Health inspection·June 19, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure their policy for Psychotropic (drugs that affect the mind, emotions, and behavior) Medication Use was implemented for one of two residents reviewed for unnecessary medications (Resident 38). This failure had the potential to place Resident 38 at risk of staff not identifying the effectiveness of the psychotropic medication and missing potential side effects placing Resident 38 at risk for adverse health outcomes. Findings: During a review of Resident 38's admission Record (contains demographic and medical information) it indicated Resident 38 was admitted to the facility on [DATE], with the diagnoses of intracapsular fracture of left femur (a break in the upper part of thigh bone), acute respiratory failure with hypoxia (do not have enough oxygen in blood), and major depressive disorder (a persistent sadness, loss of interest). During a review of Resident 38's Physician Order, dated March 6, 2025, it indicated Resident 38 had a physician order for Trazodone (antidepressant medication used to treat depression) 100mg (milligram-unit of measurement) QHS (at bedtime) for insomnia m/b (manifested by) inability to sleep. There were no documented orders to monitor for adverse side effects to Trazodone and no orders to monitor hours of sleep for Resident 38. During a review of Resident 38's undated Care Plan Report, there was no documented evidence to indicate there was a care plan initiated to address Resident 38's use of Trazodone. During a concurrent interview and record review on June 19, 2025, at 10:35 AM, with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), Resident 38's medical record was reviewed. The ADON and DON confirmed there were no monitoring orders and care plan for Resident 38's use of Trazodone. During a concurrent interview and record review on June 19, 2025, at 10:50 AM, with the DON, the facility's policy and procedure (P&P) titled, Psychotropic Medication Use dated revised February 2025, was reviewed. The P&P indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. 1. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Medications in the following categories are considered psychotropic medications Page 1 of 6 555514 555514 06/19/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0605 Level of Harm - Minimal harm or potential for actual harm .are subject to . monitoring and review requirements specific to psychotropic medications . b. Anti-depressants .3. Psychotropic medication management is an interdisciplinary [group involving the resident, family, doctor, nurses, etc.] process . includes: a. determining adequate indications for use; . c. adequate monitoring for efficacy and adverse consequences; . e. preventing, identifying, and responding to adverse consequences . The DON stated the P&P was not followed. Residents Affected - Few 555514 Page 2 of 6 555514 06/19/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

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** Based on observation, interview, and record review, the facility failed to implement their medication administration policies and procedures when: 1. A Licensed Vocational Nurse (LVN 2) administered Metoprolol (medication used to lower blood pressure) Extended Release (ER- type of medications designed to be swallowed whole to allow the medication to work gradually over time) crushed to Resident 34. 2. The controlled drug inventory (when a nurse signs verifying that the nurses performed controlled medication counts during shift change- system in place used to prevent discrepancies in narcotic medication counts) had missing signatures on multiple shifts for two carts on Unit 2. These failures had the potential to place Resident 34 at risk for adverse medication side effects and place the facility at risk for potential diversion (illegal distribution of controlled medications for illicit use) of controlled medications by staff in a highly vulnerable population of 19 residents in Unit 2. Findings: 1. During a review of Resident 34's admission Record (contains demographic and medical information) it indicated Resident 34 was admitted to the facility on [DATE], with diagnoses of anemia (body does not have enough red blood cells to carry oxygen), hypertension (high blood pressure), and multiple sclerosis (chronic disabling disease that attacks the brain and spinal cord). During a medication administration observation on June 18, 2025, at 8:26 AM, with LVN 2, LVN 2 prepared Resident 34's medications which included Metoprolol ER. LVN 2 then proceeded to crush all of Resident 34's medications. During a continued observation on June 18, 2025, at 8:35 AM, in Resident 34's room, LVN 2 administered the crushed Metoprolol ER to Resident 34. During a concurrent observation and interview on June 18, 2025, at 8:48 AM, with LVN 2, LVN 2 reviewed Resident 34's Metoprolol ER medication in the bubble pack (specialized medication packaging). LVN 2 stated the Metoprolol ER medication should not have been crushed. During a concurrent interview and record review on June 19, 2025, at 10:50 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Crushing Medications dated revised October 2024 was reviewed. The P&P indicated, Medications shall be crushed only when it is appropriate and safe to do so . 2. The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long acting or enteric coated medications). The DON stated the policy was not followed. 2. During a concurrent interview and record review on June 18, 2025, at 8:49 AM, with LVN 2, LVN 2 reviewed Cart Unit 2 B's Controlled Drug Inventory (CDI- a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses) for June 555514 Page 3 of 6 555514 06/19/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2025. The CDI indicated missing signatures on June 14, 2025, from the evening shift (3:00 PM- 11:00PM) off going and oncoming shifts. LVN 2 stated the missing shifts should have been signed. During a concurrent interview and record review on June 18, 2025, at 8:51 AM, with LVN 1, LVN 1 reviewed Cart Unit 2 A's CDI for June 2025. The CDI indicated on June 17, 2025, missing signatures from the morning shift (7:00 AM - 3:00 PM) off going shift and oncoming shift and evening shift (3:00 PM- 11:00 PM) off going shift and oncoming shift. LVN 1 stated it was not okay for the CDI to have missing signatures. LVN 1 further stated it is used to count for any discrepancies. During a concurrent interview and record review on June 19, 2025, at 10:45 AM, with the Director of Nursing (DON), the facility's Charge Nurse Job Description dated 2003 was reviewed. The Charge Nurse Job Description indicated, . Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures . Ensure that narcotic records are accurate for your shift . The DON stated the job description was not followed. 555514 Page 4 of 6 555514 06/19/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

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 maintain infection control practices when a License Vocational Nurse 2 (LVN 2) did not wear PPE (Personal Protective Equipment, such as gloves and gowns) as required under EBP (Enhanced Barrier Precautions, used to prevent the spread of resistant infections) while providing treatment to a resident in EBP isolation (Resident 117). Residents Affected - Few This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to another 65 vulnerable residents and staff in the facility. Findings: During a review of Resident 117's admission Record (clinical record with demographic information), the admission Record indicated Resident 117 was admitted on [DATE], with diagnoses of aftercare following surgery on the digestive system (an operation that fixes or treats problems in organs like the stomach, intestines, or other parts that help break down food) and encounter for attention to gastrostomy (a small opening made in the stomach to place a feeding tube for nutrition or medication). A review of Resident 117's physician orders, dated June 2, 2025, indicated, Enhanced Barrier Precautions (EBP) for high contact resident care activities r/t enteral feeding. Perform hand hygiene & apply personal protective equipment (PPE) gloves, gown . A review of Resident 117's physician's orders, dated June 3, 2025, indicated, Cleanse Tube Stoma Site [small opening in the abdomen where a gastrostomy tube is inserted] with Normal Saline & cover with dry clean dressing daily and/or PRN [as needed]. During an observation on June 19, 2025, at 9:10 AM, there was a signage posted on the wall to the right of the doorway to Resident 117's room. The signage read EBP isolation. LVN 2 entered Resident 117's room to perform treatment on Resident 117. LVN 2 did not wear the required isolation gown. LVN 2 proceeded to complete the treatment without donning the appropriate personal protective equipment (PPE). During an interview on June 19, 2025, at 9:20 AM, LVN 2 stated she had just realized she should have worn an isolation gown when providing care to Resident 117, who was on EBP isolation. She acknowledged that she failed to follow the required protocol during the treatment. During an interview on June 19, 2025, at 9:25 AM, with the Infection Preventionist Nurse (IPN), the IPN stated that all staff are expected to wear PPE, including gloves, gowns, and masks as needed, when caring for residents under isolation precautions to reduce the risk of spreading infection. During a concurrent interview and record review on June 19, 2025, at 1:45 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Enhanced Barrier Precaution, dated May 2024, was reviewed. The P&P indicated, Policy Statement. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities and when cleaning/disinfecting the environment when contact precautions do not otherwise apply. a. Gloves 555514 Page 5 of 6 555514 06/19/2025 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident .4. EBP are indicated for residents with any of the following: . 2) Wounds and wound care: generally, for residents with a chronic wounds), . The DON stated it was highly important for staff to comply with PPE protocols to reduce the risk of spreading infection. The DON further stated that the facility policy was not followed. 555514 Page 6 of 6