Health inspection·March 7, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed no more than 13 days after the admission date for 1 (Resident #333) of 27 sampled residents for whom MDS assessments were reviewed. Findings included: On 03/06/2025 at 12:50 PM, the Administrator stated the facility did not have a policy that addressed MDS assessments, but the facility went by the RAI Manual. The CMS Long-Term Care Facility RAI 3.0 3.0 User's Manual, version 1.19.1, October 2024, revealed (Z0500B) must be no later than 13 days after the Entry Date (A1600). An admission Record indicated the facility admitted Resident #333 on 02/11/2025. Resident #333's admission MDS, with an Assessment Reference Date (ARD) of 02/18/2025, revealed A1600. Entry Date was coded as 02/11/2025; however, according to Section Z of the MDS, Sections A, GG, H, I, J, L, M, N, O, P, and S of the MDS were not completed until 03/06/2025. Z0500B indicated MDS Coordinator #15 signed the assessment as complete on 03/06/2025. During an interview on 03/06/2025 at 10:52 AM, MDS Coordinator #15 stated admission MDS assessments should be completed no later than the 14th day of a resident's stay. She stated Resident #333 was admitted to the facility on [DATE], and their admission MDS assessment was late. MDS Coordinator #15 stated, We are very busy, and it got missed. During an interview on 03/06/2025 at 3:00 PM, the Director of Nursing (DON) stated the MDS coordinators were responsible for completing MDS assessments. She stated she expected all MDS assessments to be completed within their scheduled timeframes. During an interview on 03/07/2025 at 10:00 AM, the Administrator said he expected MDS assessments to be completed timely. Page 1 of 7 555435 555435 03/07/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment accurately reflected the location to which a resident was discharged for 1 (Resident #128) of 27 sampled residents for whom MDS assessments were reviewed. Residents Affected - Few Findings included: On 03/06/2025 at 12:50 PM, the Administrator stated the facility did not have a policy that addressed MDS assessments, but the facility went by the RAI Manual. The CMS Long-Term Care Facility RAI 3.0 3.0 User's Manual, version 1.19.1, October 2024, revealed section A2105: Discharge Status specified, Code 09, Hospice (home/non-institutional): if the resident was discharged to a community-based program for terminally ill persons. An admission Record indicated the facility admitted Resident #128 on 11/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of pneumonitis due to inhalation of food and vomit, other cirrhosis of liver, and type two diabetes mellitus. The admission Record indicated Resident #138 was discharged home on [DATE]. Resident #128's Treatment Administration Record (TAR) for 12/2024 revealed the transcription of an order dated 12/03/2024 to discharge the resident home on [DATE] with hospice services per the family's request. Resident #128's Progress Notes revealed a Discharge Summary, dated 12/03/2024, that indicated the resident was discharged home with their responsible party on 12/03/2024 at 1:45 PM. Resident #128's discharge MDS, with an Assessment Reference Date (ARD) of 12/03/2024, revealed section A2105. Discharge Status was coded 04, to indicate that the resident was discharged to a Short-Term General Hospital. During an interview on 03/06/2025 at 10:55 AM, MDS Coordinator #15 stated that when a resident discharged from the facility, a discharge MDS was completed. She stated the discharge assessment would include the date of discharge and the discharge location. MDS Coordinator #15 stated Resident #128 was discharged from the facility to their family member's home with hospice services. After reviewing Resident #128's discharge MDS, MDS Coordinator #15 stated the discharge MDS was coded to reflect the resident was discharged to a short-term general hospital and was coded incorrectly. MDS Coordinator #15 said the resident's discharge MDS should have been coded as 09 to reflect the resident went home with hospice services. During an interview on 03/06/2025 at 3:00 PM, the Director of Nursing (DON) stated the MDS coordinators were responsible for completing discharge MDS assessments. The DON stated Resident #128 was discharged home with hospice services. The DON confirmed Resident #128's discharge MDS assessment was incorrect. The DON stated the resident's discharge MDS should have been coded to reflect that the resident was discharged home with hospice services. During an interview on 03/07/2025 at 10:00 AM, the Administrator stated he expected all MDS 555435 Page 2 of 7 555435 03/07/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0641 assessment to be completed accurately. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555435 Page 3 of 7 555435 03/07/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #104) of 6 sampled residents reviewed for unnecessary medications was monitored for the presence of adverse drug reactions or other side effects related to the use of a prescribed antipsychotic medication. Findings included: A facility policy titled, Antipsychotic Medication Use, revised in 01/2020, indicated, 9. Nursing staff shall monitor for and report adverse consequences of antipsychotic medications to the Attending Physician. Resident #104's admission Record indicated the facility admitted the resident on 09/22/2024. According to the admission Record, the resident had a medical history that included a diagnosis of depression. Resident #104's Order Summary Report contained an order dated 12/26/2024 for Zyprexa Zydis (olanzapine orally disintegrating tablets, an atypical antipsychotic medication) 5 milligrams (mg), one-half tablet by mouth one time a day for hyperactive delirium, end of life. The Order Summary Report did not include orders to monitor for adverse drug reactions or other side effects related to the prescribed Zyprexa. Resident #104's Care Plan Report included a focus area, initiated 01/13/2025, that indicated the resident used a psychotropic medication, specifically Zyprexa, related to hyperactive delirium. Approaches dated 01/13/2025 directed staff to administer psychotropic medications as ordered by the physician and to monitor for side effects and effectiveness each shift. The focus area indicated potential adverse drug reactions included unsteady gait; tardive dyskinesia (movement disorder); symptoms of extra-pyramidal symptoms (EPS) such as shuffling gait, rigid muscles, and shaking; frequent falls; refusal to eat; difficulty swallowing; dry mouth; depression; suicidal ideations; social isolation; blurred vision; diarrhea; fatigue; insomnia; loss of appetite; weight loss; muscle cramps; nausea; vomiting; and any behavioral symptoms not usual to the person. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident was prescribed and received antipsychotic medication during the seven-day assessment look-back period. During an interview on 03/06/2025 at 1:58 PM, Licensed Vocational Nurse (LVN) #2 stated that a resident receiving Zyprexa should have orders for side effect monitoring. She stated monitoring orders should be put in place after the order for the medication was entered into the resident's electronic health record. She stated orders for side effect monitoring had to be entered independently from the medication order. After reviewing Resident #104's orders, LVN #2 stated she was unable to find orders for side effect monitoring related to the resident's prescribed Zyprexa. She stated the resident was not being monitored for side effects of the antipsychotic medication, and she saw no history of monitoring ever being ordered. 555435 Page 4 of 7 555435 03/07/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/06/2025 at 2:23 PM, LVN #1 stated antipsychotic medication orders were to be accompanied by orders to monitor for adverse drug reactions or side effects. After reviewing Resident #104's orders, LVN #1 stated Resident #104 should have monitoring orders in place for their Zyprexa, but she was unable to find an order. During an interview on 03/07/2025 at 10:02 AM, the DON stated she expected residents taking antipsychotic medications to have side effect monitoring in place. She stated side effects of antipsychotic medications were specified in the care plan. She stated it was important to monitor antipsychotic medications for potential side effects such as drowsiness, falls, and changes in cognition. The DON stated all residents taking antipsychotic medications needed to be monitored for potential side effects. The DON confirmed Resident #104 had no side effect monitoring orders in place until the prior day (03/06/2025). She stated monitoring orders should have been initiated when the medication was initially ordered and should have been caught during follow-up review as well. The DON stated she had been updating the care plans for residents with orders for antipsychotic medications but had not been checking their orders to ensure the monitoring was in place. 555435 Page 5 of 7 555435 03/07/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

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, record review, and facility policy review, the facility failed to ensure nursing staff cleaned and disinfected supplies between resident uses for 2 (Resident #72 and Resident #38) of 7 residents observed during medication administration observations. Residents Affected - Few Findings included: A facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, revealed, 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care, including, c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sterilized between residents (e.g. [exempli gratia, for example], stethoscopes, durable medication equipment). The policy specified, 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. Resident #72's admission Record revealed the facility admitted the resident on 11/14/2022. According to the admission Record, the resident had a medical history that included diagnoses of tracheostomy status (presence of an opening in the trachea from outside the neck to help oxygen reach the lungs), gastrostomy status (presence of a surgical opening into the stomach), and Klebsiella pneumoniae (a type of gram-negative bacteria with a high tendency to become antibiotic resistant). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2025, revealed Resident #72 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). According to the MDS, the resident received oxygen therapy, suctioning, tracheostomy care, and required the use of an invasive mechanical ventilator while a resident of the facility. Resident #72's Care Plan Report included an undated focus area that indicated the resident was noted with a carbapenem-resistant (resistant to a class of broad-spectrum beta-lactam antibiotics) organism. The focus area indicated the resident tested positive for Klebsiella pneumoniae carbapenemase (KPC, an enzyme produced by certain strains of Klebsiella pneumoniae that makes them resistant to carbapenem antibiotics), but no date was specified. An undated approach directed staff to implement contact precautions related to a diagnosis of KPC. Resident #38's admission Record revealed the facility admitted the resident on 02/06/2023. According to the admission Record, the resident had a medical history that included diagnoses of tracheostomy status, gastrostomy status, persistent vegetative state, and Klebsiella pneumoniae. Resident #38's Order Summary Report contained an order dated 06/01/2023 for Contact Precautions every shift for CRAB [carbapenem-resistant Acinetobacter baumanni, a highly antibiotic-resistant bacteria] (KPC) infection. Resident #38's Care Plan Report included an undated focus area that indicated the resident was noted with a carbapenem-resistant organism. The focus area indicated the resident tested positive for 555435 Page 6 of 7 555435 03/07/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few KPC on 06/01/2023. An undated approach directed staff to implement Contact Precautions every shift for CRAB (KPC) infection. An annual MDS, with an ARD of 02/14/2025, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. According to the MDS, the resident received oxygen therapy, suctioning, and tracheostomy care. During observations of medication administration on 03/04/2025 at 7:51 AM, Licensed Vocational Nurse (LVN) #10 entered Resident #72 and Resident #38's shared room. The room was also shared with one additional resident. Per a sign posted on the room door, the residents required contact precautions. The sign directed, Doctors and Staff Must: Use patient-dedicated or disposable equipment Clean & [and] disinfect shared equipment. While in the room, LVN #10 placed a plastic clipboard on Resident #72's bed, pulled up the resident's bed linens to cover Resident #72's legs, and then rubbed the resident's right shoulder. LVN #10 then cleaned her hands with hand sanitizer, changed gloves, and moved the clipboard from Resident #72's bed to Resident #38's bed, and checked Resident #38's vital signs. LVN #10 did not clean or disinfect the clipboard when moving it between the residents' beds. After assessing Resident #38's vital signs, LVN #10 moved the clipboard from Resident #38's bed back to Resident #72's bed and assessed Resident #72's vital signs. At 8:01 AM, LVN #10 removed the clipboard from Resident #72's bed and placed it on top of a personal protective equipment (PPE) cart located outside the residents' room door, then moved the clipboard to the top of the medication cart without cleaning or disinfecting the clipboard. During an interview on 03/04/2025 at 8:30 AM, LVN #10 stated she should have cleaned the clipboard between the residents or not put it on the residents' beds. LVN #10 stated the top of the medication cart was possibly contaminated from placing the clipboard on top of it. LVN #10 stated she should have used Clorox wipes to clean and disinfect the clipboard but had not thought to do so. LVN #10 further stated that not cleaning and disinfecting the clipboard between residents could potentially result in contamination of equipment and the spread of infection to the next resident. During an interview on 03/05/2025 at 2:19 PM, the Nurse Liaison (NL), who also served as the Infection Preventionist, stated the nurse's clipboard should not have been placed on the residents' beds, because of the potential for cross contamination if the nurse went into another room with the clipboard. She stated staff were trained to use Clorox wipes for cleaning and disinfecting equipment. She stated the clipboard should have been disinfected between the residents and after use with Clorox wipes. During an interview on 03/05/2025 at 2:33 PM, the Assistant Director of Nursing (ADON) stated there was a risk of contamination if a nurse took a clipboard into another resident's room. During an interview on 03/05/2025 at 2:49 PM, the Director of Nursing (DON) stated the nurse should not have gone from one resident's bed to the other resident's bed with the clipboard. The DON stated she expected nurses to disinfect equipment between residents. The DON stated Clorox wipes should have been used to disinfect the clipboard. During an interview on 03/05/2025 at 3:06 PM, the Administrator stated he expected nurses to clean equipment between residents. The Administrator stated staff should use Clorox wipes, which were designed for disinfection. 555435 Page 7 of 7