition affecting a person's mood, thinking and behavior). A concurrent interview and record review of Resident 61's MDS, dated [DATE], was conducted with MDS Coordinator (MDS-C) on April 20, 2022, at 11:53 AM. She stated Resident 61's SCSA was done because the resident was decannulated (removal of breathing tube since resident no longer needs it). She stated the latest PASRR on file was completed on January 31, 2021 and his PASRR was not re-evaluated after the completion of the SCSA. She further stated that the facility did not follow the PASRR guidelines. A review of the Department of Health Care Services Guide to Completing the PASRR Level I Screening, dated May 2018, indicated Select Resident Review (RR) (Status Update) For an Initial Preadmission Screening (PAS) or Resident Review (RR) that needs to be updated for current residents, readmissions, or inter-facility transfers due to one of the following reasons: The individual experienced a significant change in their mental or physical condition. The Resident Review should be submitted as soon as the change is discovered . According to the MDS 3.0 manual a significant change is a decline or improvement in an individual's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only) and 2. Impacts more than one area of the individual's health status and 3. Requires interdisciplinary review and/or revision of the care plan. 555350 Page 5 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure collaboration and coordination with contracted hospice services for two of 49 sampled residents (Resident 141 and 138) when: Residents Affected - Few 1. For Resident 141 there was no hospice plan of care available in the facility and there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. 2. For Resident 138 there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. This failure had the potential to cause Resident 141 and 138 not to receive hospice services based on a comprehensive person-centered care plan. Findings: 1. A review of Resident 141's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of November 30, 2021, with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 141's physician's order dated December 2, 2021, indicated, Admit patient to [name and phone number of hospice agency] at [name of skilled nursing facility]. DX [diagnosis]: COPD, Cerebral palsy [a disorder of movement, muscle tone, and posture], Hypertensive heart disease [heart disease caused by high blood pressure]. Admitting MD [medical doctor]: [name of hospice physician] . During an interview with Resident 141 on April 20, 2022, at 10:43 AM, Resident 141 stated he thought he was on hospice services but was not sure. Resident 141 stated he did not remember the last time he saw someone from the hospice agency. During an interview and record review with the Unit One Nurse Manager (UONM) on April 22, 2022, at 10:40 AM, the UONM stated Resident 141 was currently receiving hospice services. The UONM verified Resident 141's hospice binder, paper clinical record and electronic clinical record did not indicate a hospice comprehensive person-centered care plan or schedule of visits. The UONM stated the hospice care plan was supposed to be in the hospice binder for reference by facility staff. The UONM stated a schedule of hospice visits was supposed to be in the hospice binder so the facility could coordinate care with the hospice staff. During an interview with a Social Services Director (SSD 1) on April 22, 2022, at 12 PM, SSD 1 reviewed the facility's policy and procedure titled, Hospice Program, dated July 2017. SSD 1 stated it was her responsibility to coordinate care provided to the resident by the facility staff and the hospice staff, collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process and obtaining the most recent hospice plan of care specific to the resident. SSD 1 stated the hospice plan of care and schedule of visits should be in the hospice binder and it was not. 555350 Page 6 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Director of Nursing (DON) on April 22, 2022, at 12:14 PM, the DON stated the facility should have a copy of Resident 141's hospice plan of care and a schedule of visits and we do not. A review of Resident 141's Hospice Services Agreement, dated November 30, 2021, indicated, Hospice and Facility want to implement a collaborative relationship in compliance with all relevant state and federal laws that will facilitate access to Hospice care services in coordination with Facility's provision of covered services, including Room and Board Services, to Hospice's patient, who wishes to elect Hospice to provide him or her with hospice services . 2. A review of Resident 138's face sheet, indicated, Resident 21 was admitted on [DATE]. A review of Resident 138's History and Physical (H&P), dated December 1, 2021, indicated Resident 21 was admitted with decompensated heart failure (inability of the heart to function normally and meet the body's needs causing symptoms such as difficulty breathing, fatigue, and increased swelling due to fluid build-up), Cerebrovascular accident (CVA -also known as stroke, when blood flow to part of the brain is stopped which may lead to loss of certain body functions), and Chronic Kidney Disease (CKD - is a kidney damage that happens slowly over a period of time) and admitted under hospice. A review of Resident 138's physician's order, dated December 10, 2021, indicated, Admit to [name and phone number of hospice agency]; DX [diagnosis]: Hypertensive heart disease [heart disease caused by high blood pressure], Systolic congestive heart failure [failure of the heart to pump blood to the body that can lead to shortness of breath, fatigue], neuropathy [nerve damage that can cause numbness, tingling, weakness, pain], MDD [Major depressive disorder or depression, a type of mental disorder), HLD [hyperlipidemia, high level of fats or cholesterol in the blood], DM [diabetes mellitus], HTN [hypertension, high blood pressure], Hx. stroke. Admitting Physician: [name of hospice physician] . During a concurrent interview and record review, on April 22, 2022, at 9:04 AM, in Unit 1, with the Licensed Vocational Nurse (LVN 4), Resident 138's hospice binder was reviewed. LVN 4 verified the monthly calendars contained in Resident 138's hospice binder were blank. LVN 4 stated she did not know about Resident 138's hospice visit schedule. LVN 4 stated it may be Monday/Wednesday/Friday or Tuesday/Thursday/Saturday. LVN 4 was unable to find additional information regarding Resident 138's hospice schedule and visits. During an interview, on April 22, 2022, at 12:14 PM, in the social service office, with the Social Services Director (SSD 1), the facility's policy and procedure titled, Hospice Program, dated July 2017, was reviewed. The SSD 1 acknowledged social service's role in coordinating care provided to hospice residents by the facility staff and hospice staff. The SSD 1 also agreed and stated it was her responsibility to collaborate with hospice representatives and coordinate facility staff participation in the hospice care planning process and to obtain the most recent hospice plan of care specific to the resident. The SSD 1 confirmed she did not coordinate hospice care for Resident 138. During a follow up interview, on April 22, 2022, at 12:51 PM, in the conference room, with the SSD 1, Resident 138's hospice binder was reviewed. Resident 138's Interdisciplinary Group (IDG-a group of qualified individuals involved in the care planning process) meeting notes included the hospice plan of care (POC). However, on further review of the hospice POC, the SSD 1 verified there was no schedule on when skilled nursing, hospice aide, social worker, or spiritual counselor visits would be conducted. 555350 Page 7 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Hospice Program, dated July 2017, indicated the following: Our facility has designated the Social Services Director to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT [interdisciplinary team] with clinical and assessment skills who is operating within the State scope of practice act). He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident . 555350 Page 8 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary treatment and services to prevent new pressures ulcers (a skin breakdown caused by prolong pressure to the skin) from developing, affecting one of seven sampled residents (Resident 27) in accordance with the facility's policy and procedure. The facility: Residents Affected - Few 1. Failed to provide nursing interventions to prevent the occurrence of a new Stage 2 pressure ulcer (a Partial-thickness loss of skin with exposed muscles, presenting as a shallow open ulcer) on Resident 27's Right Shin. 2. Failed to follow through with Physical Therapy's recommendation of the use of leg splints (a brace used to prevent or treat contractures {a permanent tightening of muscle, tendon, skin, that cause the joints to shorten and become stiff}) and leg boot (used for positioning, and pressure reduction) for the Resident 27. 3. Failed to do a daily, weekly skin checks to inspect skin and pressure points (areas where bones are close to the surface, which are at greater risk for developing pressure ulcers) between Resident 27's legs that caused friction and a pressure ulcer. These failures contributed to Resident 27 acquiring a Stage 2 pressure ulcer to lower right anterior leg of Resident 27 in the universe of seven residents. Findings: A review of Resident 27's clinical records indicated, Resident 27 was admitted on [DATE] with the diagnoses of peripheral vascular disease (reduced blood flow to the limbs), diabetes mellitus type II (increase sugar levels in the blood), abnormal posture (rigid body positions), tracheostomy (airway passage through surgical procedure), gastrostomy status (direct access to stomach via surgical procedure for tube feeding or medications), overweight, and a healing stage IV sacral pressure ulcer (deep wounds affecting muscles, tendons, ligaments of the tail bone). During an observation and interview on April 21, 2022, at 1:24 PM, with License Vocational Nurse/Treatment Nurse (LVN/TN 2), Resident 27 was in her room lying on a low air loss mattress (therapeutic bed to prevent skin breakdown). Resident 27 had a gastrostomy tube (tube inserted through the wall of the abdomen directly into the stomach) feeding and a tracheostomy connected to a ventilator (machine that helps resident breathe). Her lower legs were rigid and drawn towards each other. The left lower leg and heel were rubbing the right shin (right anterior lower leg). An open wound about a quarter size was noted on the right lower shin. The open wound on the right lower shin was red inside and outside the wound bed. There was no skin barrier to protect the skin on the lower extremities (legs) from rubbing against each other. LVN/TN 2 confirmed the observation and took wound measurements of the open wound and indicated, 2.5 cm length, 2.0 cm width, and 0.1 cm depth. During a concurrent interview with LVN/TN 2, she stated, she had not seen the open wound on the Resident 27's right lower shin before and stated, pressure from the left leg must have caused it. During an interview on April 21, 2022, at 1:46 PM, with Certified Nursing Assistant (CNA 2) and LVN TN 2, CNA 2 stated, she saw the open wound (on Resident 27's right lower shin) this morning and 555350 Page 9 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0686 told LVN/TN 2. LVN /TN 2 acknowledged she was informed and did not have a chance to evaluate it. Level of Harm - Minimal harm or potential for actual harm During a follow up interview on April 22, 2022, at 10:50 AM, with LVN/TN 2 and CNA 2, LVN/TN 2 stated, the CNAs do weekly, and daily skin checks during showers and when providing care to residents on each shift and verbally inform the nurses when they see open wounds in the resident's skin. CNA 2 was asked to show documentation of seeing the pressure ulcer,CNA 2 stated that they verbally inform the nurses if we see pressure sores. CNA 2 was not able to provide evidence of daily skin checks. Residents Affected - Few During a concurrent observation and interview in Resident 27's room on April 21, 2022, at 1:50 PM, with the Director of Nursing (DON), and Physical Therapy Director (PTD), the DON observed and acknowledged Resident 27 had an open wound to the right lower shin. DON stated, we will get physical therapy evaluation, the contractures had been the contributing factor. The PTD stated they will evaluate Resident 27 for possible splint. During an interview on April 22, 2022, at 11:07 AM, with the Physical Therapy Director (PTD), he stated, the facility should have had a flat sheet and a soft sheet between Resident 27's legs. He stated, it will help create a skin barrier because she is really contracted. He stated the open wound on the right shin was from prolonged pressure between the right lower shin and the left leg. During an interview on April 22, 2022, at 11:58 AM, with RN supervisor (RN 1), she stated Residents with contractures should be checked daily for skin breakdown and redness specially areas prone to prolonged pressure. A follow-up interview with PTD and record review of PTD notes on April 22, 2022, at 2:28 PM, he stated, the use of leg splints and leg boots were recommended in January 2021, but they were not implemented. He stated, he cannot find documentation that his recommendation was carried out and followed through. During a review of Resident 27's Order Summary Report, dated from January 2021 to April 21, 2022, indicated, there was no physician's order to apply leg splints and leg boots for the lower extremities. During a review of Resident 27's Care Plan for skin, revised on October 19, 2021, indicated, Focus: Resident has potential for skin breakdown related to history of skin integrity impairment, fragile skin, incontinence of bowel and bladder, poor mobility. Interventions: CNA to report any skin abnormalities to the LVN/RN charge nurse when showering. During a review of Resident 27's Care plan for abnormal posture, dated March 8, 2022, indicated, Focus: Physical Therapy related to abnormal posture. Goal: Bilateral lower extremity hip, ankle, and knee passive range of motion to prevent further contracture, main skin integrity and prevent pressure ulcer. There were no interventions provided in the careplan to include skin care for bilateral lower extremities. The facility's policy titled, Prevention of Pressure Ulcer, revised October 2010, indicated, Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. interventions and preventive measures: residents with high risk factors: . 5. Risk Factor-Immobility .b. use pillows or wedges to keep bony prominences such as knees or ankles from touching each other . c. when in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with 555350 Page 10 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0686 other devices as recommended by therapist and prescribed by the physician. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Prevention of Pressure Injuries, revised April 2018, indicated, Policy: the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Skin Assessment: .3. Inspect the skin on a daily basis when performing or assisting with personal cares or activities of daily living.b. Inspect pressure points (sacrum (hips), heels, buttocks, coccyx (tail bone), elbows, ischium (lower back), trochanter (upper part of the thigh), etc.) . e. Reposition resident as indicated on the care plan. Prevention: . 4. use a barrier product to protect skin from moisture . 6. do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 7. use facility approved protective dressings for at risk individuals. Residents Affected - Few 555350 Page 11 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

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 needed treatment and services to maintain physical function were provided for one of 49 sampled residents (Resident 21) when an order for range of motion was not renewed in a timely manner. This failure had the potential to result in negative outcomes, such as contractures and a further decline in mobility, which would negatively affect Resident 21's physical health and well-being. Findings: During a review of Resident 21's admission Record (contains demographic information), on [DATE], at 12:45 PM, the admission Record indicated, Resident 21 was readmitted to the facility on [DATE] with disencephalopathy (disease of the brain that alters brain function or structure) and hypoxemia (low blood oxygen levels). During a review of Resident 21's Progress Notes, dated [DATE], the Progress Notes indicated, Resident 21 was readmitted to the facility after being hospitalized for encephalopathy and hypoxemia . The Progress Notes further indicated Resident 21 had generalized muscle weakness, and the assessment and plan included passive RNA [Restorative Nurse Assistant] program RANGE OF MOTION to bilateral UE [upper extremity] and LE [lower extremity] extremity every day shift 3x/week [three times per week] as tolerated. During an observation, on [DATE], at 11:54 AM, in Unit 1, Resident 21 was noted lying supine (positioned on back) with both feet touching the foot of the bed. During an interview, on [DATE], at 12:06 PM, in Unit 1, with the Licensed Vocational Nurse (LVN 3), LVN 3 stated the current RNA order for Resident 21 is to apply a hand roll to the left hand as tolerated. During a review of Resident 21's Order Summary Report, dated February 24, 2022, the Order Summary Report indicated, RNA program RANGE OF MOTION to BUE [bilateral upper extremities] and BLE [bilateral lower extremities] every day shift for maintain physical function for 90 days with a start date [DATE] and end date [DATE]. During an interview, on [DATE], at 12:30 PM, in Unit 1, with the Restorative Nurse Assistant (RNA 1), RNA 1 stated Resident 21 had an order to apply a hand roll to prevent contracture of the hand and wrist. RNA 1 stated, the order for range of motion to bilateral upper and lower extremities was not reordered. During an interview, on [DATE], at 12:45 PM, in Unit 1, with the Physical Therapy Director (PTD), he stated when an order for an RNA program service expired, the RNA or nurse was supposed to notify him so he could reassess the resident and enter a new order for RNA program services. The PTD further stated, he was not made aware Resident 21's order for RNA program range of motion was expired. During a follow up interview, on [DATE], at 1:15 PM, with the PTD, in the conference room, Resident 21's RNA treatment documentation was reviewed. The PTD verified range of motion to the bilateral 555350 Page 12 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0688 upper extremities and bilateral lower extremities was not done from [DATE] and on. Level of Harm - Minimal harm or potential for actual harm During an interview, on [DATE], at 9:04 AM, in Unit 1, with RNA 2, RNA 2 stated if an order for RNA was expired, she notified the PTD who puts in a new order for the RNA program service. RNA 2 stated, the RNAs were supposed to communicate with the PTD directly if an RNA order needed to be renewed. Residents Affected - Few During an interview, on [DATE], at 10:25 AM, in the Director of Nursing's (DON's) office, with the DON, the DON stated when a resident's order for RNA program range of motion was expired, the RNA was supposed to notify the PTD who would assess the resident and enter a new order for range of motion. During a review of Resident 21's care plan, revised date [DATE], the care plan interventions indicated, RNA program RANGE OF MOTION to BUE and BLE every day shift . A review of Resident 21's Restorative Nursing Assistant (RNA) Treatment documentation, dated [DATE] and [DATE], indicated, Resident 21 did not receive RNA program range of motion services to bilateral upper and lower extremities after [DATE]. 555350 Page 13 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a tube surgically inserted for the administration of medications and nourishment) was verified for placement and flushed prior to and after administration of medications for one of four sampled residents (Resident 31). These failures had the potential to place Resident 31 at risk for complications such as aspiration (a condition in which stomach content enter the lungs) and gastrostomy tube blockage. Findings: During a review of Resident 31's clinical record, the face sheet (contains demographic and medical information), undated, indicated, Resident 31 had diagnoses that included cerebrovascular disease (disease resulting to damage in the brain from interruption of its blood supply), chronic respiratory failure (disease where the body fails to maintain gas exchange) and hypertensive heart disease (high blood pressure). During a medication administration observation on April 21, 2022, at 6:19 AM, inside Resident 31's room, with Licensed Vocational Nurse (LVN 5), LVN 5 administered labetalol (medication to decrease blood pressure) and famotidine (medication to decrease excess stomach acid) via GT to Resident 31. LVN 5 did not verify the placement of GT prior to medication administration. Water flushes were not administered on Resident 31 before and after medication administration and in between medications. During a review of Resident 31's Physician's Order Summary Report, dated April 21, 2022, the document indicated, Flush enteral tube [a medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake] with 20-30 ml (milliliters- unit of measurement for volume) of water before and after medication and with 5-10 ml (milliliters) water between each medication. During an interview on April 21, 2022, at 6:22 AM, with LVN 5, LVN 5 acknowledged the findings and stated, I did not check GT placement, I am sorry but I should have to make sure it [GT] is in the right place. LVN 5 also stated GT should have been flushed with water before and after medication administration, and in between medications to prevent clogging. During a concurrent interview and record review of the facility's, Enteral Tube Medication Administration Procedures, on April 21, 2022 at 11:56 AM, with the Director of Nursing (DON), DON stated the facility's policy and procedure on administration of medications using GT was not followed. During a review of the facility's Policy and Procedure (P&P), titled Enteral Tube Medication Administration Procedures, undated, the P&P indicated, .Procedure . Verify tube placement. Unclamp tube and use either of the following procedures: Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. Aspirate stomach contents with syringe. Reclamp tube to maintain a closed system .Flush the tube with 30 ml of water prior to medication administration. Administer the medication and flush the tube with water. Flush the tube with 30 ml of water or as directed . 555350 Page 14 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure care of each resident was supervised by a physician and medical care needs are provided throughout the resident stay for two of 49 sampled residents (Residents 24 and 139) when: Residents Affected - Few 1. For Resident 24, a licensed staff took blood pressure on the resident's right arm when Resident 24's physician's order indicated no blood pressures on the right arm. Resident 24's right arm had a non-functioning Arteriovenous Fistula (AVF, blood connection made of veins and arteries, used during hemodialysis, process of removing toxins and waste from the kidneys). This failure had the potential to affect the health and safety of the resident. 2. For Resident 139, the physician did not sign the Physician Orders for Life-Sustaining Treatment (POLST) within 30 working days. These failures had the potential for Resident 139's right to decide regarding life-sustaining treatment and resuscitation during a medical emergency. Findings: 1. A review of Resident 24's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of January 4, 2021, with a diagnosis of dependence on renal dialysis (a treatment for people whose kidneys are failing). During an observation and interview of Resident 24 on April 21, 2022, at 1:58 PM, Resident 24 arrived back to the skilled nursing facility from her dialysis treatment (a Certified Nursing Assistant (CNA 1) provided Spanish translation). Resident 24 stated she felt dizzy and tired. Resident 24 stated nothing bad happened while she was receiving dialysis treatment today (April 21, 2022). During an observation and interview with a Charge Nurse (CN 1) on April 21, 2022, at 2:04 PM, (CNA 1 provided Spanish translation). CN 1 performed a dialysis return assessment. Resident 24 stated she did not have pain. CN 1 took Resident 24's vital signs (body temperature, blood pressure, heart rate and respiration). A review of Resident 24's physician's order dated January 5, 2021, indicated, No IV [Intravenous- a way of giving a drug or other substance through a needle or tube inserted into a vein], blood draw [a procedure in which a needle is used to take blood from a vein] or BP [blood pressure] on right arm. During an interview and record review with CN 1 and CNA 1 on April 21, 2022, at 2:26 PM, CN 1 stated she took the residents blood pressure on the right arm and verified the physician's order dated January 5, 2021, indicated no blood pressure on Resident 24's right arm. CNA 1 who had been providing Spanish translation confirmed CN 1 had taken Resident 24's blood pressure on the right arm. CN 1 stated she should not have taken the blood pressure on the right arm. During an interview with the Director of Nursing (DON) and the Unit One Nurse Manager (UONM) on 555350 Page 15 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few April 21, 2022, at 3:39 PM, the DON stated CN 1 should have followed the physician's order and not taken the blood pressure on the resident's right arm. The UONM stated CN 1 should have followed the physician's order and not taken the blood pressure on the resident's right arm. A review of the facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated the following: Purpose: The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins and chambers of the heart. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. A review of the facility's policy and procedure titled, Medication and Treatment Orders, dated July 2016, indicated, Medication and treatment orders will be carried out as written. 2. A review of Resident 139's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of February 27, 2021, with a diagnosis of unspecified dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance (such as: sleep disturbances and agitation (physical or verbal aggression, general emotional distress, restlessness, pacing, shredding paper or tissues and/or yelling). A review of Resident 139's Physician Orders for Life-Sustaining Treatment (POLST) dated February 27, 2021, was conducted. There was no documented evidence to show the physician had signed and dated the POLST. (297 working days had passed without a physician's signature) During an observation and interview with Resident 139 on April 20, 2022, at 10:12 AM, Resident 139 was laying quietly in bed watching television. The Surveyor introduced herself. Resident smiled and looked at the surveyor. The Surveyor attempted a conversation with Resident 139, but the resident's attention turned back to the TV. Resident 139 appeared to be talking to herself, but the surveyor could not hear the words. Resident 139 was calm and did not appear to be in distress. During an observation and interview with Resident 139 on April 22, 2022, at 10:30 AM, Resident 139 was lying flat in the bed and looking at the ceiling. Resident 139 appeared to be quietly talking to herself. The Surveyor could not make out the words. The Surveyor introduced herself. Resident 139 turned her head and looked at the Surveyor and smiled. The Surveyor attempted a conversation with Resident 139. Resident 139 continued to stare at the ceiling and talk to herself. Resident 139 did not appear to be in distress. During an interview and record review with a Social Services Director (SSD 1) on April 20, 2022, at 2:55 PM, SSD 1 stated she was the social worker for Resident 139. SSD 1 verified the POLST had not been signed by the physician and should have been. During an interview and record review with the Director of Nursing (DON) on April 21, 2022, at 6:53 AM, the DON verified Resident 139's POLST had not been signed by the physician. The DON stated the doctor was to sign orders within 30 days of the initiation of the order and this was not done. 555350 Page 16 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled Physician Orders for Life Sustaining Treatment (POLST), dated 2017, indicated the following: Policy Statement: . The POLST is a physician order form that complements an advanced directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician orders. Policy Interpretation and Implementation: . 5. Once the POLST form is completed, it must be signed by the resident, or if the resident lacks decision-making capacity the resident's legally recognized health care decision-maker. AND the attending physician. 555350 Page 17 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

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 ensure safe and sanitary food preparation were maintained, as well as safe and sanitary practices were maintained in the kitchen when: Residents Affected - Many 1. There were food crumbs and grease residue in the oven that had the potential to promote bacteria growth within this area as well as attract microorganism (small organisms which have the potential to cause disease) carrying pests. 2. The floor under the oven and stove had food crumbs and grime that had the potential to attract microorganism carrying pests. 3. There were streaks of white residue on the sides of the oven and stove that had the potential to attract microorganism carrying pests. These failures had the potential to increase risk of resident harm related to disease causing microorganisms contaminating the residents' food which could cause food-borne illness to a population of immuno-compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on April 19, 2022, at 8:30 AM, with the Dietary Services Director (DSD), an oven contained food crumbs, and grease residue. The DSD stated that the oven had not been functioning for 2 months, so they just keep it closed. During a record review of the facility's policy and procedure titled, Sanitation, dated 2018, indicated, Policy: All equipment shall be maintained as necessary and kept in working order .9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. In a review of the FDA Federal Food Code 2017, 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, .(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. During a concurrent observation and interview with the Dietary Services Director (DSD), on April 19, 2022, at 8:35 AM, the floor under the stove and oven had food crumbs and grime. The DSD stated that it should be clean, and further stated, that maintenance should deep clean the floor monthly. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a record review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. During a review of the facility policy's titled Sanitation, dated 2018, indicated .9. All utensils, 555350 Page 18 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over the stove, which will be cleaned by the maintenance staff. 3. During a concurrent observation and interview with the DSD, on April 19, 2022, at 8:37 AM, streaks of white residue were noted on the sides of the oven and the stove. Dietary Services Director (DSD) verified white residue on the oven and stove. In a review of the FDA Federal Food Code 2017, 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, .(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a record review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 555350 Page 19 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures for two of 213 residents (Resident 369 and 114) when: Residents Affected - Few 1. A Respiratory Therapist (RT 1) did not perform hand hygiene after glove removal following a ventilator (breathing machine) check on Resident 369. 2. A Licensed Vocational Nurse (LVN 5) did not perform hand hygiene following a blood sugar check on Resident 114. These failures had the potential for cross contamination and spread of infection which can adversely affect the health and wellbeing of 213 medically compromised residents. Findings: 1. During an observation on April 20, 2022, at 9:26 AM, inside Resident 369's room, RT 1 touched the ventilator screen, circuit and suction cannister (a temporary storage container used to collect infectious medical waste) with gloved hands. RT 1 later removed his gloves, discarded it and exited the resident's room. RT 1 did not perform hand hygiene after he removed his gloves. During an interview on April 20, 2022, at 9:27 AM, with RT 1, RT 1 acknowledged that he did not wash his hands or perform hand hygiene after he removed the gloves. RT 1 stated it was important to wash hands after glove use and removal to prevent cross contamination. 2. During an observation on April 21, 2022, at 5:49 AM, by the door of Resident 114's room, LVN 5 used a glucometer (a small, portable machine used to measure how much sugar is in the blood) and checked Resident 114's blood sugar. After the procedure, LVN 5 removed his gloves, discarded the used gloves and exited the resident's room without performing hand hygiene. During a subsequent observation on April 21, 2022, at 5:53 AM, LVN 5 donned a pair of gloves on both hands, prepared insulin (medication to lower blood sugar levels) and administered it to the resident. LVN 5 then removed his gloves. LVN 5 did not perform hand hygiene after removal of used gloves. During an interview on April 21, 2022 at 5:56 AM, with LVN 5, LVN 5 acknowledged the findings, and stated that he should have washed his hands or performed hand hygiene every time he removed his gloves. LVN 5 also stated that not washing hands can lead to cross contamination. During a concurrent interview and record review of the facility's Handwashing/Hand Hygiene policy and procedure (P&P), on April 22, 2022 at 8:21 AM, with the Infection Preventionist (IP 1) , the surveyor discussed the findings for RT 1 and LVN 5 not performing hand washing/hand hygiene after removal of gloves. IP 1 stated that staff were expected to perform hand hygiene after removing gloves and after patient care including contact with patient care equipment or devices. IP 1 further stated the facility's policy procedure on hand hygiene was not followed. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised March 2020, the P&P indicated, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: .2. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections 555350 Page 20 of 21 555350 04/25/2022 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol- based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .6. Use an alcohol-based hand rub containing at least 65% [percent] alcohol. 7. Handwashing: soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications . i. After contact with a resident's intact skin; .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. after removing gloves; . 8. Hand washing is the final step after removing and disposing of personal protective equipment; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Procedure: Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand washing. 555350 Page 21 of 21