Health inspection·September 20, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light was accessible for one of six sampled Residents (Resident 9) when Resident 9's call light was found on the floor. Residents Affected - Few This failure had the potential to result in Resident 9 unable to use the call light system to call for any assistance Resident 9 may require. Finding: A review of Resident 9's admission Record (contains demographic and medical information) dated April 7, 2023, the admission Record indicated Resident 9 was admitted to the facility with the diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, and reasoning), and gout (inflamed, painful joints). During a concurrent observation and interview on September 16, 2024, at 10:33 AM, with Resident 9, in Resident 9's room, the call light was observed on the floor adjacent to Resident 9's bed. Resident 9 stated he could not reach his call light. During a concurrent observation and interview on September 16, 2024, at 10:36 AM, with Resource Respiratory Therapist (RRT), in Resident 9's room, the RRT observed the call light on the floor. The RRT stated it should not be on the floor. During a concurrent interview and record review on September 20, 2024, at 9:30 AM, with the Chief Nursing Officer (CNO), the undated facility's policy and procedure (P&P) titled, Answering the Call Light, was reviewed. The P&P indicated, . 5. Ensure that the call light is accessible to the resident when in bed . The CNO stated the P&P was not followed. Page 1 of 10 555772 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assistance during mealtime as required by the care plan for 1 of 6 sampled residents (Resident 50) which resulted in Resident 50 being left with an uncovered and unattended breakfast tray which compromise the quality and temperature of the meal. Residents Affected - Few This failure had the potential to lead to inadequate nutrition and placed Resident 50 at risk for malnutrition. Finding: A review of Resident 50 admission Record (contains demographic and medical information) the admission record indicated Resident 50 was admitted to the facility on [DATE], with diagnosis of dementia (a condition that affects the brain and makes it harder for a person to think clearly, remember things, or make decisions) and hypertension (elevated blood pressure). During a review of Resident 50's Care Plan dated June 21, 2024, indicated, [AGE] years old female at risk for malnutrition r/t [related to] dementia ., Goal, maintain adequate nutrition & [and] hydration status , Interventions .set up meal tray, assist and give verbal cues . During an observation on September 18, 2024, at 7:45 AM in Resident 50's room, Resident 50 was lying in bed, facing the window, with her eyes closed and asleep. An unattended, uncovered and untouched breakfast tray was on the bedside table. The tray contained a bowl of soggy cereal, a plate with scrambled eggs and toast, an open 125 Milliliter (ml- a unit of measurement) carton of cranberry-raspberry juice, and an 8 ounce (oz- a unit of measure) open carton of milk. The food had been left uncovered and untouched by Resident 50 for over twelve minutes. During an interview on September 18, 2024, at 7:50 AM with the Procurement Director (PD- a person who is to ensure that the necessary supplies, equipment and services are available for the facility to operate), the PD observed Resident 50's uncovered and untouched breakfast tray and confirmed that it had been left unattended. The PD stated that she would look for a staff member to assist Resident 50. During an interview on [DATE], at 7:57 AM, with a Certified Nurse Assistant 1 (CNA 1), CNA 1 arrived and confirmed that Resident 50 requires assistance with eating. CNA 1 acknowledged that the tray had been left uncovered and unattended, causing the food to become cold. CNA 1 was not assigned to Resident 50, however CNA 1 offered to assist the resident with her meal. During an interview on September 19, 2024, at 10:32 AM with Certified Nurse Assistant 2 (CNA 2), CNA 2 admitted delivering the breakfast tray and leaving it uncovered and unattended. CNA 2 further acknowledged that Resident 50 requires assistance during meals but admitted that she forgot to return to assist th resident. During a concurrent interview, and record review on [DATE], at 9:51 AM with the Chief Nursing Officer (CNO) the facility's policy and procedure (P & P) titled, Activities of Daily Living (ADLs), supporting dated March 2024, was reviewed. The P&P indicated, Residents will provide with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily 555772 Page 2 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0677 Level of Harm - Minimal harm or potential for actual harm living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . The CNO confirmed the P&P was not followed by the staff. Residents Affected - Few 555772 Page 3 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of two sampled Residents (Resident 49 and 9) received treatment and care when the facility did not follow their policy and Procedures (P&P): Residents Affected - Few 1. For Resident 49, the medication Linzess (a medication used to treat constipation) was not available from the pharmacy to be administered as ordered by the physician. This failure resulted in Resident 49 not receiving the medication and placing Resident 49's health and safety at risk. 2. For Resident 9, the treatment Administration Record (TAR) was not documented as being done on May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024 to Resident 9's right hip wound. This failure had the potential to result in worsening of skin condition placing Resident 9 at risk for further injuries. 3. For Resident 9, a Change in Condition Evaluation form (COC) and a SBAR (S-situation B-background A-assessment R-recommendation -A type of Communication Form) were not done for positive wound infection on April 17, 2024. This failure had the potential to result in an unidentified complications for Resident 9. Findings: 1. A review of Resident 49's admission Record (contains medical and demographic information) dated June 5, 2024, the admission Record indicated Resident 49 was admitted to the facility with the diagnoses of wedge compression fracture of T-11-T-12 vertebra (spinal break caused by too much pressure on the spine), diabetes mellitus type 2 (too much sugar in the blood), and hypertension (elevated blood pressure). During a concurrent observation and interview on September 16, 2024, at 9:49 AM, with Resident 49, in Resident 49's room, Resident 49 was dressed in casual clothing, laying on his bed, watching television. Resident 49 stated he has constipation (unable to poop). A review of Resident 49's physician orders dated September 14, 2024, the physician orders indicated, Give 72 mcg (microgram-a unit of measurement) by mouth one time a day for GI (gastrointestinal) until October 15, 2024, one capsule at least 30 minutes before the first meal of the day on an empty stomach once a day for 30 days. During a medication cart observation on September 18, 2024, at 1:40 PM, with Licensed Vocational Nurse 2 (LVN 2), the medication cart was opened and inspected. Resident 49's medication Linzess was unable to be found. During a concurrent interview and record review on September 18, 2024, at 1:45 PM, with LVN 2, Resident 49's MAR dated September 2024 was reviewed. The MAR indicated Linzess was given on September 17, 2024 and September 18, 2024 by LVN 2. LVN 2 stated she made a mistake and attempted to document that she could not give the medication as it had not yet been delivered by pharmacy. Resident 49 was 555772 Page 4 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0684 not given the medication for 4 days as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on September 20, 2024, at 9:38 AM, with the CNO, the facility's P&P titled, Administration of Medications dated reviewed December 2023, was reviewed. The P&P indicated, . It is the policy of this facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. Residents Affected - Few 2. A review of Resident 9's admission Record (contains demographic and medical information) dated April 7, 2023, the admission Record indicated Resident 9 was admitted to the facility with the diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, and reasoning), and adult failure to thrive (lack of interest). A review Resident 9's Physician's Order dated May 12, 2024, indicated Resident 9 was to receive the following treatment, Cleanse [clean] right hip pressure injury [localized damage to the skin and underlying soft tissue] with .25% strength Dakin's solution [diluted bleach solution], pat dry, pack undermining with 0.25% strength Dakin's solution, soaked gauze, cover wound bed with calcium alginate [wound dressings made from seaweed-derived], cover with bordered foam dressing twice daily x [times] 30 days every day and night shift for right hip pressure injury for 30 Days. A review of Resident 9's TAR for wound care from May 1, 2024, through May 31,2024, revealed staff did not documented wound care treatment as being done per physician's orders for two days for day shift, for May 27, 2024, and May 31, 2024. A review of Resident 9's Physician's Order dated July 15, 2024, indicated Resident 9 was to receive the following treatment: Cleanse right hip pressure injury with .25% strength Dakin's solution, pat dry, pack undermining with 0.25% strength Dakin's solution, cover wound bed with calcium alginate, cover with bordered foam dressing twice daily x 30 days every day and night shift for stage 3 [full thickness tissue loss] pressure injury to right trochanter [hip] for 30 Days. A review of Resident 9's TAR for wound care from August 1, 2024, through August 31,2024, revealed staff did not document wound care treatment as being done per physician's order for 2 days, for day shift on August 5, 2024, and August 10, 2024. During a concurrent interview and record review, on September 19, 2024, at 4:20 PM with Licensed Vocational Nurse Wound Care Certified (LVN WCC), reviewed Resident 9's TAR for May 1, 2024, through May 31, 2024, and August 1, 2024, through August 31, 2024. LVN WCC stated May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024, are missing check mark and nurse's initial in the box. LVN WCC stated, if treatment is done, nurses document on the TAR. LVN WCC stated, she is not sure why the documentation on the TAR for those days are missing. LVN WCC stated, she was not working at the facility at the time, but she believes, it was not being done. LVN WCC further stated, when she finished the wound care treatment, she document in the TAR by clicking the box for the treatment and documents in the progress note. During a concurrent interview and record review, on September 19, 2024, at 4:45 PM with the Chief Nursing Officer (CNO), reviewed Resident 9's TAR, for wound care from May 1, 2024, through May 31, 2024, and August 1, 2024, through August 31, 2024. The CNO acknowledged, May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024, Resident 9 had missing documentation for wound treatment for the day shifts as ordered by the physician. The CNO further stated, she expects the nurses to carry out the treatments and document. 555772 Page 5 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview, and record review on September 20, 2024, at 9:00 AM with the CNO, reviewed the facility's policy and procedure (P&P) titled, Skin Assessment, with reviewed date 3/13/2024. The P&P indicated, Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's order . All wound or skin treatments should be documented in the resident's clinical record at the time they are administered . The CNO acknowledge the P&P and stated, the nurses should follow physician's orders and document. During a subsequent interview and record review, with the CNO, on September 20, 2024, at 9:52 AM, reviewed the facility's P&P titled, Documentation and Charting, with reviewed date of December 2023. The P& P indicated, A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care in an accurate and chronological manner . The CNO stated, she would expect staff to follow physician's orders. 3. A review of Resident 9's clinical record titled, Progress Notes, Type: Nursing Note, dated April 17,2024. The Progress notes, Type: Nursing Note, indicated, resident cont [continue] to be monitor for Positive wound culture to rt [right] hip pt [patient] has started PO [oral] order of Bactrim DS [antibiotic] . A review of Resident 9's clinical record titled, eINTERACT Change in Condition Evaluation for the Month of April 2024. There is no documented evidence a change of condition evaluation was done for Resident 9's positive wound culture for April 17, 2024. A review of Resident 9's clinical record titled, SBAR [S-situation B-background A-assessment R-recommendation] Communication Form and Progress Note for RNs/LPN/LVNs for the Month of April 2024. There is no documented evidence a change of condition/SBAR was done for Resident 9's positive wound culture for April 17, 2024. During a concurrent interview and record review, on September 20, 2024, at 10:00 AM with the CNO, Resident 9's Progress Notes, Type: Nursing Note dated April 17, 2024, was reviewed. It indicated, resident cont to be monitor for Positive wound culture to rt hip pt has started PO order of Bactrim DS . The CNO acknowledge the progress note. The CNO further stated, it should have been a change of condition (COC) initiated for the wound infection. The CNO stated someone dropped the ball. The CNO expectation is for staff to initiate a COC for newly identified conditions. The CNO further stated, .no SBAR done. During a concurrent interview and record review on September 20, 2024, at 10:20 AM with the CNO, the facility's policy and procedure (P&P) titled, Change of Condition, with reviewed date December 2023, was reviewed. The P&P indicated, Document resident change of condition and response in SBAR UDA and update resident care plan, as indicated . The CNO acknowledged the P&P and stated, we did not do SBAR for positive wound infection. 555772 Page 6 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0692 Provide enough food/fluids to maintain a resident's health. 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 the dietary restrictions as indicated on the allergy diet card was followed for 1 of 6 sampled Residents (Resident 14) when Resident 14's diet card indicated Resident 14 had food allergies to cranberry. Residents Affected - Few This failure had the potential for Resident 14 to develop serious and fatal allergic reactions. Finding: During a review of Resident 14's admission Record (contains demographic and medical information) the admission record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses of paroxysmal atrial fibrillation (irregular heartbeat), asthma (a condition in which airways in the lungs become narrow, swollen, making hard to breath) and gastroesophageal reflux disease (GERD-a condition in which stomach acid frequently flows back into your esophagus). During an observation on September 18, 2024, at 8:01 AM, in Resident 14's room, Resident 14 was complaining about her breakfast tray to the staff, which had been served with two cartoons of cranberry juice of 125 ml, each, [ milliliters - unit of measurement of liquid volume], despite the documented allergy to cranberries on Resident 14's diet card. Further observation revealed the Medical Data Set Nurse (MDSN), was informed of Resident 14 compliant and promptly removed the two cartoons 125 ml each of cranberry juice from the room. MDSN confirmed with Resident 14 she had not consumed the juice and assure her that another type of juice would be provided. During a concurrent interview and record review on September 18, 2024, at 8:03 AM, with the MDSN the Diet Card dated September 18, 2024 was reviewed. It indicated, beverages: 8 oz Juice (NO CRANBERRY), further review revealed Allergies: CRANBERRY, WALNUTS. The MDSN confirmed Resident 14's allergies and stated she should not have been served cranberry juice and stated that it was an oversight. During an interview on September 18, 2024, at 8:48 AM with Resident 14, Resident 14 expressed concerns about the staff serving her cranberry juice, despite informing the facility of her allergies. Resident 14 stated, that if she consumed cranberries, her allergic reaction would cause her to develop hives on her tongue. Resident 14 further expressed frustration that the facility is not consistently adhering to her documented dietary restrictions. During a concurrent interview and record review on September 18, 2024, at 10:05 AM, with the Chief Nursing Officer (CNO) Resident 14's Diet Card dated September 18, 2024, was reviewed. The CNO acknowledged Resident 14 dietary restrictions were clearly stated on the card and confirmed that cranberry juice should not have been served. During an interview on September 18, 2024, at 11:02 AM, with License Vocational Nurse 2 (LVN 2), LVN 2 stated that she occasionally comes to help out at this facility and is familiar with Resident 14. However, when she delivered Resident 14's tray, she missed seeing the allergy information indicating Resident 14 is allergic to cranberries. LVN 2 expressed that this oversight was unintentional. During an interview on September 18, 2024, at 11:17 AM with Licensed Vocational Nurse 3/Wound care 555772 Page 7 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0692 Level of Harm - Minimal harm or potential for actual harm certified nurse (LVN 3, / WCC) stated that she was checking the breakfast trays with another nurse and missed the food allergy information for Resident 14. LVN 3/WCC explained that when checking the trays, they were focused on diet types and food textures, but overlooked the allergy information. LVN 3 / WCC acknowledged the importance of checking for food allergies, as residents could have serious allergic reactions, such as rashes or throat swelling if given food, they are allergic to. Residents Affected - Few During a concurrent interview and record review on September 19, 2024, at 9:52 AM with the CNO, the facility's policy and procedure (P&P) titled, Food Allergies and Intolerances dated March 2024 was reviewed. The P&P indicated, Residents with food allergies and / or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident to the allergen(s). Assessments and Interventions: 3. Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment . The CNO confirmed that staff did not follow their P&P. 555772 Page 8 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for two of six sampled Residents (Resident 48 and 49) when: Residents Affected - Few 1. Resident 48 had missing interdisciplinary team (IDT- interdisciplinary team- a mix of different disciplines in medicine that meet to discuss patient's care) investigation and recommendation from a fall Resident 48 sustained on August 21, 2024. 2. Resident 49 had inaccurate documentation on the medication administration record for a medication documented as given but the medication had not arrived from pharmacy. These failures had the potential to place Resident 48 and 49 at risk for missed interventions being updated in the plan of care, inaccurate count of medications, further falls, and missed adverse side effects from medications. Findings: 1. A review of Resident 48's admission Record (contains medical and demographic information) dated May 31, 2024, the admission Record indicated Resident 48 was admitted to the facility with the diagnoses of dementia (loss of brain function-thinking, remembering, and reasoning), chronic pain syndrome (pain that lasts for longer than three months), and malignant neoplasm of brain (cancerous tumor in brain). A review of Resident 48's SBAR- Change of Condition Report (Situation, Background, Assessment, and Recommendation/Request - a structured communication framework used in medicine) dated August 21, 2024, the SBAR - Change of Condition Report indicated Resident 48 had a . witnessed fall and was seen hitting his head against the wooden railing. Resident 48 was sent to the hospital. A review of Resident 48's Care Plan - at risk for falls (document that outlines the type of care a patient needs and how to provide that care) dated June 4, 2024, the Care Plan - at risk for falls indicated it had not been updated since June 4, 2024. During a concurrent interview and record review on September 19, 2024, at 11:29 AM, with Minimum Data Set Nurse (MDSN), Resident 48's Assessments (list of different types of assessments used for residents) under IDT Meeting Note was reviewed. There were no IDT meeting notes for the fall Resident 48 sustained on August 21, 2024. MDSN stated there should have been an IDT meeting for Resident 48's fall. During a concurrent interview and record review on September 20, 2024, at 9:36 AM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Fall Prevention dated reviewed December 2023 was reviewed. The P&P indicated, It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence .5. If there is an existing plan of care if the resident's medical record pertaining to falls it should be updated to reflect newly identified risk factors and approaches . the complete incident report, post fall evaluation, and incident investigation report will be reviewed by the facility Interdisciplinary Team. The CNO stated the P&P was not followed. 555772 Page 9 of 10 555772 09/20/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0842 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on September 20, 2024, at 9:36 AM, with the CNO, the facility's P&P titled, Fall Management System dated reviewed December 2023, was reviewed. The P&P indicated, .5. The investigation will be reviewed by the Interdisciplinary Team . a. a summary of the investigation and recommendations will be documented in the resident's clinical record . 6. Resident's care plan will be updated. The CNO stated the P&P was not followed. Residents Affected - Few 2. A review of Resident 49's admission Record (contains medical and demographic information) dated June 5, 2024, the admission Record indicated Resident 49 was admitted to the facility with the diagnoses of wedge compression fracture of T-11-T-12 vertebra (spinal break caused by too much pressure on the spine), diabetes mellitus type 2 (too much sugar in the blood), and hypertension (elevated blood pressure). A review of Resident 49's Medication Administration Record (MAR) for the month of September 2024 was reviewed. The MAR indicated Linzess (medication for chronic constipation) Oral Capsule 75 MCG (microgram-unit of measurement) was administered on September 17th, 2024, and September 18, 2024. During a medication cart observation on September 18, 2024, at 1:40 PM, with Licensed Vocational Nurse 2 (LVN 2), the medication cart was opened and inspected. Resident 49's medication Linzess was unable to be found. During a concurrent interview and record review on September 18, 2024, at 1:45 PM, with LVN 2, Resident 49's MAR dated September 2024 was reviewed. The MAR indicated Linzess was given on September 17, 2024 and September 18, 2024 by LVN 2. LVN 2 stated she made a mistake and attempted to document that she could not give the medication as it had not yet been delivered by pharmacy. LVN 2 further stated the September 17, 2024 and September 18, 2024 documentation was not accurate. During a concurrent interview and record review on September 20, 2024, at 9:38 AM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Documentation and Charting dated reviewed December 2023, was reviewed. The P&P indicated, It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care in an accurate and chronological manner . 6. The elements of quality medical nursing care . The CNO stated the P&P was not followed. During a concurrent interview and record review on September 20, 2024, at 9:38 AM, with the CNO, the facility's P&P titled, Administration of Medications dated reviewed December 2023, was reviewed. The P&P indicated, . 9. Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. The CNO stated the P&P was not followed. 555772 Page 10 of 10