Health inspection·October 6, 2023

F 0642 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Persons Completing the Assessment .indicated, every section of the MDS was e-signed and completed with the Minimal Data Set Assessment Resource (MDSR-a resource staff member knowledgeable about the computerized resident assessment instrument) MDSR's signature. 2. During a review of Resident 29's clinical record, the admission Record (contains demographic and clinical data) indicated Resident 29 was admitted to the facility on [DATE], with diagnoses which included Cerebral Infarction (a blockage in a blood vessel supplying blood to the brain), contracture ( a fixed tightening of muscle, tendons, ligaments, or skin) to right hand, and unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning) with agitation. During a concurrent interview and record review, on October 6, 2023, at 10:52 AM, with the Director of Nursing (DON), the DON reviewed Resident 9's MDS Assessment , dated August 11, 2023, and stated, the MDS, [Section E 0200] was not coded correctly because Resident 29 yells and screams daily, almost constantly from her room and has had auditory and visual hallucinations as well. The MDS, Section Z [Section Z0500], titled Signature of N Assessment Coordinator Verifying Assessment Completion, was e-signed with the DON's e-signature, dated August 16, 2023. The DON stated she did not sign or verify the MDS Assessment. The DON further stated her electronic signature was compromised at the time of the assessment completion and used by another staff member to verify and complete this MDS assessment. During a review of Resident 29's MDS Assessment dated August 16, 2023, Section Z[Z0400] Signature of Persons Completing the Assessment .indicated, every section of the MDS was e-signed and completed with the MDSR's signature. 3. During a review of Resident 41's clinical record, the admission Record (contains demographic and clinical data) indicated Resident 41 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), Chronic Obstructive Pulmonary Disease (chronic illness that causes airflow blockage and breathing-related problems), and unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning). During a concurrent interview and record review, on October 6, 2023, at 11:12 AM, with the Director of Nursing (DON), the DON reviewed Resident 41's MDS Assessment , dated August 25, 2023, and stated, The MDS [Section E 0200] was not coded correctly because Resident 41 has behaviors of lashing out at staff and residents. She has the disposable dinnerware for safety reasons, so that she cannot throw cups, utensils and plates at others. Her behavior is witnessed on a daily basis . The MDS, Section Z [Section Z0500], titled Signature of RN Assessment Coordinator Verifying Assessment Completion, was e-signed with the DON's e-signature, dated September 4, 2023. The DON stated she did not sign or verify the MDS Assessment. The DON further stated her electronic signature was compromised at the time of the assessment completion and used by another staff member to verify and complete this MDS assessment. During a review of Resident 41's MDS Assessment dated September 4, 2023, Section Z[Z0400] Signature of Persons Completing the Assessment .indicated, every section of the MDS was e-signed and completed with the MDSR's signature. During an interview on September 22, 2023, at 1:20 PM, with ADMIN, the ADMIN stated there had not been any in-services or training regarding MDS assessments for RN/DON or other staff within the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0642 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on September 22, 2023, at 1:30 PM, with the administrator (ADMIN), the ADMIN stated the facility did not have an in house MDS coordinator. The ADMIN stated the corporate MDSR was acting as MDS coordinator for the facility and the MDSR is a Licensed Vocational Nurse (LVN). During an interview on September 22, 2023, at 1:35 PM, with the DON, the DON stated the MDSR was not in the facility often, maybe once a month. The DON further stated she has not had training or in services regarding MDS assessments since she became the DON at the facility. During an interview on September 22, 2023, at 1:45 PM, with the Director of Nursing (DON), the DON stated she knows a Registered Nurse needs to coordinate MDS assessments and sign off the completion portion of the MDS, but thought someone else from corporate was doing the assessments because the MDSs were up to date and there were no overdue assessments. The DON further states she has not had any training related to MDS assessments. During a concurrent interview and record review, on September 22, 2023, at 2:10 PM, with ADMIN, the facility's policy and procedure (P&P) titled, MDS Assessment Coordinator, revised 2019, was reviewed. The P&P indicated, A Registered Nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). The ADMIN stated, they do not have an RN MDS Assessment coordinator as specified in their per policy because there was not enough staff to fill the position and therefore it was filled with an LVN (the MDSR). During a concurrent interview and record review, on September 22, 2023, at 2:15 PM, with ADMIN, the facility Job Description: Registered Nurse, revised May 2022, was reviewed. The Job Description: Registered Nurse under Duties and Responsibilities indicated .Participate in completing sections of the Minimum Data Set (MDS) assessment as requested .Participate in initial, comprehensive, quarterly, change of condition and other resident assessments using appropriate MDS forms . The ADMIN stated the DON/RN has not received any formal training related to MDS assessments. During a concurrent interview and record review, on September 22, 2023, at 3:05 PM, with ADMIN, the facility's policy and procedure (P&P) titled, MDS Assessment Coordinator, revised 2019, was reviewed. The P&P indicated, .3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment (MDS); and b. Identifying each section completed . The ADMIN confirmed the MDSR was signing all portions of the MDS. During a concurrent interview and record review, on September 22, 2023, at 3:10 PM, with ADMIN, the facility's policy and procedure (P&P) titled, Electronic Signatures and Electronic Orders dated April 2021 was reviewed. The P&P indicated, Policy Statement: The facility permits the use of electronic signatures and orders in accordance with recognized standards and laws .2. The HCP [Healthcare Providers] will receive an individual identifier access code from an appropriate administrative person. The access code is for his/her use only. 3. Our computer program controls access to information based on the individual's personal identifier code and therefore, his or her professional qualifications . The ADMIN stated, the facility did not follow their policy and procedure when the MDSR used the DON's e-signature to verify completion of MDS assessments. During an interview on October 3, 2023, at 9:50 AM, with the Social Worker (SW), the SW stated, no formal training was offered related to the MDS. The SW further stated, she has done section B,D,E and P, but not on every assessment. The SW states she will check assessment progress in [electronic health record], but many times the MDS is already completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0642 Level of Harm - Minimal harm or potential for actual harm During an interview on October 5, 2023, at 1:51 PM, with MDSR, the MDSR stated she was the designated MDS coordinator for the facility and was an LVN. The MDSR further stated, she completed MDS assessments by logging into the [electronic health record] as the DON and signing the completion for the MDS assessments between April 2023 and end of August 2023. The MDSR stated she did not in-service staff on MDS assessments including the DON. Residents Affected - Some A review of a facility document titled MDS/RAI Coordinator Competency Assessment, revised 2020, the document indicated .Duties and Responsibilities section: Care Plan and Assessment Functions .Ensure that each portion of the resident assessment is signed and dated by the person completing that portion of the MDS .Staff Development Functions, .Conduct training programs for appropriate staff on the completion of the MDS and use of the RAI manual . A review of the job description titled MDS Coordinator - Job Duties and Responsibilities undated, the MDS Coordinator - Job Duties and Responsibilities indicated .Essential Functions: .Handles confidential information appropriately and is HIPPA compliant .Follows established policies and guidelines .Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator . A review of the CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment instrument, this manual provides guidelines and definitions for completing MDS assessment), revised October 2019, indicated, .Z0400, which documents when portions of the assessment information were completed by assessment team members .Nursing homes may use electronic signatures for medical record documentation, including the MDS, when permitted to do so by the state and local law and when authorized by the nursing home's policy. Nursing homes must have written policies in place that meet any and all state and federal privacy and security requirements to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs. A review of the CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment), revised October 2019, indicated .Z0500: Signature of RN Assessment Coordinator Verifying Assessment Completion: . For Z0500B, use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator. This date will generally be later than the date(s) at Z0400, which documents when portions of the assessment information were completed by assessment team members .Nursing homes may use electronic signatures for medical record documentation, including the MDS, when permitted to do so by state and local law and when authorized by the nursing home's policy. Nursing homes must have written policies in place that meet any and all state and federal privacy and security requirements to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure portable air conditioning (AC) units in 16 of 57 resident rooms (Rooms 100-112, and 114-116), were setup for use according to manufacturer's instructions. All 16 AC units were placed on top of plastic storage totes and were not on a stable, flat, and level surface. This failure had the potential to increase the risk of injury to the residents within the facility in the event that an AC unit were to fall. Findings: During an observation on October 2, 2023, at 10:44 AM, 16 resident rooms were observed to have portable AC units which were setup for use on top of plastic tote storage containers. During an interview on October 2, 2023, at 1:11 PM, with the Administrator (ADMIN), the ADMIN stated the facility was having difficulties maintaining appropriate temperatures in the summer, so they had portable AC units in use in some of the resident rooms. The ADMIN further stated the AC units had been in use since spring or summer of 2023 (the ADMIN could not recall a specific date). During an interview on October 2, 2023, at 1:17 PM, with the Building and Facility Director (BFD), the BFD stated the air conditioning unit did not work for rooms 100-112 and 114-116 (16 rooms) and that the facility had portable air conditioners in use in those rooms. The BFD stated the reason the AC units were setup on top of totes was to catch condensation which ran from a tube from the rear of the AC unit, and into the plastic tote which would eventually be drained. During an interview on October 4, 2023, at 11:25 AM, with the BFD, the BFD stated he was the individual who read the operators manuals for the portable AC units to ensure they were setup per manufacturer's instructions. The BFD stated if an AC tipped over, the risk was that it could harm a resident. During a concurrent observation and interview on October 4, 2023, at 11:47 AM, with the Environmental Services Director (ESD), All 16 portable AC units were observed throughout the 16 affected rooms. The AC units were observed to be placed on the plastic totes and would wobble from side to side with light contact. Tote lids were observed to be slightly concave (having an outline or surface that curves inward like the interior of a circle or sphere) due to the weight of the AC unit on top of the plastic tote lid. One portable AC unit in room [ROOM NUMBER] had only three of four wheels on the tote while the other wheel was off the tote lid and was unsupported. Three portable AC units in rooms [ROOM NUMBER] were seen to be partially on the lip of the tote (which was elevated) while the rest of the AC was placed on the center of the tote lid (which was not elevated) the base of the AC was not on a flat surface and all 3 AC units were not upright and were leaning to one side. Two portable AC units in rooms [ROOM NUMBERS] had tote lids which were so concave they appeared to be creating a crease or fold in the tote lid and both AC units were not upright and were leaning to one side. The ESD agreed the AC units were not on a stable, flat surface, and that the tote lids were not stable with the weight of the AC units. The ESD also acknowledged many of the AC units were not upright and were leaning to one side and that the AC in room [ROOM NUMBER] had one wheel which was unsupported. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the operators manuals for the portable AC units provided by the facility, the following was indicated: 1. Operators Manual 1 (for AC units in rooms [ROOM NUMBERS]), titled, [brand name of AC 1] Owner's Manual Air Conditioner, undated, indicated, Please read this manual carefully before operating your set and retain it for future reference .CAUTION to reduce the risk of fire, electric shock, or injury to persons when using this appliance, follow basic precautions, including the following: .Install the air conditioner on a sturdy, level floor capable of supporting up to 110 lbs (pounds) .Installation on a weak or unlevel floor can result in the risk of property damage and personal injury. 2. Operators Manual 2 (for AC units in room [ROOM NUMBER]), titled, [brand name of AC 2] Owner's Manual Air Conditioner, undated, indicated, .Installation Instructions. Selection of installation location. 1. Place the unit on a level floor. 3. Operators Manual 3 (for AC units in rooms 101, 110, 111, 112, and 105), titled, [brand name of AC 3] This is a Manual. Portable Air Conditioner, undated, indicated, Important safety instructions .23 Place on a stable, level surface during use .Tips for correct use .8. Make sure the appliance is standing on a level surface . 4. Operators Manual 4 (for AC units in rooms 100, 103, 104, 106, 107, 108, 109, and 115), titled, [brand name of AC 4] User Manual Portable Type Room Air Conditioner, dated September 2022, indicated, Safety Precautions. To prevent injury to the user or other people and property damage, the instructions shown here must be followed. Incorrect operation due to ignoring of instructions may cause harm or damage. The level of risk is shown by the following indications [warning symbol] This symbol indicates a hazardous situation which, if not avoided, could result in death or serious injury .[warning symbol] Be sure the air conditioner has been securely and correctly installed according to the installation instructions in this manual .Installation instructions .Make sure that you install your unit on an even surface . During a concurrent interview and record review on October 4, 2023, at 12:22 PM, with the BFD, all operators' manuals for the AC units (operators manual 1, 2, 3, and 4) were reviewed. The BFD acknowledged the AC units were supposed to be placed on a flat level surface. The BFD further acknowledged the operators manual 1 indicated, install the air conditioner on a sturdy, level floor capable of supporting up to 110 lbs. Installation on a weak or unlevel floor can result in the risk of property damage and personal injury . The BFD stated he did not remember seeing this information when he previously reviewed the operator's manual. During an interview on October 6, 2023, at 10:24 AM, with the Administrator (ADMIN), the ADMIN stated it was his responsibility to ensure equipment in the facility was used according to operator manuals and manufacturer's instructions. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated September 28, 2023, the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. During a review of the facility's policy and procedure titled, Supplies and Equipment, Use of, undated, the policy indicated, Policy statement. Personnel must use assigned equipment and supplies with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 care to promote safety. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 7 of 7