Health inspection·July 8, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of six sampled Residents (Resident 1) despite Resident 1's admitting diagnosis of stimulant (drugs that increase the activity of the central nervous system) use and a positive illicit drug test results from the urine drug screening during the recent hospitalization. This failure placed Resident 1 at risk for undetected drug use or relapse, undetected overdose that could result in medical emergency and had the potential for delayed delivery of care and mental health decline. Findings: Resident 1 was admitted to the facility mid-2025 with a diagnoses of deep skin infection caused by bacteria and other stimulant abuse. A review of Resident1's Brief Interview for Mental Status (BIMS), dated 5/15/25, the BIMS indicated Resident 1 had a score of 15 out of 15 which indicated Resident 1 was cognitively intact. A review of Resident 1's Order Summary Report (OSR), dated 5/14/25, the OSR indicated, .Resident has mental capacity to make decisions. A review of Resident1's Nurses Notes (NN), dated 6/30/25 at 5:15 a.m., the NN indicated, .Resident has been outside mostof [sic] day with significant other. Resident brought back inside .this writer did ask if Resident had taken anything while outside d/t [due to] hx [history] of meth [methamphetamine, highly addictive central nervous system stimulant, high potential for abuse] abuse and significant other at the facility . A review of Resident1's NN, dated 6/30/25 at 9:28 a.m., the NN indicated, Upon receiving shift report from the night nurse it was noted that pt [patient] from Room (number) had spent most of the previous evening outside with her significant other .Due to the elevated temperature and per pt request, pt was sent outto [sic] hospital @ [at] 0923 for further evaluation report was given to (name of hospital). A review of Resident 1's hospital History and Physical (H&P), dated 6/30/25, the H&P indicated, Patient appears intoxicated [under the influence of a substance] and not able to add any history voluntarily .positive for meth and fentanyl [potent synthetic opioid that has high risk of overdose]. Page 1 of 3 056109 056109 07/08/2025 Woodland Post-Acute 678 3rd Street Woodland, CA 95695

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's hospital Discharge Summary (DS), dated 7/2/25, the DS indicated, Discharge Diagnosis: Diagnosis this visi .Toxic encephalopathy (neurologic disorder) and Polysubstance abuse (using more than one drug or substance) .U-Tox [Urine Drug Screening] positive for meth and fentanyl . A review of Resident 1's NN, dated 7/2/25 at 1:50 p.m., the NN indicated, Resident returned from [name of hospital] at 1:45 pm via gurney . However, there was no indication of Resident 1's positive drug screening for methamphetamine and fentanyl. A review of Resident1's NN, dated 7/5/25 at 10:59 a.m., the NN indicated, Resident is always hanging outside the smoking area after hours . A review of Resident1's NN, dated 7/6/25, at 5:49 a.m., the NN indicated, After reviewing the DC (Discharge) Summary, it is noted that Resident's tox screen was positive for Meth and Fentanyl. Spoke with the Resident and Resident stated that she has been actively using . A review of Resident1's Medical Record (MR) included there was no documented evidence that care plan had been developed for Resident 1's stimulant use during initial admission and after Resident'1 recent urine drug screening tested positive for meth. During an interview with the License Nurse (LN) 1 on 7/8/25 at 12:49 p.m., LN 1 stated that if a Resident drug screening came back positive, the MD [Medical Director], DON [Director of Nursing] and ADM [Administrator] needed to be notified at once. LN 1 added the facility needed to have a care plan for the Residents and to provide education about the complications of drug use. During an interview with the Physical Therapist (PT) at 7/8/25 at 2:16 p.m., the PT stated, Partner comes here regularly to visit her, and they are smoking together all the time. The PT added staff do not accompany Resident 1 and the spouse when they were outside. The PT also stated, I have seen him before to visit her and stayed for a long time. The pt added, there was no care plan implemented regarding the situation and stated, nurses have not relayed any plans to me. During an interview with the Activities Director (AD) on 7/8/25 at 2:47 p.m., The AD stated the spouse was at the facility every day. The AD added Resident 1 and the spouse were mostly staying outside smoking in the patio and they were unsupervised by staff. The AD stated, (Resident 1's Name) can go out anytime and it won't be supervised. Independent smokers can go out and smoke anytime. It is a home-like environment. During a concurrent interview and records review with the Social Service Director (SSD) on 7/8/25 at 2:54 p.m., The SSD confirmed that she was aware of Resident 1 stimulant use during admission and stated, She said she used to do that with the husband in the car. the SSD also confirmed that there was no care plan in effect for Resident 1's substance use. When asked if Resident 1 could have used a stimulant in the facility, the SSD stated, It was a possibility based on Resident 1's recent drug screening. During an interview with Resident 1 on 7/8/25 at 3:15 p.m., when asked about her recent urine drug screening, Resident 1 stated, I used two weeks ago. Resident 1 confirmed that she used meth in the premises of the facility and stated, I used it outside around the corner [facility], there's no staff there. Resident 1 added that her spouse regularly visited her. 056109 Page 2 of 3 056109 07/08/2025 Woodland Post-Acute 678 3rd Street Woodland, CA 95695

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 7/8/25 at 3:26 p.m., the DON confirmed that Resident 1 was allowed to go outside unsupervised around the premises of the facility. When asked if the facility had initiated a plan for Resident 1's substance use, the DON stated, 'I am not sure if a plan was started. The DON stated, The facility should have started a risk management and IDT (Interdisciplinary Team) meeting, and that monitoring should have been implemented because of Resident 1's substance abuse history. The DON also added that a care plan should have been started and stated, It was important for nurses to know what's going on with her [Resident 1] and to have a plan of care, so they know what they need to do with the situation and that everybody was aware of the situation. The DON also stated that she expected the nurses to review the Resident's discharge papers from the hospital, which included the history and physical. The DON later confirmed that the facility did not follow up with the Resident and did not have a care plan in effect to Resident 1's substance use. During a review of the facility's policy and procedure (P&P) titled, Care of Resident with Substance Use Disorder, dated 11/30/22, the P&P indicated, PROCEDURE .2. An individualized care plan with person-centered intervention will be developed .addressing the risk of overdosing .and drug - seeking behavior, including leaving the facility without notifying staff . 3. A resident identified with known history of substance abuse will be monitored for signs and symptoms of possible use, such us frequent leaves of absence with or without facility knowledge . 4. The facility shall make efforts to prevent substance use while in the facility . 5. Interdisciplinary Team (IDT) members will conduct a meeting with the resident and/or the residents legal representative . 056109 Page 3 of 3