Valley Healthcare Center

F-F689 S483.25(d)(1) (The resident environment remains as free of accident hazards as is possible;) and was identified on 3/4/25 at 6:53 p.m., regarding the following deficient practices:

*The facility failed to ensure safe smoking practices were followed when smoking residents were in possession of smoking materials (cigarettes and lighters) and smoking unsupervised.

*The facility failed to conduct smoking assessments on admission and on a quarterly basis to ensure smokers were identified in the facility and monitored for smoking activities.

*The facility failed to develop individualized care plans addressing smoking activities.

The IJ was called in the presence of the Administrator and DON

Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or

actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was

received on 3/6/25, at 12:35 p.m. and included the following:

*Conducted a thorough and complete smoking assessments for all residents who smoke in the facility.

*Implementation of a new smoking screening assessment which screens the resident for safety and capability to participate in smoking activities.

*Secured all lighters from smoking residents and ensured lighters were kept in a locked box located in the medication room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 *Monitored and supervised the residents during smoking activities, with staff responsible for securing and distributing lighters. Level of Harm - Immediate jeopardy to resident health or *Updated the admission process to include admitting nurse to interview and assess the resident for smoking safety and complete the smoking assessment.

Residents Affected - Some *Updated the Medication Administration Record for resident who are an identified smoker so Licensed nurses can monitor and observe residents who smoke. Note: The nursing home is disputing this citation. *Updated the care plans for all smoking residents.

*In-serviced all staff on the facility's smoking policy and procedures and safety measures related to smoking.

* The QA nurse and DSD met with all 10 residents who were identified as a smoker to inform the residents regarding the new protocol with disposable lighters. The disposable lighters will now be in possession of the facility instead of residents who smoke.

*Continuous monitoring of the designated smoking area will take place every half hour by staff to ensure that any residents who are smoking, are smoking in a safe manner and no changes of condition are taking place.

A monitoring log will be filled out by the staff member and kept on file for further evaluation and review.

The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on 3/6/25, at 4:15 p.m., in the presence of the Administrator and DON.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37363 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the appropriate Residents Affected - Few respiratory care was provided to two of two final sampled residents (Residents 51 and 67) when:

1. The facility failed to follow the physician's order for oxygen administration for Resident 51.

2. The facility failed to obtain a physician's order for oxygen administration for Resident 67.

This failure had the potential for respiratory complications related to inadequate oxygen administration for Residents 51 and 67.

Findings:

1. During a facility tour on 3/3/25 at 8:50 a.m., Resident 51 was observed in room with nasal cannula cannula (NC - a small, flexible tube with two prongs, used to deliver supplemental oxygen or increased airflow to a patient through their nostrils) using oxygen concentrator at the rate of 1 LPM (Liters Per Minute - a unit that express flow rate). In addition, a sign oxygen in use was also observed outside Resident 51's door.

During an interview on 3/3/25 10:10 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 confirmed Resident 51 was using an oxygen concentrator with nasal cannula at the rate of 1 LPM instead of 2 LPM.

During a concurrent interview and electronic record review with Medical Records (MR) on 3/3/25 at 11 a.m., MR confirmed Resident 51's current physician's orders indicated, O2 (oxygen) at 2 LPM via NC (nasal cannula) for SOB (shortness of breath) every shift.

During an interview on 3/7/25 at 3 p.m. with Licensed Vocational Nurse (LVN4), LVN4 stated the charge nurse is responsible for checking resident's oxygen concentrator for the correct rate of flow.

A review of Resident 51's admission record dated 3/7/25 indicated Resident 51 was admitted to facility on 12/19/24 with diagnoses (process of identifying disease process) which included chronic obstructive pulmonary disease ([COPD]a lung and airway disease causing breathing problem).

A review of Resident 51's History and Physical (H&P), dated 12/20/24, the H & P indicated, Resident 51 had

the mental capacity to make own decision.

A review of Resident 51's Minimum Data Sheet ([MDS] - (a federally mandated resident assessment tool) dated 12/26/24, section C, indicated Resident 51 has no cognitive impairment. In addition, Resident 51's MDS section O indicated Resident 51 is on oxygen therapy.

A review of Resident 51's Order Summary Report dated 3/3/25, indicated an active physician's order dated 1/15/25 for O2 at 2 LPM via nasal cannula for SOB.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0695 A review of Resident 51's Care Plan Report dated 12/26/24, indicated, .Provide oxygen as indicated by resident condition and/or provider order. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated, .Steps in the Procedure . 8. Turn on the oxygen. Unless otherwise ordered, start the flow of Residents Affected - Few oxygen at the rate of 2 to 3 liters per minute.

2. During a facility tour on 03/3/25 at 8:50 a.m., Resident 67 was observed in his room with nasal cannula using his oxygen concentrator at the rate of 5 LPM. In addition, a sign oxygen in use was also observed outside Resident 67's door.

During an interview on 3/3/25 10:10 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 confirmed Resident 67 was using an oxygen concentrator with nasal cannula at the rate of 5 LPM.

During an interview with the Medical Records (MR) on 3/3/25 at 11 a.m., MR confirmed there is no physician's order for Resident 67 for oxygen administration.

During a concurrent interview and electronic record review with MR on 3/4/25 at 2:45 p.m., MR confirmed Resident 67 had a new physician's order for oxygen administration dated 3/4/25. A review of Resident 67's physician's order indicated, Oxygen at 2-5 L (liters) per N/C (nasal cannula) for SOB (Shortness of Breath), low O2 (oxygen) sats (saturation), comfort. PRN (as needed) every shift for history of respiratory failure. Start Date: 3/4/2025 15:00 (3 p.m.).

During an interview with Registered Nurse (RN 1) on 3/7/25 at 2:50 p.m., RN 1 stated the charge nurse is responsible for carrying out the all the physician's order including oxygen administration at start of resident admission.

During a review of Resident 67's admission record dated 3/7/25 indicated Resident 67 was admitted to facility on 12/18/24 with diagnoses (process of identifying disease process) which included acute respiratory failure with hypoxia (lack of oxygen in the tissues of the body).

A review of Resident 67's History and Physical (H&P), dated 12/20/24, the H & P indicated, Resident 67 had

the mental capacity to make own decision.

A review of Resident 67's Minimum Data Sheet ([MDS] - a resident assessment tool) dated 12/24/24, section C, indicated Resident 67 has no cognitive impairment.

A review of Resident 67's Weekly assessment dated [DATE REDACTED] indicated Resident 67 was assessed as independent.

A review of Resident 67's Care Plan initiated on 3/3/25 indicated, Oxygen settings: O2 via nasal prongs at 2-5 liters as needed. For low oxygen saturation for SOB (shortness of breath) and comfort.

A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated, . Preparation 1. Verify there is a physician's order for this procedure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38492 potential for actual harm Based on interview, and record review, the facility failed to provide the necessary care for one of one Residents Affected - Few sampled residents (Resident 204). The facility failed to ensure Resident 204's Sevelamer (a medication used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis) was administered as ordered by the physician on the days the resident left the facility for dialysis (also known as hemodialysis; a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This had the potential for Resident 204 not getting the appropriate doses of medications as ordered, resulting in health complications.

Findings:

A review of Resident 204's Admission Record, dated 3/5/25, indicated Resident 204 was admitted to the facility on [DATE REDACTED].

A review of Resident 204's History and Physical Examination, dated 2/21/25, indicated Resident 204 had a diagnosis of ESRD (End-Stage Renal Disease, a severe and irreversible condition where the kidneys have lost most of their function and can no longer adequately filter waste products from the blood) on HD (hemodialysis) Tuesdays, Thursdays, and Saturdays.

During a concurrent interview and record review on 3/7/25 at 9:03 a.m. with Registered Nurse (RN) 1, Resident 204's medical record was reviewed. RN 1 verified Resident 204's Order Summary Report, dated 3/6/25 had the following physician's active orders:

- A physician's order dated 2/20/25, for Sevelamer HCl (hydrochloride) oral tablet 800 mg (milligrams - a unit of measurement), give two tablets by mouth with meals for on HD.

- A physician's order dated 3/3/25, for dialysis every Tuesday, Thursday, and Saturday with a pickup time of 11:00 a.m., and drop off time at 4:45 p.m.

A review of Resident 204's Medication Administration Record (MAR), dated for 2/1/25 to 2/28/25, showed Sevelamer with a chart code of 1 documented on 2/27/25 for the 12:00 p.m. dose. RN 1 stated a documentation of 1 of the MAR meant absent from home without meds and verified Resident 204's Sevelamer was not administered.

Further review of Resident 204's MAR, dated for 3/1/25 to 3/31/25, indicated Sevelamer with a chart code of 1 was documented on 3/1/25, 3/4/25, and 3/6/25 for the 12;00 p.m. dose. RN 1 stated Sevelamer was not given to Resident 204 on 3/1/25, 3/4/25, and 3/6/25 because Resident 204 was absent from home without meds.

RN 1 stated the facility was supposed to send the medication with Resident 204 on dialysis days or communicate with dialysis to ensure the resident received the medication.

During an interview on 3/7/25 at 9:11 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 204 did not receive the Sevelamer medication as ordered by the physician and verified the medication was not administered consistently before Resident 204 left for dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0698 During a review of the facility's policy and procedure titled End-Stage Renal Disease, Care of a Resident with, dated 10/01, indicated . education and training of staff includes, specifically . timing and administration Level of Harm - Minimal harm or of medications, particularly those before and after dialysis and . agreements between this facility and the potential for actual harm contracted ESRD facility include all aspects of how the resident's care will be managed including how information will be exchanged between the facilities. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44529

Residents Affected - Few Based on observations, interviews, and record reviews, the facility failed to ensure a resident's nutritional and dietary needs were met when the Registered Dietitian (RD) failed to review the quarterly assessment.

This had the potential for nutritional and dietary needs to remain unmet for one of six sampled residents (Resident 18).

Findings:

During an interview on 3/3/25 at 11:28 a.m. with Resident 18, Resident 18 stated she had episodes of weight fluctuations due to her advanced age. Resident 18 further stated she received Lasix (a medication that helps reduce fluid buildup in the body) for fluid retention.

During a record review on 3/5/25 at 8:31 a.m. of Resident 18's profile on the Electronic Medical Record (EMR), the profile indicated Resident 18 was initially admitted to the facility on [DATE REDACTED], with diagnoses including acute (sudden) kidney failure, morbid obesity among others.

During a concurrent interview and record review on 3/7/25 at 9:05 a.m., with the Dietary Services Supervisor (DSS), Resident 18's Nutritional Screening Assessment (NSA) was reviewed. The DSS stated the last assessment done for Resident 18 was on 11/27/24.

During a phone interview on 3/7/25 at 9:07 a.m. with the RD, the RD stated the duties and responsibilities of

an RD included completing assessments of residents' nutritional status. RD further stated that residents, at

the least, will be seen quarterly and annually, and as needed .

During a concurrent interview and record review on 3/7/25 at 9:48 a.m. with the Quality Assurance Nurse (QA), Resident 18's NSA (Nutritional Screening Assessment) was reviewed. The QA stated the facility's expectation was for the RD to visit and see residents on admission, quarterly, annually, and as necessary.

The QA stated the last RD visit for Resident 18 was on November 27, 2024, further stating the next visit for

the quarterly assessment should have been completed before the end of February 2025. The QA stated Resident 18 should have been seen by the RD, even though the expected quarterly assessment was missed. The QA stated the RD was in the facility on March 5, 2025, but Resident 18's record did not indicate

the RD visited and assessed Resident 18.

During a concurrent interview and record review on 3/7/25 at 11:10 a.m. with the QA, the facility's policy and procedure (P&P) titled, Dietitian, revised October 2017, was reviewed. The P&P indicated, .A qualified, competent, and skilled Dietitian will help oversee the food and nutrition services in the facility .9. Our facility's Dietitian is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents .f. Participating in quality assurance and performance improvement (QAPI) when food and nutrition services are involved . The QA stated the RD should assess all residents for nutritional needs on admission, quarterly and annually as the minimum expectation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0800 During the same concurrent interview and record review with the QA, the facility's P&P titled, QAPI- Role of

the Dietitian/Food Services Manager, revised April 2014, was reviewed. The P&P indicated, .Duties and Level of Harm - Minimal harm or Responsibilities .10. Visiting residents periodically to evaluate the excellence of meals served, likes and potential for actual harm dislikes, etc .16 . Reviewing and revising care plans and assessments as necessary, but at least quarterly .

The QA stated periodically meant visits done for quarterly and annually at the minimum, further stating they Residents Affected - Few did not follow their policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48985

Residents Affected - Many Based on observation, interview, and record review, the facility failed to adhere to established food safety and sanitation standards when:

1. A container of parsley flakes was past the best buy date.

2. Two unopened bags of bread were past the best buy date.

3. Food debris was found on the floor under the stove and under the large food mixer.

4. A scoop was on top of grains and cereals container.

5. Wet trays that were stacked together and not air dried.

These had the potential to place susceptible residents who receives food from Dietary Services at risk for food-borne illnesses.

Findings:

1. During a concurrent observation of the kitchen and interview, on 3/3/25, at 8:39 a.m., with the Dietary Services Supervisor (DSS), a container of parsley flakes was found on the spice rack with past best buy date of 02/23/2025. DSS confirmed that the container of parsley flakes was past the best buy date and should be discarded.

During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, Quality Assurance (QA) Nurse, and Administrator, the undated facility's policy and procedure (P&P) titled, Non-Leftover Food Products (Including Labeling & Dating of Products), was reviewed. The P&P indicated, .It is the policy of this facility to use food products by the manufacturers expiration date or, when no expiration date is provided, within time periods generally accepted as safe .DSS stated that she threw away all food that was past the best buy date as that was the facility's best practice.

2. During a concurrent observation of the kitchen and interview on 3/3/25, at 09:02 a.m., with the DSS, two bags of bread were found on the bread rack with a past best buy date of 2/26/25. DSS verified that the two bags of bread were past the best buy date.

During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the undated facility's policy and procedure (P&P) titled, Non-Leftover Food Products (Including Labeling & Dating of Products), was reviewed. The P&P indicated, It is the policy of this facility to use food products by the manufacturers expiration date or, when no expiration date is provided, within time periods generally accepted as safe. DSS stated that she threw away all food that was past best the buy date as that was the facility's best practice.

3. During an observation of the kitchen on 3/3/25, at 8:35 a.m., with the DSS, food debris were found on the floor under the kitchen stove.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0812 During an observation of the kitchen and interview on 3/3/25, at 8:42 a.m., with the DSS, food debris were found on the floor under the large food mixer. DSS stated, the kitchen area was expected to always be clean. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the facility's P&P titled, Sanitation dated October 2008 was reviewed. The P&P indicated, .1. Residents Affected - Many All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .

4. During an initial observation tour of the kitchen and interview on 3/3/25 at 08:53 a.m., with the DSS, a scoop was found on top of the grains/cereal container. The DSS stated that it should not be placed on top of

the grains/cereal container and pointed to another shelf where the scoop should be kept inside a clear container.

During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the facility's P&P titled, Food Receiving and Storage, revised October 2008 was reviewed.

The P&P indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .1. Food Services. or other designated staff, will maintain clean food storage areas at all times .

The DSS stated the facility did not follow their policy.

5. During an observation of the kitchen and interview on 3/3/25, at 09:20 a.m., with the Dietary Services Supervisor (DSS), wet trays were found stacked together and not air dried. DSS stated that all trays should be air dried before storing.

During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the facility's P&P titled, Sanitation dated October 2008 was reviewed. The P&P indicated, .10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. The DSS stated they did not follow the facility policy.

During a review of the 2022 FDA (Food and Drug Administration) Food Code, 4-901.11 indicated, Equipment and Utensils, Air-Drying Required .After cleaning and SANITIZING, EQUIPMENT and UTENSILS: ((A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 48985 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure garbage and refuse was not Residents Affected - Many overflowing and dumpster's lids were completely closed.

This failure had the potential to attract pests (like flies and rodents) and spread diseases and infection to the residents.

Findings:

During a concurrent observation and interview on 3/5/25, 3:25 p.m., with the Maintenance Supervisor (MS), two dumpsters located at the side of the facility across the parking lot were observed with the lid not completely closed and not covering the dumpsters. Multiple bags of trash created an overflow on the dumpster's lid. Maintenance Supervisor stated the trash should not be overflowing, and lids should be closed completely.

During a concurrent interview and record review on 3/7/25, at 11:10 a.m. with the Dietary Services Supervisor (DSS), Quality Assurance (QA) Nurse, and Administrator, the facility's undated policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, the policy indicated, .6. Outside dumpsters provided by garbage pickup service will be kept closed and free of surrounding litter . The Administrator confirmed the facility was not in compliance and the lid should always be closed all the way.

During a review of the 2022 FDA (Food and Drug Administration) Food Code, 5-501.115 titled Maintaining Refuse Areas and Enclosures the Food Code indicated, .Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or

the entry of rodents .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0825 Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48985 potential for actual harm Based on observation, interview, and records review, the facility failed to obtain initial screening for Residents Affected - Few rehabilitative services for one of 20 sampled residents, (Resident 455) upon admission.

This failure had the potential to result in a decrease in resident's range of motion (the extent and degree of movement a joint or series of joints can achieve) mobility and muscle strength.

Findings:

During a review of Resident 455's Admission Record, (a document showing a summary of the resident's information), dated 3/5/25, indicated, Resident 455 was admitted to the facility on [DATE REDACTED].

During a review of Resident 455's History and Physical Examination, (H&P) dated 1/29/25, indicated, Resident 455 had a past medical history of Cerebrovascular accidents (CVA), (commonly known as stroke, occur when blood flow to the brain is interrupted, leading to brain damage), Hemiplegia ( a condition characterized by paralysis or severe weakness on one side of the body). H&P indicated Resident 455 has

the capacity to make needs known but cannot make medical decisions. H&P further indicated that Resident 455 is on hospice ( a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease).

During a review of Resident 455's MDS (MDS, a federally mandated assessment tool), section GG (Functional Abilities and Goals), dated 1/29/25, Resident 455 needed substantial maximal assistance for mobility.

During an interview on 3/3/25 at 11:37 a.m., with Resident 455, Resident 455 stated that he wanted to regain strength and function of his left arm and left leg and wanted to be able to stand up again. Resident 455 stated that he does exercises only three to five times a week.

During a concurrent interview and record review, on 3/06/25 at 1:45 p.m., with Restorative Nurse Assistant (RNA), RNA stated that Resident 455 has no orders for rehabilitative therapy. Furthermore, Resident 455 has orders for omni cycle (a motorized rehabilitation system used in nursing homes to help patients with limited strength and muscle control participate in therapeutic exercise, focusing on improving balance, coordination, and muscle function) three to five times per week for sixty days. RNA confirmed that Resident 455 has orders for omni cylce.

During an interview on 3/07/25 at 9:40 a.m., with Director of Rehab (DOR), DOR stated that residents on hospice upon admission, are not being assessed or screened for the need for rehab services. DOR stated that rehab services for hospice residents are provided by the hospice facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0825 During a concurrent interview and record review on 3/07/25 at 2:07 p.m., with the Director of Rehab (DOR),

the facility's undated policy and procedure (P&P) titled PT/OT/ST Therapy services Resident Screening, Level of Harm - Minimal harm or indicated that, A therapy screen will be completed upon admission, readmission, quarterly or when any potential for actual harm resident shows a significant change in functional ability or safety. A screen indicates if an evaluation is warranted or not . DOR confirmed that as per policy, a therapy screening will be completed upon admission Residents Affected - Few on all residents. Furthermore, DOR confirmed that Resident 455 should have been screened upon admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39539 potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control and Residents Affected - Few prevention measures when:

1. Licensed Vocational Nurse (LVN) 2 did not perform proper hand hygiene (the process of cleaning one's hands to remove dirt, germs, and microorganisms with soap and water or an alcohol based foam or gel)

during medication administration for Residents 48, 58, and 59.

2. Certified Nurse Assistant (CNA) 1 failed to perform hand hygiene and don (put on) gloves and an isolation gown before entering Resident 355 room, who was on Contact Isolation Precautions (a set of precautions used to stop the spread of germs from a patient to others).

3. Two sharps containers (used for safe disposal of used needles and syringes) were observed filled past the full line indicator (a line marker indicating the container needs to be replaced) for two of three sampled medication carts (Carts 2 & 3). This had the potential risk for infections related to needlestick injuries (injuries caused by punctures from needles used in medical procedures).

These failures had the potential for cross contamination and spread of infection which can adversely affect

the health and wellbeing of the residents, staff, and visitors.

Findings:

1. During a Medication Administration observation on 3/5/25 at 9:09 a.m., LVN 2 prepared the medications for Resident 59. LVN 2 donned (put on) a new pair of gloves and sanitized the wrist BP (Blood Pressure - the force of blood pushing against the walls of the arteries) monitor. LVN 2 then placed the BP monitor on top of

the medication cart, doffed (removed) the used pair of gloves, and waited two minutes for the wrist BP monitor to dry. Afterwards, LVN 2 entered Resident 59's room and placed the BP monitor on the resident's wrist. LVN 2 did not perform hand hygiene after sanitizing the wrist BP monitor, and before and after touching Resident 59. After obtaining Resident 59's BP, LVN 2 proceeded to prepare Resident 59's medications. Once all the medication tablets were placed inside a plastic cup, LVN 2 proceeded to administer the medications to Resident 59. LVN 2 did not perform hand hygiene before and after medication administration. After administering medications to Resident 59, LVN 2 stated he will proceed to administer medications to Resident 58.

During another Medication Administration observation on 3/5/25 at 9:26 a.m., LVN 2 used hand sanitizer prior to donning a new pair of gloves. LVN 2 proceeded to sanitize the wrist BP monitor, doffed the used gloves, and then waited for the BP monitor to dry for two minutes. Once the BP monitor was dry, LVN 2 entered Resident 58's room and placed the BP monitor on the resident's wrist. After obtaining the BP, LVN 2 prepared the medications. LVN 2 did not perform hand hygiene after sanitizing the BP monitor and before and after touching the resident. Once all the medication tablets were placed inside a plastic cup, LVN 2 administered the medications to Resident 58. LVN 2 did not perform hand hygiene before and after medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0880 During a follow-up Medication Administration observation on 3/5/25 at 10:45 a.m., LVN 2 stated he will be administering insulin (a medication that helps regulate blood sugar levels) to Resident 48. Prior to Level of Harm - Minimal harm or administering the medication, LVN 2 sanitized his hands and donned a new pair of gloves. LVN 2 then potential for actual harm placed the glucose meter (a device that measures the amount of sugar in the blood) and lancet (a sharp tool used to make incisions or pricks in the skin) on a clean tray and entered Resident 48's room. LVN 2 used an Residents Affected - Few alcohol pad to clean Resident 48's finger and waited for it to dry. Upon pricking the finger with the lancet, no blood came out. LVN 2 removed his gloves, did not perform hand hygiene, and proceeded to retrieve a new lancet from the medication cart. LVN 2 donned new gloves, cleaned the resident's finger with an alcohol pad, waited for it to dry, and pricked the finger using the lancet. Upon pricking the finger, LVN 2 wiped away the first drop of blood with gauze. However, LVN 2 realized he did not have a glucose test strip (a small strip of material used with a glucose meter to measure blood sugar levels) available in the tray. While still wearing both gloves on, LVN 2 went back to the medication cart located in the doorway. LVN 2 kept the right glove on and only removed the left glove to retrieve a glucose test strip from the medication cart. LVN 2 did not perform hygiene. Once LVN 2 obtained the glucose test strip and placed it on the tray, LVN 2 donned a new glove on his left hand and proceeded to check the resident's glucose level. There was no hand hygiene performed after wiping the first drop of blood from the resident's finger, before opening the medication cart, and before checking the resident's glucose level. LVN 2 proceeded to administer the correct dose of insulin to Resident 48. However, LVN 2 did not perform hand hygiene before and after administering the medication.

During an interview on 3/5/25 at 11:00 a.m. with LVN 2, LVN 2 was asked about the facility's infection control practices during medication administration. LVN 2 stated hand hygiene should be performed before and after administering medications. LVN 2 stated hand hygiene should also be performed before and after touching

the resident. LVN 2 was informed of the observation findings. LVN 2 acknowledged the findings. LVN 2 stated he should have performed hand hygiene and removed both gloves after checking the resident's glucose level.

During an interview on 3/6/25 at 3:50 p.m. with the Director of Staff Development (DSD), the DSD was asked about the facility's infection control policies during Medication Administration. The DSD stated the policy was for the staff to perform hand hygiene before and after administering medication, anytime a staff entered and left the resident's room, and before and after touching the resident. The DSD stated the importance of performing hand hygiene was to ensure infection was not transmitted to other people.

A review of the facility's policy and procedure titled Administering Medications, revised 4/2019, indicated . Staff follows facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable .

A review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised 8/2019, indicated . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with the residents .c. Before preparing or handling medications .g. Before handling clean or soiled dressings, gauze pads, etc .i. After contact with a resident's intact skin .j. After contact with blood or bodily fluids .k. After handling used dressings, contaminated equipment, etc l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .m. After removing gloves .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0880 46488

Level of Harm - Minimal harm or 2. During a review of Resident 355's Admission Record, (a document showing a summary of the resident's potential for actual harm information) dated 3/5/25, indicated Resident 355 was admitted to the facility on [DATE REDACTED].

Residents Affected - Few A review of Resident 355's Order Summary Report, dated 3/7/25, showed an active physician's order dated 2/18/25, indicating Contact Isolation Precautions R/T (related to) Bacteremia.

During an observation on 3/3/25 at 12:45 p.m., in front of Resident 355's room, CNA 1 entered Resident 355's room without wearing gloves and a gown. Resident 355's room had a sign in front of the room indicating, See nurse before entering the room and a plastic bin with drawers containing Personal Protective Equipment ([PPE] - items like gloves, gowns, masks, respirators, goggles or face shields, used to protect from infectious agents) outside the door. CNA 1 assisted Resident 355 with his cellphone, then returned the cellphone to Resident 355 and proceeded to exit the room without performing hand hygiene.

During an interview on 3/3/25 at 12:50 p.m. with CNA 1, CNA 1 stated the facility's policy was to use PPE when providing direct care for a resident on Contact Isolation Precautions. CNA 1 verified she did not wash her hands after assisting Resident 355 and the next time CNA 1 would perform hand hygiene is when she entered another resident's room.

During an interview on 3/4/25 at 9:35 a.m. with Treatment Nurse (TN) 2, TN 2 acknowledged Resident 355 was on Contact Precautions due to an active infection in urine. TN 2 stated prior to entering Resident 355's room, staff must perform hand hygiene and don PPEs including a gown and gloves. TN 2 further stated that if staff entered Resident 355's room and touched any of Resident 355's belongings, including a cellphone, donning PPEs were required, and hand hygiene must be performed prior to the exit of Resident 355's room.

During an interview on 3/5/25 at 8:55 a.m. with Registered Nurse (RN) 1, RN 1 verified Resident 355 was on Contact Isolation and stated the expectation prior to entering the room was to perform hand hygiene and don PPEs and prior to exiting of the room was to remove PPEs and perform hand hygiene. RN 1 stated the importance of hand hygiene and following the infection control protocol for a resident in isolation, was to prevent spread of infection, organism, and bacteria.

During a concurrent interview and record review with the DSD on 3/7/25 at 8:52 a.m., the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised August 2019, indicated .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for

the following situations: . b. before and after direct contact with residents; .l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; .n. Before and after entering isolation precaution settings . The DSD verified the facility's hand hygiene policy and stated staff must adhere and follow the policy as mentioned above.

44529

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 056183 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056183 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Healthcare Center 1680 North Waterman Avenue San Bernardino, CA 92404

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 0880 3. During a concurrent observation and interview on 3/3/25 at 10:40 a.m. with LVN 3, LVN 3 was observed attending to Medication Cart 3. There was a sharps container attached to the side of the medication cart that Level of Harm - Minimal harm or was filled past the full line indicator. LVN 3 stated whoever was assigned to the cart is responsible for potential for actual harm changing and disposing sharps container when it is full, further stating the container on Medication Cart 3 should have been replaced because the contents were past the full line indicator. Residents Affected - Few

During a concurrent observation and interview on 3/5/25 at 9:02 a.m. with LVN 2, LVN 2 was observed attending to Medication Cart 2. The sharps container attached to the side of the medication cart was observed filled past the full line indicator. LVN 2 stated whoever was assigned to the cart is responsible for changing and disposing sharps container when it is full, further stating the container on Medication Cart 2 should have been replaced because the contents were past the full line indicator.

During a concurrent interview and record review with the Quality Assurance (QA) Nurse , on 3/7/25, at 11:10 a.m., of the facility's P&P, titled, Sharps Disposal, revised January 2012, indicated, .The facility shall discard contaminated sharps into designated containers .Policy Interpretation and Implementation .3 .c. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container . The QA Nurse stated they did not follow their policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 056183