Health inspection·April 17, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards (refer to elements of the resident environment that have the potential to cause injury or illness) for one of three sampled residents (Resident 1) when Resident 1 ingested a cleaning solution left by a housekeeper (HSK 1) in Resident 1's room on March 2, 2025. This failure resulted in Resident 1 to be transferred to the General Acute Care Hospital (GACH) for higher level of care and suffered from additional health issues. Findings: During a review of Resident 1's admission Record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of end-stage renal disease (ESRD- serious condition where the kidneys are no longer able to filter waste and excess fluid from the blood treatment used to remove toxins), heart failure (when the heart is not pumping blood as well as it should) and non-ST elevation myocardial infarction (NSTEMI a type of heart attack and involves partial blockage of blood flow to the heart). Further review indicated Resident 1 left the facility against medical advice (AMA - a patient choosing to leave a health care facility against the recommendations of their doctor or other healthcare professionals) on March 31, 2025. During a review of Resident 1's MDS (Minimum Data Set - standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive [involving conscious intellectual activity] Patterns), dated January 30, 2025, it indicated Resident 1 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognitive function) score of 14. (A BIMS score of 13 to15 indicates intact cognitive function.) During a review of Resident 1's Physician Order, dated March 2, 2025, at 12:15 PM, it indicated May sent out to [Name of General Acute Care Hospital] ER (Emergency Room) via 911 for further eval R/T (related to) patient [Resident 1] claiming taking a sip of cleaner liquid. During a review of Resident 1's Change of Condition Notes (details significant deviations from a resident's baseline status, including physical, cognitive, behavioral, or functional changes), dated March 2, 2025, at 1:09 PM, it indicated .Claimed to CN (Charge Nurse) drinking a purple liquid in a clear cup place at bedside Table. Per pt (patient) he drank a sip, and soon as I tasted, I spit it out. small amt (amount) of water noted on the floor by pt feet. Pt in w/c (wheelchair) at bedside Page 1 of 5 555514 555514 04/17/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0689 .Recommendation of Primary Clinician (s): sent out to ER via 911 for further evaluation . Abdominal / GI (gastrointestinal) Status Evaluation .Pt claiming drinking cleaning liquid . Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's ED (Emergency Department) Notes from the GACH, dated March 2, 2025, at 1:15 PM, it indicated Pt bib (brought in by) amb (ambulance) from SNF (Skilled Nursing Facility) with c/o (complaint of) drinking a surface cleaner on accident, pt states he is having some mouth tingling (like a light burning) .History of Present Illness, Chief complaint: Ingestion of cleaner .hx (history) of ESRD .presents to the ED c/o ingestion of [Brand Name of the Multi Surface Cleaner]. The pt stated that some filled a drinking cup with the cleaner, but he thought it was water, so he swallowed small amount and then spit the rest out. He noted some tingling to his tongue and lips which is now discomfort .ED Medical Decisions Making .presents with ingestion of a cleaning agent that was left in a cpt (cup) a cleaning person next to his bed at the facility ., they said this was an accident and they have already had a discussion with the cleaning staff. Patient arrived and said he had tingling in his mouth . Patient Instructions: Continue to wash out your mouth today . During a review of Resident 1's Nursing Notes titled Change in Condition x (for) 72 hours, dated March 2, 2025, at 2:28 PM, it indicated .patient [Resident 1] claiming drinking cleaning liquid .per housekeeping staff, patient was out of the room smoking and decided to go in room to clean, floor was sticky and stepped out the room to grab a cleaning liquid for the floor. Housekeeping staff was unable to find a bottle to pour cleaning liquid in, being unsuccessful grabbed a clear plastic cup and put cleaning liquid in cup. Housekeeping was going to returned to room after grabbing what she need to finish cleaning but pt returned to room before her and pt grabbed clear cup thinking it was water and took a sip. Small amt of purple color liquid noted in cup. Per housekeeping the amount noted in cup was the same amount that was poured in the cup to clean. During a review of Resident 1's Health Status Note dated March 2, 2025, at 6:29 PM, it indicated Resident 1 back from ER at 5:45 PM . Resident Alert . resident claims that it feels different in the back of his throat (said it might be due to made himself gag) . New order from Hospital, Chlorhexidine (mouth wash which kills or prevents growth of bacteria, which helps to reduce inflammation of gums.) requested. During a review of HSK 1's Written Statement, dated March 2, 2025, it indicated Cleaning Resident 1's room I went to get something that would get the cranberry juice off the floor little cup majority was put on floor to dissolve was coming right back He [Resident 1] was outside smoking Roommates daughter was waiting to come in as the floor was drying. During a review of Resident 1's Physician's Progress Notes, dated March 3, 2025, it indicated Patient swallowed multi-surface cleaner on previous day and had sent to the ED (Emergency Department) for evaluation. At the time of this exam primary complaint is with regard to pain in throat and mouth. Patient demonstrated w/ (with) cup of water approximately how much of the substance he drank and how much he spit out .Neck . mild tenderness to palpation. Abd (abdomen area): Tender to palpation (specific area of the body becomes painful when gently touched or pressed) of abdominal surface with hands .AIP (Assessment and Immediate Plan; physician assessment and next steps to follow), Resident 1 demonstrated with cup approximately 100 cc (cubic centimeters- unit of measurement) . During a review of Resident 1's of Care Plan Report dated March 3, 2025, it indicated the resident has risk for alteration in gastro-intestinal status and complications r/t claiming ingestion of cleaning liquid on March 2, 2025 .Goal, the resident will remain free from discomfort, complications or s/sx (sign and symptoms) related to gastrointestinal alterations . approaches/task, ENT (Ear Nose 555514 Page 2 of 5 555514 04/17/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0689 and Throat; refers to a medical specialty or a doctor who specializes in treating conditions related to those areas of the body.) consult for irritation of throat . Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's Physician Order dated March 3, 2025, at 5:09 PM, it indicated May have ENT consult d/t (due to) irritation of throat. During a review of Resident 1's Social Service Note, dated March 3, 2025, at 5:11 PM, it indicated SSD (Social Services Designee visited with the resident in office with regards to recent incident in which he accidentally ingested cleaning solution .after going to the smoking patio and saw a clear plastic cup and took a sip. Per patient he then Spit out the liquid .then SSD asked resident how he was feeling physically, to which resident stated that swallowing regular food was irritation to his throat .SSD also suggested requesting for an ENT consult from MD (Medical Doctor). SSD to request authorization from [Name of Insurance Company] . During a concurrent observation and interview, on March 12, 2025, at 10:14 AM, Resident 1 was lying in bed, alert, oriented, and able to verbalize his needs. Resident 1 stated on March 2, 2024, he went outside for a little bit, and when he came back into his room, he drank from disposable cup left on his bedside table by the housekeeper. He stated he thought it was water, but after drinking it, he knew something was wrong right away because it didn't taste like water, it tasted like chemical. Resident 1 stated he attempted to induce vomiting by inserting his finger into his mouth and screamed for assistance. Resident 1 further stated when no one responded, he rolled into the hallway and yelled Nurse, Nurse for help. During further interview on March 12, 2025, at 10:16 AM, Resident 1 described the ingested liquid as corrosive acid (a strong chemical that can burn or damage the skin, eyes or internal tissues). Resident 1 stated after the incident, he was sent to the Emergency Department (ED), where the ED doctor prescribed him an oral mouth wash to help with the irritation. He further stated after returning to the facility, he was seen by the facility's physician, who noted ongoing discomfort in his throat and provided a referral for him to be seen by an ENT (ear, nose and throat doctor) specialist. Resident 1 stated he had blisters (painful skin condition where fluid fills a space between layers of skin) toward the back of his mouth, and he continued to feel irritation when swallowing. Resident 1 further stated, My case worker is scheduling an ENT appointment following the incident. During an interview on April 11, 2025, at 9:04 AM, with the Assistant Director of Nursing (ADON), the ADON, stated the incident involving Resident 1 occurred on March 2, 2025, at approximately 12:30 PM. The ADON stated she was informed by facility staff that Resident 1 was transferred to the hospital via 911 due to possible ingestion of an unknown substance. The ADON further stated a housekeeper admitted to pouring a cleaning solution into a disposable cup, which she used to clean the floor in Resident 1's room. The ADON further stated the housekeeper left the remaining cleaning solution in the cup by Resident 1's bedside table, and upon hearing the resident was returning to the room, quickly left the area. The ADON stated Resident 1 later entered his room, picked up the cup and drank from it, believing it was water. The ADON further stated Resident 1 attempted to induce vomiting and initially reported he drank half the cup, but later stated it was only a sip. During an interview on April 11, 2025, at 9:22 AM, with the Minimum Data Set Nurse (MDS 1), MDS 1 stated Resident 1 left facility AMA on March 31, 2025, which was before his ENT consult could occurred. During a concurrent interview and record review, on April 11, 2025, at 9:48 AM, with the 555514 Page 3 of 5 555514 04/17/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0689 Level of Harm - Actual harm Residents Affected - Few Maintenance Director (MDR), a facility document titled Safety Data Sheet(a document that explains important information about a chemical product) for[Brand Name of the Multi Surface Cleaner], dated September 5, 2014, was reviewed. The Safety Data Sheet, indicated Hazard Statement combustible liquid, causes serious eye damage, skin irritation and may cause an allergic reaction .Section 4: First aid measures, if Swallowed: Rinse mouth if you feel unwell, get medical attention . Section 11. Toxicological information, skin contact: may include localized redness, swelling, itching, dryness, cracking, blistering, and pain .Ingestion: Gastrointestinal Irritation: Signs and symptoms may include abdominal pain, stomach upset, nausea, vomiting and diarrhea. The MDR stated the chemical ingested by Resident 1 was a heavy-duty multi-purpose cleaner. The MDR stated all chemicals have spray labels; however, he confirmed there had been no in-service training provided for the housekeeping staff regarding the prohibition of placing chemicals in disposable cups without labels until after the incident occurred. During further interview on April 11, 2025, at 9:57 AM, with the MDR, the MDR stated housekeeping staff were not trained to place chemicals in disposable cups without proper labeling, as it becomes impossible to identify the chemical if something happens. The MDR further stated it could be mistakenly consumed by anyone, including resident or family members. The MDR stated it was the important to store chemicals in their proper place and ensure all containers are clearly labeled to prevent accidents. During a concurrent observation and interview, on April 11, 2025, at 10:01 AM, the MDR, in the housekeeping supply room, the MDR showed the chemical used in the incident involving Resident 1. It was [Brand Name of Multi-Surface Cleaner], which came in a sealed 2-liter (unit of measurement for liquids) plastic container. The MDR stated housekeepers obtain the cleaning solution by attaching the sealed bottle to the fill dispenser, which is mounted to the wall. The MDR further stated the dispenser automatically dilutes the concentrate with water and dispenses the solution. During an interview on April 11, 2025, at 10:12 AM, with Housekeeper (HSK 2), HSK 2 stated it was the important not to pour chemicals into unlabeled containers because it could cause harm to residents especially if accidentally ingested. During an interview on April 11, 2025, at 10:30 AM, with the Social Worker (SW 1), the SW 1 stated Resident 1's ENT referral was initiated on March 3, 2025, following the physician's recommendation. The SW 1 further she faxed the referral to the insurance company on March 4, 2025, but she did not conduct a follow-up after the referral was sent. The SW 1 stated I assumed it [Resident 1's ENT referral] went through. The SW 1 further although the ENT provider was scheduled to see all residents between April 2, 2025, through April 4, 2025, Resident 1 was not evaluated because he left the facility AMA on March 31, 2025. During a concurrent phone interview and record review on April 16, 2025, at 2:46 PM, with the Administrator (Admin) and the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Storage Areas, Environmental Services dated 2001, was reviewed. The P&P indicated, Policy Statement Housekeeping and .department storage areas shall be maintained in a clean and safe manner . 3. Cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. The DON acknowledged the policy was not followed and further stated It's not our normal practice. During a concurrent phone interview and record review, on April 16, 2025, at 2:52 PM, with the Admin and the DON, the facility's P&P titled Hazard Labeling Policy, dated 2001, was reviewed. The P&P 555514 Page 4 of 5 555514 04/17/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0689 Level of Harm - Actual harm Residents Affected - Few indicated, Section 5. Workplace labeling for hazardous chemicals not shipped directly form a manufacturer or distributor to the facility shall include either: a. The same information (specified above) required for chemicals .b. each of the following: (1) product identifier; (2) a method (s) . (3) other information available to employees .11. Employees are not to tamper with, deface, remove, or destroy existing labels on incoming hazardous chemicals, unless the container is immediately marked with the required information . The Admin stated the policy was not followed by staff. During a continued phone interview and record review, on April 16, 2025, at 3:02 PM, with the Admin and the DON, the facility's job description titled Housekeeper, revised January 2010, was reviewed. The Housekeeper job description indicated, .safety and sanitation, follow proper techniques when mixing chemicals, disinfectants, and solutions used for cleaning. Refer to manufacturer's instructions when necessary. Follow established policies governing the use of labels and MSDS (Material Safety Data Sheet; document that provides detailed information about a chemical substance) ., Participate in appropriate in-service training program prior to performing task that involved potential exposure to blood, body fluids, or hazardous chemicals. Report missing or improperly labeled containers of hazardous chemicals to your supervision. The Admin stated the job expectation was not followed in this incident. 555514 Page 5 of 5