Health inspection·August 13, 2025

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 for one of seven sampled residents (Resident 1), the medication Eliquis (a prescription medication that functions as a blood thinner to prevent and treat various types of blood clots) was reconciled with the physician.This failure resulted in Resident 1 receiving four doses at twice the strength, placing her at risk for bleeding and other adverse effects.Findings: A review of Resident 1's medical records indicated Resident 1 was admitted on [DATE], and discharged on July 10, 2024, with diagnoses of infected amputated stump, renal dialysis, (treatment removes waste products and excess fluids from the bloodstream, while maintaining the proper chemical balance of the blood), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), peripheral vascular disease (PVD - is a slow and progressive circulation disorder), and left and right below the knee amputations.A review of Resident 1's history and Physical dated July 1, 2024, indicated Resident 1 had the capacity to make decisions.On July 15, 2025, at 10:33 a.m., during an interview with the Licensed Vocational Nurse, (LVN), stated that when a resident returns from the General Acute Care Hospital (GACH), the medications list from the GACH is reviewed and sent to the physician for reconciliation. The LVN stated for residents prescribed Eliquis, signs and symptoms for bleeding were assessed and documented every shift. A review of Resident 1's Discharge Medication List from the hospital, dated June 29, 2024, indicated .Medication. Eliquis. 5MG Oral Tablet. How to take. TAKE 2.5 Milligrams ORAL TWICE A DAY. A review of Resident 1's Order Summary dated June 29, 2024, indicated .Eliquis Oral Tablet 5 MG (Apixaban [an anticoagulant]) Give 1 tablet by mouth two times a day for ANTICOAGULANT. and discontinued on July 1, 2024.A review of Resident 1's Order Summary dated July 1, 2024, at 11:53 p.m., indicated Communication Method: Phone.Order Summary: Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to PERIPHERAL VASCULAR DISEASE.A review of Resident 1's Medication Administration Record indicated:-Dated June 2024, indicated Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for ANTICOAGULANT . -Dated July 2024, indicated .Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for ANTICOAGULANT .Further review of Resident 1's MAR for June and July 2024, indicated that on June 30 and July 1, 2024, Resident 1 received Eliquis 5 mg twice daily, rather than the intended 2.5 mg twice daily. On July 15, 2025, at 1:08 p.m., an interview and record review of Resident 1's Discharge Medication List dated June 29, 2024, MAR, and Order Summary were conducted with the Director of Nursing (DON). The DON stated the correct dose should have been Eliquis 2.5 MG two times a day. The DON stated Resident 1 received Eliquis 5 mg twice daily for a total of four doses before a telephone order confirmed Eliquis at 5 MG. A review of the facility's policy and procedure titled Reconciliation of Medications on Admission revised July 2024, indicated .1. Medication reconciliation is the process of comparing Residents Affected - Few Page 1 of 4 555353 555353 08/13/2025 Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 3. Using an approved medication other, list all medications from the medication history, the discharge summary, and the previous MAR (if applicable) . 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. 555353 Page 2 of 4 555353 08/13/2025 Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow policy and procedure for safe use of the Hoyer lift, (a portable total patient lifting tool to assist in transferring patients in and out of bed), for one of seven sampled residents, (Resident 2). This failure had the potential to cause injury and resulted in Resident 2 feeling unsafe.Findings:A review of Resident 2's medical records indicated Resident 2 was admitted on [DATE], with diagnoses of orthopedic aftercare, left displaced trimalleolar fracture, (broken ankle bone that the pieces have moved apart, creating a gap), displaced comminuted fracture of shaft of right fibula, (the smaller bone in the lower leg is broken into multiple pieces, and these pieces have moved out of their normal alignment), fracture of manubrium, (broken breastbone), nondisplaced fracture of seventh cervical vertebra, (broken neck bone), multiple left and right rib fractures (broken rib bones), wedge compression fracture of third lumbar vertebra, (broken bone in the lower back), pneumothorax, (a collapsed lung), wedge compression fracture of first thoracic vertebra, (broken upper back bone), and bed sore of the left heel. A review of Resident 2's History and Physical dated July 14, 2025, indicated resident had capacity to make decisions.On July 14, 2025, at 2:48 p.m., an interview was conducted with Resident 2. Resident 2 stated she did not want to discuss the incident with the Hoyer lift again. Resident 2 stated it is in the records. On July 14, 2025, at 3:08 p.m., an interview was conducted with the Physical Therapist, (PT). The PT stated that on July 2, 2025, Resident 2 was non-weight bearing, and the Hoyer lift was required for out of bed transfers. On July 15, 2025, at 10:35 a.m., an interview was conducted with the Registered Nurse. The RN stated that on July 2, 2025, Resident 2 reported that Certified Nursing Assistant (CNA) used the Hoyer lift without a second staff member. The RN stated the strap slipped out of place, and Resident 2 fell onto the bed. The RN stated she assessed Resident 2 for injuries, and found none. The RN confirmed that the Hoyer lift requires at least two people. On July 15, 2025, at 11:12 a.m., an interview was conducted with CNA 1. CNA 1 stated on July 2, 2025, during her morning shift, CNA 2 requested her assistance with using the Hoyer lift for Resident 2's shower. CNA 1 stated that when she entered Resident 2's room, CNA 2 was lifting Resident 2 without assistance. CNA 1 stated, one of the straps snapped loose, and Resident 2 was lowered back onto her bed. CNA 1 stated, Resident 2 requested not to be lifted again, however, she observed CNA 2 lifted Resident 2 with the Hoyer lift again. CNA 1 stated that at least two staff members are required to use the Hoyer lift. On July 15, 2025, at 11:39 a.m., a telephone interview was conducted with CNA 2. CNA 2 stated, she was aware that two staff members are required to use the Hoyer lift. CNA 2 stated she started lifting Resident 2 with the Hoyer lift without CNA 1. CNA 2 stated one of the straps snapped out of place and she lowered Resident 2 onto the bed. On July 15, 2025, at 11:51 a.m., a telephone interview was conducted with the Director of Staff Development, (DSD). The DSD stated, CNA 1 reported the incident on July 2, 2025. The DSD stated, Resident 2 was upset and did not want CNA 2 to assist her in the future. The DSD stated, CNA 1 informed that CNA 2 had used the Hoyer lift by herself and Resident 2 was upset and did not want CNA 2 to assist her. The DSD stated that CNA 2 was given a verbal warning, and provided education that the Hoyer lift required two people to operate. A review of the facility's document titled Performance Improvement Plan dated July 2, 2025, indicated .Employee Name [name of CNA 2].Type of warning.verbal.Performance/Behavior to be Addressed.EMPLOYEE FAILED TO PERFORM 2 PERSON CARE DURING HOYER LIFT TRANSFER.A review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical revised July 2024, indicated The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.General Guidelines. 1. At least 555353 Page 3 of 4 555353 08/13/2025 Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503

F 0689 two (2) nursing assistants are needed to safely move a resident with a mechanical lift.2. Mechanical lifts may be used for tasks that require.e. Toileting or bathing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555353 Page 4 of 4