Health inspection·March 16, 2023

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 observation, interview, and record review, the facility failed to accurately code the status of a pressure injury (a wound developed on bony prominences as a result of prolonged pressure) in the Minimum Data Set (MDS - a computerized clinical assessment) for Resident 31. Residents Affected - Few This failure had the potential to inaccurately reflect Resident 31's status to the oversight agency (Center for Medicare and Medicaid Services - CMS), who provides funding for Resident 31. Findings: During a review of Resident 31's clinical record, the face sheet (contains admission and demographic information), indicated Resident 31 was admitted on [DATE], with diagnoses which included chronic respiratory failure (long term dysfunction or complications of the lungs), intestinal obstruction (a condition in which digested material is prevented from passing normally through the bowel), and chronic kidney disease (long term dysfunction or complications of the kidneys). Upon further review of the clinical record for Resident 31, the admission Assessment dated May 6, 2021, indicated Resident 31's skin was assessed by a licensed nurse and no pressure injuries were noted upon admission. During an observation on March 14, 2023, at 3:08 PM, Resident 31 was observed in bed, with a foam wedge placed under the left side of her body, offloading weight from her sacral area. Resident 31 was observed on a low air loss mattress (an air mattress to help cushion a body's bony prominences, while letting out air very slowly through tiny holes to help keep the skin dry and free of moisture). During a concurrent interview and record review with a MDS Nurse (MDS 1) on March 15, 2023, at 9:35 AM, Resident 31's Quarterly MDS Assessment, dated February 13, 2023, and Skin Assessment - Pressure Ulcer, dated October 10, 2022, were reviewed. The skin assessment indicated a Sacrum Stage 4 (pressure injury is staged to specify depth - stage 4 indicates exposed muscle or bone) developed on October 4, 2021. The skin assessment also indicated the sacral pressure injury was not present upon admission. The Quarterly MDS Assessment's Section M: Skin Conditions indicated the pressure injury was coded as present upon admission/entry or reentry. After the review, MDS 1 confirmed this was not coded accurately, and should have been coded as not present on admission, since the pressure injury developed in the facility. During an interview with the Director of Nursing (DON) on March 16, 2023, at 3:35 PM, Resident 31's Quarterly MDS Assessment, dated February 13, 2023, and Skin Assessment - Pressure Ulcer, dated October 10, 2022, were reviewed. The DON confirmed the pressure injury was inaccurately coded in Section Page 1 of 18 555494 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few M: Skin Conditions, and should have been coded to reflect the pressure injury was not present upon admission. During a review of CMS's Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual Version 1.17.1, revised October 2019, the RAI Manual indicated instructions for properly coding section M, .For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home . 555494 Page 2 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR - a federal screening requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) after a diagnosis of Schizophrenia (a serious mental illness that affects how a person think, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations) had been identified after admission for Resident 78. This failure had the potential for Resident 78 not to be accurately assessed by a qualified mental health professional, in order to ensure proper placement related to his mental illness. Findings: During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included acute necrotizing hemorrhagic encephalopathy (a central nervous system disease secondary to a viral infection, causing brain damage). A PASRR had been submitted upon Resident 78 admission to the facility, but did not indicate a mental illness diagnosis, or the need for further screening. Further review of the clinical record indicated Resident 78 had a psychiatry consult for further evaluation, on September 27, 2022, one month after he was admitted to the facility. The consult notes indicated .He [Resident] has history of schizophrenia and being in psychiatric hospitals in the past .Patient is having auditory hallucinations . During a concurrent observation and interview on March 13, 2023, at 8:22 AM, Resident 78 was observed lying in bed, mumbling, and talking to himself. No one else was at his bedside at the time. When interviewed, the resident was able to engage in simple conversation and answer questions but was noted to be very easily distracted and talkative about details not pertaining to the original conversation. During an interview with the Director of Nursing (DON) on March 14, 2023, at 3:27 PM, the DON stated the expectation was for a new PASRR to be submitted once a diagnosis of a mental illness had been identified, in order for Resident 78 to be properly referred to and evaluated by a qualified mental health professional. The DON confirmed another PASRR was not submitted for Resident 78 and stated it should have. During an interview with the Administrator (ADM), on March 14, 2023, at 4:30 PM, the ADM stated the facility did not have a policy to specifically address the resubmitting of the PASRR for a new diagnosis of mental illness. The ADM further stated the PASRR should have been resubmitted, to indicate a resident review and status change had occurred. 555494 Page 3 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 identify mental disorders during the Preadmission Screening and Resident Review (PASARR-a screening to identify the presence of serious mental illness) for one of one sampled resident (Resident 61). Residents Affected - Few This failure had the potential to cause Resident 61 not to receive specialized mental health services. Findings: A review of Resident 61's face sheet (a document that gives a summary of resident 61 information), undated, indicated Resident 61 was admitted to the facility on [DATE], with a diagnosis of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear). A review of Resident 61's PASARR dated November 5, 2022, indicated, .Result of Level I Screening: Level I - Negative, . Reason Code: No Serious Mental Illness. Section III - Serious Mental Illness - Definition: 10. Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? NO. Explain: 11. After observing the Individual or reviewing their records, do you believe the Individual may be experiencing serious depression or anxiety, unusual or abnormal thoughts, extreme difficulty coping, or significantly unusual behaviors or does the individual actively engage in community mental health services? NO. During an interview and concurrent record review with the Director of Nursing (DON) on March 15, 2023, at 1:49 PM, the DON reviewed Resident 61's clinical record and Resident 61's level I PASARR dated November 5, 2022. The DON stated the level I PASARR was filled out incorrectly and should have indicated Resident 61's diagnoses of schizophrenia and anxiety disorder. The DON stated since the level I PASARR was incorrect Resident 61 did not receive a level II PASARR assessment to identify specialized mental health services Resident 61 might need. A review of the facility's policy and procedure titled, PASRR Completion Policy, undated, indicated, Policy Statement: The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. PRACTICE GUIDELINES: 1. Center Administrator will designate either the Admissions Director, Social Worker, or designee to make sure that the PASSRR and/or Level of Care (LOG) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID, the PASRR must be completed prior to admission. If the resident is deemed hospital exempted that must be clearly documented in the transfer documents prior to admission from the acute care facility. 2. Administrator will also designate a backup in case the designated person is not available. 3. Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission. 555494 Page 4 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services to maintain and improve one of one sampled resident (Resident 36) ability to communicate her needs to the facility staff. Residents Affected - Few This failure had the potential to cause Resident 36's needs to go unmet resulting in frustration, pain, and discomfort. Findings: A review of Resident 36's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included: amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and dependence on respirator/ventilator (dependent on mechanical ventilation). During an observation and interview with Resident 36 on March 13, 2023, at 8 AM, Resident 36 was unable to speak. Resident 36 was able to mouth the words yes and no and make eye contact but nothing more. Resident 36 was unable to move any part of her body, not even her head to indicate yes or no. There were no communication aids available in Resident 36's room. During an interview with a Licensed Vocational Nurse (LVN 1) on March 13, 2023, at 3:43 PM, LVN 1 stated she read Resident 36's lips for yes and no and to determine what Resident 36 needed. LVN 1 stated if she could not understand what Resident 36 was trying to say she would conduct a Zoom meeting- using the webcam to engage in virtual meetings with Resident 36's husband who assisted with understanding what Resident 36 needed. During an observation and interview with LVN 1, a Certified Nursing Assistant (CNA 1), a Respiratory Therapist (RT 1) and Resident 36 on March 13, 2023, at 4:12 PM, CNA 1 stated he helped Resident 36 with repositioning and brief changes. CNA 1 stated he could sort of read Resident 36's lips. CNA 1 stated if he could not read Resident 36's lips he would get another staff person to try. LVN 1 and CNA 1 were in Resident 36's room and Resident 36 was trying to communicate mouthing multiple words. LVN 1 and CNA 1 were concentrating on Resident 36's mouth but could not understand what Resident 36 was trying to say. There was an alphabet/picture communication board lying on an overbed table positioned next to the far wall. LVN 1 and CNA 1 stated they did not use the alphabet/picture communication board (a communication visual aid. It was designed specifically to suit a person's needs, using an Alphabetical key and pictures depicting pain, hot, cold, etc . The resident used an eye gaze or partner assisted scanning to facilitate communication). LVN 1 stated RT 1 was very good at reading Resident 36's lips and she would get RT 1 to help read Resident 36's lips. RT 1 arrived in Resident 36's room. RT 1 stated she did not use the alphabet/picture communication board. RT 1 read Resident 36's lips. Through RT 1's translation, Resident 36 stated the staff did not use the alphabet/picture communication board. Resident 36 stated she would like the staff to use the alphabet/picture communication board, but they did not. During an observation and interview with Resident 36 and Resident 36's husband on March 14, 2023, at 10:41 AM, Resident 36's husband stated the staff could not understand Resident 36. Resident 36's 555494 Page 5 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few husband stated he had been working with the facility's Social Services Director (SSD) to get a computer type communication device, but it had been three months and the SSD had not updated him on the progress. Resident 36's husband had his own alphabet/picture communication board and white board with a dry erase marker. Resident 36's husband used the alphabet/picture communication board to communicate with Resident 36 by pointing and reading aloud each letter of the alphabet. Resident 36 would mouth yes when he reached the correct letter and Resident 36's husband would write the letter on the white board, until he had enough of a sentence to understand what Resident 36 was trying to say. Using this method, Resident 36 stated there had been times she did not get the help she needed because the staff could not understand her. Resident 36's husband stated the staff should be using the alphabet/picture communication board and he thought they had been. During an interview with the SSD on March 14, 2023, at 3:33 PM, the SSD stated Resident 36's husband had made a request for a computer type communication device. The SSD stated she had been having trouble obtaining a physician's order for the device. A review of Resident 36's care plan, dated revised, February 5, 2023, indicated, Impaired communication r/t [related to] inability/difficulty to express self, related to tracheostomy status. Will be able to relate to others effectively daily. Speak clearly and enunciate distinctly. Use touch when approaching the resident. Notify MD as indicated. Communication board as indicated. There was no documented evidence to show care planning of the back-up communication method of Zoom, meetings with Resident 36's husband or the acquisition of a computer type communication device. During an interview and concurrent record review, with the Director of Nursing (DON) on March 14, 2023, at 3:54 PM, the DON stated it was unacceptable that the staff were not using the communication board or had a white board available to write Resident 36's responses. The DON stated LVN 1 should have updated the care plan to reflect using Zoom, meetings as a back-up communication plan with Resident 36's husband and had not. The DON stated the acquisition of the computer type communication device should have been care planned and had not. The DON reviewed Resident 36's care conference meetings from April 10, 2022, to March 14, 2023, and stated the acquisition of the computer type communication device should have been discussed in the care conference meetings and had not. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process, b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care, f. participate in determining the type, amount, frequency and duration of care, g. receive the services and/or items included in the plan of care, and h. see the care plan and sign it after significant changes are made. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met, . 555494 Page 6 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

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 observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 36) was repositioned every two hours to promote healing of Resident 36's Stage IV pressure sore (an injury caused by prolonged pressure that is very deep, reaching into muscle and bone). Residents Affected - Few This failure had the potential to cause Resident 36's Stage IV pressure sore to worsen or additional pressure sores to develop. Findings: A review of Resident 36's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included: amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and dependence on respirator/ventilator (dependent on mechanical ventilation). A review of Resident 36's care plan, dated revised, February 5, 2023, indicated, at high risk or unavoidable for developing pressure sore, bruising, discoloration, and other types of skin breakdown related to impaired mobility, impaired cognition, fragile skin, . Minimize the risk of skin breakdown/bruising/pressure sore daily. Turn and position as needed when in bed or wheelchair. A review of Resident 36's Skin Assessment, dated March 14, 2023, indicated, left lateral (side) ankle, Stage IV pressure sore. During an observation of Resident 36 on March 13, 2023, at 8 AM, Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. A letter sized paper was positioned on top of Resident 36's blanket near the bottom of the bed and indicated not to move resident without husband present. Resident 36 was unable to speak. Resident 36 was able to mouth the words yes and no and make eye contact but nothing more. Resident 36 was unable to move any part of her body, not even her head to indicate yes or no. During an observation of Resident 36 on March 13, 2023, at 11:28 AM, Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. A letter sized paper was positioned on top of Resident 36's blanket near the bottom of the bed and indicated not to move resident without husband present. Three hours and 30 minutes had passed without Resident 36 changing position. During an interview with a Licensed Vocational Nurse (LVN 1) on March 13, 2023, at 3:43 PM, LVN 1 stated Resident 36's husband came in once per day from 8:30 AM to 2 PM. LVN 1 stated Resident 36's husband was concerned Resident 36 was not being repositioned properly and wanted to be present to ensure her position and comfort. LVN 1 stated she had spoken with Resident 36's husband explaining the resident needed to be changed and repositioned every 2 (two) hours and as needed and it was not possible for him to be present every time. LVN 1 stated the note on the bed was to accommodate the husband to some extent. LVN 1 stated the Certified Nursing Assistants (CNAs) should be repositioning Resident 36 every two hours. Resident 36 was in bed positioned on her back with both arms lying atop of 555494 Page 7 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0686 the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. Level of Harm - Minimal harm or potential for actual harm During an observation of Resident 36 on March 14, 2023, from 7:36 AM to 10:41 AM, Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. A letter sized paper that indicated not to move resident without husband present had been removed. Three hours had passed without Resident 36 changing position. Residents Affected - Few During an interview with Resident 36's husband on March 14, 2023, at 10:41 AM, Resident 36's husband stated the CNAs did not position her (Resident 36) comfortably and the night shift CNAs were the most difficult. Resident 36's husband had his own alphabet/picture communication board (a communication visual aid. It was designed specifically to suit a person's needs, using an Alphabetical key and pictures depicting pain, hot, cold, etc . The resident used an eye gaze or partner assisted scanning to facilitate communication) and white board with a dry erase marker. Resident 36's husband used the alphabet/picture communication board to communicate with Resident 36 by pointing and reading aloud each letter of the alphabet. Resident 36 would mouth yes when he reached the correct letter and Resident 36's husband would write the letter on the white board, until he had enough of a sentence to understand what Resident 36 was trying to say. Using this method, Resident 36 stated she did not want to be moved without her husband present because the staff hurt her when they moved her. Resident 36 stated her husband did it better. Resident 36's husband stated they needed three people to move her and they don't do it. Resident 36's husband stated the ventilator gets dislodged and she cannot breathe, and it scares her. During an interview with a Certified Nursing Assistant (CNA 2) on March 14, 2023, at 11:23 AM, CNA 2 stated she gave Resident 36 a shower every Tuesday and Friday. CNA 2 stated Resident 36 needed three CNAs and one Respiratory Therapist (RT) to move Resident 36 safely and comfortably. CNA 2 stated she did not know how the CNAs moved Resident 36 on the night shift. A review of Resident 36's care plan, dated revised, February 5, 2023, was conducted. There was no documented evidence to show an intervention for three CNAs and one RT to reposition Resident 36. During an interview with a Certified Nursing Assistant (CNA 5) on March 16, 2023, at 7:41 AM, CNA 5 stated she had cared for Resident 36 on March 15, 2023, and had been assigned to care for Resident 36 this morning (March 16, 2023). CNA 5 stated she was responsible for repositioning every two hours, but she repositioned every two hours only if Resident 36's husband was present. CNA 5 stated if Resident 36 was soiled she would change the resident even if the husband was not present. CNA 5 stated if she had a knowledgeable CNA to help her, she would reposition Resident 36 with two CNAs, if she had a CNA who did not know Resident 36 well, she would use three CNAs to reposition her. CNA 5 stated she did not chart repositioning Resident 36. During an interview with the Director of Nursing (DON) on March 16, 2023, at 8:11 AM, The DON stated there was no area where the repositioning was charted every two hours. The DON stated the previous DON had created a care plan where she accommodated Resident 36's husband's request not to reposition Resident 36 without him present. The DON stated she found out about this a week ago and it was completely unacceptable. The DON stated Resident 36 was in their care and must be repositioned every two hours for her own wellbeing. The DON stated she had begun addressing this issue and was informed by staff that Resident 36 refused to be repositioned and Resident 36's husband was adamant about not repositioning Resident 36 without him present. The DON stated she had directed the staff to reposition Resident 36 every two hours, but they had been indoctrinated (brain washed) into always waiting 555494 Page 8 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the husband. The DON stated the previous DON should have investigated the concerns of Resident 36's husband and Resident 36 when they stated no repositioning without the husband present and the issues could have been addressed and care planned so Resident 36 could be repositioned every two hours. The DON stated Resident 36 should have been repositioned every two hours and was not. A review of the facility's policy and procedure titled, Repositioning, dated May 2013, indicated, Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 4. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. 5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Interventions: 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. The program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated. 2. Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used b. The condition of the skin; c. The overall condition of the resident; d. The response to the current repositioning schedule; and e. Overall treatment objectives. 3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. 555494 Page 9 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

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** 2. A review of Resident 43's medical record, Face Sheet, undated, indicated Resident 43 was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). During an observation with Resident 43 on [DATE], at 7:49 AM, Resident 43 was smoking in the designated smoking area on an outside patio. The patio contained four ashtrays, a fire blanket, and a fire extinguisher. A review of the fire extinguisher's inspection tag indicated the inspection years of 2017 through 2021. During an interview with a Maintenance Director (MD) on [DATE], at 9:49 AM, the MD stated he was responsible for the inspection of the fire extinguishers for the facility. The MD stated the facility contracted with a company to check the fire extinguishers once per year and he checked the fire extinguishers once per month. The MD verified the inspection tag on the fire extinguisher in the smoking area had expired. A review of the facility's Smoking Policy - Residents, dated [DATE], indicated, This facility has established and maintains safe resident smoking practices. A review of the facility's Fire Extinguisher Policy, undated, indicated, Local fire authorities, or other authorized agencies, will conduct a yearly inspection of all fire extinguishers, shall record the results of their findings on that agency's inspection record, and shall give the Administrator a copy of the inspection results. Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and a valid assistance device (fire extinguisher) to prevent accidents when: 1. Resident 50 was found smoking on the outside patio without one-to-one supervision. This failure had the potential for Resident 50 to have a smoking accident. 2. A fire extinguisher's inspection tag had expired, and the fire extinguisher was mounted in the smoking area for use. This failure had the potential for residents to be exposed to injuries for outdated equipment. Findings: During an observation on [DATE], at 1:30 PM, Resident 50 was seen smoking unsupervised on the outside patio under the rain. During an interview on [DATE], at 1:39 PM, with Resident 50, Resident 50 stated they have been smoking unsupervised for a long time. During a review of Resident 50's Face Sheet, (contains demographic information), undated, indicated Resident 50 was admitted on [DATE], with a diagnosis to include cerebral infarction (disrupted blood flow to the brain), lack of coordination and muscle weakness. 555494 Page 10 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 50's medical record, Safe Smoking Evaluation (Smoking facility)- V2, dated [DATE], indicated, .B. Vision: 1. Does Resident have any visual deficit(s)? a. Yes . 2. Additional Comments: Unable to hold anything with hands for some time because of hemiplegia (weakness of one side of the body) from old CVA ( Cerebrovascular accident: loss of blood flow from a part to part of the brain) 15 years ago .C. Dexterity :1. Does Resident have dexterity problem(s): a.Yes 2. Additional comments: Unable to hold anything heavy with both hands .E. Safety: . Resident's need for adaptive equipment .c. One-on-one assistance. During a concurrent interview and record review, on [DATE], at 2:20 PM, with the Director of Nursing (DON), Resident 50's Safe Smoking Evaluation(Smoking facility)-V2, dated [DATE] was reviewed. The Safe Smoking Evaluation (Smoking facility)-V2 indicated Resident 50's need for adaptive equipment is to have one to one assistance. DON stated they did not provide one-to one assistance as stated in the smoking evaluation when they allowed Resident 50 to smoke unsupervised. During a concurrent interview and record review, on [DATE], at 2:20 PM with the DON, Smoking Policy Residents, (undated) was reviewed. The policy indicated, .Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: .11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times. DON stated her expectation is for staff to provide supervision as the policy indicated but it was not followed 555494 Page 11 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 respiratory care when a Physicians order for Oxygen therapy was not followed for one of three residents (Resident 59). Residents Affected - Few This failure had the potential for resident 59 to experience shortness of breath. Findings: During an observation on March 13, 2023, at 11:40 AM, in Resident 59's room, Resident 59 was receiving 4 Liters (L) (Liters= unit of measurement) of oxygen via nasal cannula (a tube placed in the nose to deliver oxygen). During a review of Resident 59's medical record, Face Sheet (contains demographic information), undated, indicated Resident 59 was admitted on [DATE], with a diagnosis to include Chronic Obstructive Pulmonary Disease (COPD-lung diseases that block airflow and make it difficult to breathe). During a concurrent observation and interview on March 13, 2023, at 12:00 PM, with Licensed Vocational Nurse (LVN1), LVN 1 was observed checking the amount of oxygen Resident 59 was receiving. LVN 1 stated Resident 59 was receiving 4L of Oxygen. LVN 1 reduced the oxygen level to 2 L. LVN 1 also stated she is responsible for making sure residents are receiving the correct oxygen therapy per the physician's order. LVN 1 further stated, I know the order is 2 - 4 L but I will check. During a concurrent interview and record review on March 13, 2023, at 12:02 PM with LVN1, Resident 59's physician's order for oxygen therapy was reviewed. The physician's order indicated, Oxygen at 2 L via nasal cannula continuously every shift for shortness of breath related to COPD. LVN 1 stated, Resident 59 had always received 4 L of oxygen instead of 2 L as ordered by the physician. LVN 1 also stated the physician's order was not followed. During a concurrent interview and record review on March 13, 2023, at 12:11 PM, with the Director of Nursing (DON) Resident 59's physician's order for oxygen therapy was reviewed. The physician's order indicated, Oxygen at 2 L via nasal cannula continuously every shift for shortness of breath related to COPD. DON stated the order was not followed. During a concurrent interview and record review on March 13, 2023, at 12:16 PM, with the DON, the facility policy, Oxygen Administration, (undated) was reviewed. It indicated, Preparation: 1. Verify that there is a physician's order .Review the physician's orders or facility protocol for oxygen administration. The DON stated the policy was not followed. 555494 Page 12 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated Resident 78 was admitted on [DATE], with current diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations). Further review of the clinical record indicated the resident had a current physician's order for Seroquel Oral Tablet 50 mg [milligram - unit of measurement] .Give 1 tablet by mouth two times a day for schizophrenia m/b [manifested by] auditory hallucinations . During a concurrent observation and interview on March 13, 2023, at 8:22 AM, Resident 78 was observed lying in bed, mumbling, and talking to himself. No one else was at his bedside at the time. When interviewed, Resident 78 was able to engage in simple conversation and answer questions but was noted to be very easily distracted and talkative about details not pertaining to the original conversation. During a concurrent interview and record review with a Licensed Vocational Nurse (LVN 7) on March 15, 2023, at 6:15 AM, Resident 78's Medication Administration Record (MAR), dated March 2023, was reviewed. The MAR indicated the resident had missed three doses of Seroquel on three separate days, March 9, 2023, March 12, 2023, and March 13, 2023, for the scheduled 8:00 PM administration time. LVN 7 stated the doses were not given because the bubble pack (a card-like package) containing the medication for 8:00 PM had run out. LVN 7 stated she did not look in the emergency kit (kit containing medications for emergency use, or for instances when meds are not available from pharmacy yet), and stated she should have. LVN 7 further stated she did not notify the MD of the missed doses and should have. During an interview with the Director of Nursing (DON) on March 15, 2023, at 6:19 AM, the DON stated the expectations were for the licensed nursing staff to give the medications as ordered by a physician. The DON stated that if for any reason the medication was not available in the cart, the pharmacy should be contacted, and the emergency kits should be utilized so the resident does not miss a dose. The DON further stated another expectation was for the physician to be notified of any missed doses. The DON stated the potential for not giving medication doses as ordered was for the resident to experience symptoms or decreased effectiveness of the medication. A review of the facility's policy and procedure (P&P) titled Administering Medications, revised 2019, indicated .4. Medications are administered in accordance with prescriber orders, including any required time frame .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training . Based on observation, interview, and record review the facility failed to ensure medications were properly given as ordered for two sampled residents (Resident 193 and 78) when: 1. Resident 193 did not receive the full dose of Amiodarone (a medication used to treat a fast or irregular heartbeat) as ordered by a physician. This failure had the potential to cause Resident 193 to experience symptoms or discomfort. 555494 Page 13 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0755 Level of Harm - Minimal harm or potential for actual harm 2. Resident 78 did not receive three doses of Seroquel (antipsychotic medication to treat mental illness) as ordered by a physician. This failure had the potential to cause an increase in hallucinations or other negative psychosocial effects for Resident 78. Findings: Residents Affected - Few 1. A review of Resident 193's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 193 was admitted to the facility on [DATE], with a diagnosis of Cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). During a medication pass observation and interview with a Licensed Vocational Nurse (LVN 5) on March 15, 2023, at 8:43 AM, LVN 5 retrieved one 200 mg (milligram-a unit of measurement) tablet of amiodarone (a medication used to treat a fast or irregular heartbeat) from its package. LVN 5 crushed the tablet into a fine light pink powder and poured it into a pill cup for administration into Resident 193's j-tube (jejunostomy tube-a soft, plastic tube placed through the abdomen into the small intestine, for administering medication and nutrition). LVN 5 added a small amount of water to the pill cup and poured the contents into Resident 193's j-tube. LVN 5 did not mix the water with the fine pink powder or rinse the pill cup with additional water, resulting in a substantial amount of the medication remaining in the pill cup and Resident 193 not receiving the full dose of the medication. LVN 5 stated there was still some of the medication left in the pill cup and she should have rinsed the pill cup with additional water and poured it into Resident 193's j-tube. A review of Resident 193's physician's order dated March 2, 2023, indicated, Amiodarone . Oral Tablet 200 MG, Give 1 tablet via J-tube for arrhythmia . [irregular heartbeat]. During an interview with the Director of Nursing (DON) on March 15, 2023, at 9:47 AM, the DON reviewed the remaining medication in Resident 193's pill cup. The DON stated Resident 193 did not get her full dose of amiodarone and LVN 5 should have rinsed the cup with water to administer the full dose. A review the facility's policy and procedure titled, Administering Medications through an Enteral [involving or passing through the intestine] Tube, undated, indicated, Steps in the Procedure . Dilute medication: a. Remove plunger from syringe. Add medication and appropriate amount of water to dilute. b. Dilute crushed (powdered) medication with at least 30 ml [milliliters-a unit of measurement] purified water (or prescribed amount). 555494 Page 14 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor antipsychotic medication for effectiveness and adverse [harmful] side effects for one of one sampled resident (Resident 12). This failure had the potential to cause ineffective control of symptoms to go unrecognized and unaddressed. In addition, Resident 12 had the potential to suffer prolonged adverse side effects of the medication. Findings: A review of Resident 12's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 12 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs.) A review of Resident 12's physician's order dated February 23, 2023, indicated, Risperidone [an antipsychotic medication to treat bipolar disorder] Oral Tablet 3 [three] MG [milligrams-a unit of measurement] Give 1 [one] tablet via G-Tube [a tube inserted through the wall of the abdomen directly into the stomach] one time a day for bipolar disorder m/b [manifested by] mood swings causing irritability. A review of Resident 12's Physician's Progress Note, dated February 23, 2023, indicated, She [Resident 12] is seen for psychiatry evaluation as requested for her depression and bipolar disorder.Plan/Recommendations/Interventions: .Cont. [continue] Risperdal [Risperidone] 3 [three] mg qday [daily] for bipolar disorder m/b mood swings caused by irritability.Monitor for any changes in behavior/mood/symptoms. During an interview and concurrent record review with the Director of Nursing (DON) on March 16, 2023, at 9:11 AM, the DON reviewed Resident 12's Medication Administration Record (MAR). The DON stated the monitoring for the Risperidone's effectiveness for controlling symptoms and for any adverse side effects was supposed to be documented on the MAR and it was not. During an interview with the Nurse Practitioner (NP), who had ordered Resident 12's Risperidone, on March 16, 2023, at 9:24 AM, stated he had put into his order to monitor for the adverse side effects of the Risperidone and monitoring for the effectiveness of the medication. The NP stated it was his expectation that this monitoring was being done. A review of the facility's policy and procedure titled, Psychotropic Medication Use, dated July 2022, indicated, Residents, Families and/or the representative are involved in the medication management process. Psychotropic medication management includes: .adequate monitoring for efficacy [effectiveness] and adverse consequences; and preventing, identifying, and responding to adverse consequences. 555494 Page 15 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist with dental services needed for one of six sampled residents (Resident 196). Residents Affected - Few This failure prevented Resident 196 from obtaining an identified need for dental services. Findings: In a review of Resident 196's face sheet (a document containing basic information, demographics, and diagnoses), indicated Resident 196 was self-responsible and was admitted to the facility on [DATE]. A review of Resident 196's physician order, dated February 16, 2023, indicated, Dental evaluation and treatment as indicated. During a concurrent observation and interview with Resident 196 on March 13, 2023, at 4:23 PM, Resident 196 was seen inside his room, observed with missing entire upper teeth and some lower teeth. Resident 196 stated he came to the facility with the same oral condition, but no one had approached him about dental services. Resident 196 further stated he could use dentures but was not made aware the facility could arrange for the services. During an interview with the Social Service Director (SSD) on March 14, 2023, at 3:58 PM, the SSD stated their department was responsible for arranging dental services for residents in the facility. The SSD provided a list of residents serviced on the last dental visit to the facility on February 23, 2023. Resident 196 was not included in the list of residents seen by the dentist on that day. During a concurrent interview and record review with the SSD on March 15, 2023, at 8:26 AM, of the master list of residents provided by Dentist 1, the SSD verified Resident 196 was not included in the list to be seen by the dentist for his next scheduled visit on March 23, 2023. The SSD stated the dental office requested for face sheets of residents that the dentist would add to the master list of residents to be seen on his next visit, but Resident 196's name was still not included in the list. The SSD stated Resident 196's name should have been included in either of the two lists reviewed. During a concurrent interview and record review with the Administrator (ADM) on March 15, 2023, at 2:30 PM, of the facility's policy and procedure (P&P), titled, Dental Services, revised 2016, indicated, .Policy Interpretation and Implementation .1. Routine and 24-hour emergency dental services are provided to our residents through: .c. Referral to community dentist; or .d. Referral to other healthcare organizations that provide dental services . Further review indicated, .6. Social service representatives will assist residents with appointments The ADM stated there were no documents indicating Resident 196 was seen and evaluated by the dentist, nor was Resident 196 included in the list of residents to be seen on the upcoming dental visit on March 23, 2023. The ADM stated the facility did not follow their policy. 555494 Page 16 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 follow proper sanitation and food safety practices to prevent foodborne illnesses as evidenced by food debris, black grime and dirt were observed under the kitchen stove and griddle. This failure had the potential to result in food contamination and foodborne illnesses to medically compromised population of 71 of 94 residents in the facility. Findings: During a concurrent observation and interview with the Kitchen [NAME] (KC 1) on March 13, 2023, at 8:35 AM, there were food debris, black grime and dirt seen under the kitchen stove and griddle. The KC 1 stated the floor should be kept clean and free from debris and dirt. During an interview with the Dietary Service Supervisor (DSS) on March 14, 2023, at 3:15 PM, the DSS stated they had designated staff assigned each day for mopping and sweeping the kitchen floor. The DSS stated the kitchen floors should be kept clean, otherwise it could potentially attract insects and rodents which could contaminate food. During a concurrent interview and record review with the Administrator (ADM) on March 16, 2023, at 1:00 PM, of the facility's policy and procedure (P&P), titled, General Appearance of Food and Nutrition Department, dated 2018, indicated, Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition .2 .Sweep the floor, pushing all debris forward. Use a dustpan to remove and dispose of debris as it accumulates The ADM stated the kitchen should be kept clean. The ADM further stated the facility did not follow their policy. In a review of the FDA ( Food and Drug Administration) Federal Food Code 2017, 4-402.12 titled, Fixed Equipment, Elevation or Sealing, indicated, The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food. 555494 Page 17 of 18 555494 03/16/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to practice infection prevention and control in accordance with their policy for one of six sampled residents (Resident 73) when a foley catheter (a flexible tube that a clinician passes through the bladder) drainage bag was observed touching the floor. Residents Affected - Few This failure had the potential to cause catheter-associated complications including urinary tract infection for Resident 73. Finding: During record review of Resident 73's face sheet (a document containing basic information, demographics and diagnoses), indicated Resident 73 and was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.) During a concurrent observation and interview with the Infection Preventionist (IP) on March 15, 2023, at 8:05 AM, Resident 73's urine drainage bag was observed touching the floor. The IP stated the drainage bag should not touch the floor because it can potentially cause infection to Resident 73. During a concurrent interview and record review with the Director of Nursing (DON) on March 15, 2023, at 12:00 PM, of the facility's policy and procedure, titled, Catheter Care, Urinary, revised August 2022, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Infection Control .2. Be sure the catheter tubing and drainage bag are kept off the floor . The DON stated they did not follow their policy. 555494 Page 18 of 18