Health inspection·March 15, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - A progress note dated [DATE], indicated, Resident is on alert charting for confusion, aggressive assaultive behavior towards staff and other residents and for a witnessed fall . [Staff] were both in there with me encouraging the resident to get back into his own bed, he had told both [Staff] to shut up. He finally got into his bed. - A progress note dated [DATE], indicated, This Resident [Resident 2] Was found (in room [Resident 3 ' s room number]) with both hands around this resident's neck after CNA heard, a scream from Room, entered quickly, she immediately released hands from, victim, separating them both calling for assistance. Victim was examined, some noted red marks, noted at back of neck, of victim, no injuries noted from aggressor. MD/ [Medical Doctor] and emergency contact notified, And MD notified orders to transfer to ER [Emergency Room] for acute physical aggression. Local authorities notified and came to assess., orders to discontinued to transfer and placed on one on one for safety [staff monitoring]. - A Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated, Resident 2 was cognitively intact having anxiety disorder and receiving antianxiety and antipsychotic medication. A review of Resident 3 ' s medical record included the following documents: - An admission record printed on [DATE], indicated Resident 3 was most recently admitted to the facility in summer of 2023 with diagnoses including muscle weakness, anxiety, depression (a mental condition of feeling down), and dementia. - A care plan dated [DATE], indicated, [Resident 3] has a potential for psychosocial well-being problem r/t [related to] dementia and depression. He is at risk for deceased socialization, depression and further decline. - A care plan dated [DATE], indicated, [Resident 3] was the victim of physical altercation with another resident on [DATE]. - A Nursing note dated [DATE], indicated, [Resident 3] reports c/o [complains of] Patient was the victim in a resident to resident incident. patient was choked by peer. Patient noted with redness to neck. that began on [DATE] 4:50 PM and have gotten better since the onset. resident in close contact with aggressor make the symptoms worse, while keeping patient separate from aggressor improve the symptoms. These symptoms have not occurred before. - A Nursing note dated [DATE], indicated, Heard Yelling coming from room [Resident 3 ' s room number] while passing my meds, upon entering room seen CNAs between patients separating them, patient was screaming and stating he was getting chocked, upon assessment seen red marks around his neck. no major injuries sustained, will continue to monitor for any changes. - A MDS dated [DATE], indicated that Resident 3 was cognitively intact and had diagnoses of anxiety and depression. During a concurrent observation and interview on [DATE] at 9:00 a.m. with Resident 3 in his room, Resident 3 was observed sitting on the wheelchair next to his bed facing outside window, no red marks or scratches observed on his neck. Resident 3 stated that he was safe until he had been chocked by this beast (referring to Resident 2). Resident 3 stated that he did not know what triggered Resident 2 to attack him and they used to be roommates in the past. Resident 3 stated that he heard Resident 2 entering his room he probably said [Resident 2 ' s name] it ' s your lucky day. Resident 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 2 of 8 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 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few described how on the day of the incident he was sitting on the wheelchair facing window and how Resident 2 approached him and grabbed his neck with both hands. Resident 3 stated that he screamed for help and staff shortly came and separated both residents. Resident 3 stated, it hurts my reputation. Resident 3 expressed concern that he could possibly be attacked again because Resident 2 still wonders the hall. In an interview on [DATE] at 12:52 p.m. LN 1 stated that on [DATE] he helped responding to calls for help in separating Resident 2 and Resident 3 and as he walked in Resident 3 ' s room at the time of the incident he saw Resident 3 on the wheelchair and Resident 2 nearby and CNA 3 on the side separating the residents. LN 1 also confirmed that Resident 2 had prior history of aggression toward staff. In a phone interview on [DATE] at 9:15 a.m. CNA 3 stated that on [DATE] she responded to creaming from Resident 3 ' s room and as she walked in the room, she saw Resident 3 sitting in the wheelchair facing the window and Resident 2 standing by the side with hands over Resident 3 ' s neck. CNA 3 asked Resident 2 to stop and separated both residents. In a phone interview on [DATE] at 2:36 p.m. Director of Nursing (DON) confirmed that Resident 2 had history of aggressive behavior prior to the reported incident that occurred on [DATE]. DON also stated that she expects facility residents to be free from physical or verbal harm from staff or other residents. A review of the facility ' s Policy and Procedure (P&P), revised [DATE], titled, Safety and Supervision of Residents, 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 .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .Employees shall be trained on potential accident hazard and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents .risk factors and environmental hazards include the following .falls .unsafe wondering. A review of the facility ' s P&P dated 11/2017, titled, Freedom From Abuse, Neglect and Exploitation Abuse, indicated, The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation . Definition of Abuse: The willful infliction of injury . Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Resident to resident abuse: a. Cognitive impairment or mental disorder does not preclude a resident from being abusive . c. Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g. physical, sexual or verbal aggression; taking, touching or rummaging through another ' s property; wandering into another ' s rooms/space). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 3 of 8 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 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 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 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 interview and record review, the facility failed to ensure professional standards were met when Licensed Nurse (LN2) left refused medications scheduled for the morning administration at Resident 4 ' s bedside, marked them as administered and took medications back during the evening shift, crushed them and mixed them with food and attempted to administer the medications to the Resident 4. Residents Affected - Few These failures resulted in Resident 4 ' s distrust of staff, refusing care and food, and stating that staff are trying to poison her. These failures also had the potential for unattended medications to be taken by other residents which could result in bodily harm. Findings: A review of Resident 4 ' s admission record indicated Resident 4 was most recently admitted to the facility early 2024 with diagnoses which included sepsis (A life-threatening complication of an infection), diabetes (a chronic health condition that affects how body processes sugar), depression (a mental condition of feeling down), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 4 ' s Medication Administration Record (MAR) for February of 2024 indicated that the following medications were marked as refused or administered to Resident 4 at scheduled times by LN 2 on 2/25/24: -Ascorbic Acid (a vitamin medication) Tablet 500 mg (milligram, unit of measurement), give 1 tablet by mouth one time a day. Marked as given at 8:00 a.m. -Ferrous Gluconate (a supplement used to treat red blood cell deficiency) Oral Tablet 240 mg, give one tablet by mouth in the morning .with breakfast. Marked as given at 7:30 a.m. -Furosemide (a medication that stimulates higher urine output) Oral Tablet 20 mg, give one tablet by mouth one time a day for BLE (bilateral lower extremities) edema. Marked as given at 8:00 a.m. -Insulin Glargine (a medication for lowering blood sugar) Subcutaneous Solution 100 unit/ml (units per milliliter, concentration) inject 10 units subcutaneously (under the skin) at bedtime. Marked as refused at 8:00 p.m. -Lovenox (a blood thinning medication used to prevent blot clots) injection solution 40mg/0.4ml (a concentration ratio of milligrams to milliliters), inject 0.4 ml subcutaneously one time a day. Marked as given at 8:00 a.m. -Magnesium Oxide (a mineral supplement medication) oral tablet 400 mg, give one tablet by mouth one time a day for supplementation. Marked as given at 8:00 a.m. -Metoprolol Succinate ER (a blood pressure medication in extended release formulation) 25 mg, give 3 tablets by mouth one time a day for high blood pressure. Marked as given at 8:00 a.m. -Multiple Vitamin Tablet, give 1 tablet by mouth one time a day for supplementation. Marked as given at 8:00 a.m. -Zinc Sulfate Capsule 220 mg, give 1 capsule by mouth one time a day for supplementation. Marked as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 4 of 8 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 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 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 0684 given at 8:00 a.m. Level of Harm - Minimal harm or potential for actual harm -Active Liquid Protein, two times a day for supplementation give 30ml. Marked as given at 8:00 a.m. and 4:00 p.m. Residents Affected - Few - No orders to administer scheduled medications at 5:30 p.m. (with administration window of 1 hour prior and after scheduled time 4:30 p.m. to 6:30 p.m.) were found. A review of Resident 4 ' s Order Summary Report, active orders as of 2/25/24, indicated, May crush crushable meds in applesauce or other carrier PRN [as needed] During a concurrent observation and interview on 3/8/24 at 2:47 p.m. Resident 4 was observed in her room sitting on the wheelchair near her bedside and drinking diet soda from an aluminum can (original container). Full pitcher of water with full cup of water were noted by the surveyor and Resident 4 stated that she doesn ' t drink water because she can ' t trust what ' s in that water. Resident recalled events that happened around 2/25/24 and stated, One of the CNAs took ice cream and spiked it with medication. She continued by stating that staff who brought the ice cream did not tell her that it contained medications. Resident 4 stated that she looked at the ice cream and told the staff that it was tainted with something and staff replied that it was fine and she can get another one if resident wanted the ice cream. Resident 4 further stated that the same staff member brought her ice cream again stating that it was a new ice cream, but it was the same tainted ice cream with medications. Resident 4 stated that staff were trying to poison her. In an interview on 3/8/24 at 1:33 p.m. Social Services Director stated that after incident on 2/25/24 involving Resident 4, she had to follow up after Resident was refusing to eat and drink stating that something is being added to her food and after some negotiations resident agreed to eat packaged or sealed foods and drinks. In a phone interview on 3/26/24 at 10:12 a.m. CNA 4 stated that she was working with Resident 4 on 2/25/24 both morning and evening shifts, and around 5:30 p.m. on that day, she went to Resident 4 ' s room to discuss food options and Resident 4 asked for an ice cream. In the room, she noted a medicine cup half full of medications was at the resident ' s bedside and she brought it to the nurse who was in the doorway. CNA 4 stated that LN 2 was near the entry to the room working on medications cart. CNA 4 stated that LN 2 confirmed that medications brought in the cup were left with the resident since the morning administration. CNA 4 observed how LN 2 crushed medications out of the cup that was brought from the Resident 4 ' s bedside. When CNA 4 brought the ice cream for Resident 4, LN 2 took the ice cream and added crushed medications to it and mixed it up. Later, LN 2 came out of the room and informed that Resident 4 refused the ice cream because it was contaminated and asked CNA 4 to get another ice cream. When CNA 4 brought another ice cream, LN 2 took it and added a top portion from the first ice cream containing most crushed medications and mixed in into the new ice cream that was brought. Shortly LN 2 came out of the Resident 4 ' s room and threw away the second ice cream that was brought. CNA 4 added that later, during room rounds Resident 4 was refusing all care including being changed because she didn ' t trust staff. In a phone interview on 3/29/24 at 12:23 p.m. LN 2 confirmed that on the morning of 2/25/24 Resident 4 refused her morning medications and the cup with medications was left on the bedside table. LN 2 also confirmed that medications remained in Resident 4 ' s room at around 5:30 p.m. and LN 2 took those medications and crushed them and tried to administer them with ice cream. Resident 4 refused. LN 2 confirmed that she did not notify the physician of Resident 4 ' s medication refusal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 5 of 8 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 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a phone interview on 3/29/24 at 2:36 p.m. Director of Nursing (DON) stated that she did not believe Resident 4 was allowed to manage her own medications, and LN 2 should have observed Resident 4 swallowing the morning medications and not leave them in the room. She also confirmed that unlabeled medications should not have been taken back from the room for further administration attempts, and nurse should have informed resident of the medications that were added in food (ice cream). DON confirmed that each medication should be crushed separately. DON also stated that residents have the right to refuse medications and nurses should educate residents on risk and benefits of medications and notify doctors regarding refusals. DON confirmed that the risk of not administering timely blood pressure medications scheduled for Resident 4 ' s administration on 2/25/24 included stroke and other complications. A review of the facility ' s policy and procedure (P&P) titled Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .Factors that are considered include .honoring resident choices and preferences .Medications are administered within one (1) hour of their prescribed time .If a drug is withheld, refused, or given at the time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided to that drug and dose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 6 of 8 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 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 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 - Few 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 provide an environment free of accident hazards for one of two sampled residents (Resident 1) with falls when, Resident 1 was left alone in the wheelchair in her room while staff attempted to locate the footrests for the wheelchair and Resident 1 sustained a fall from the wheelchair during that time on the morning of 2/15/24. These deficient practices resulted in Resident 1 sustaining an avoidable fall [NAME] resulted in a scalp laceration (cut on the head). Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility in fall of 2018 with diagnoses that included Alzheimer ' s disease (A progressive disease that destroys memory and other important mental functions), muscle weakness, need for assistance with personal care, and unspecified convulsions. A review of Resident 1 ' s progress note dated 2/15/24 indicated, patient had an unwitnessed fall with injury that began on 02/15/2024 6:30 AM and have gotten worse since the onset. patient has been leaning foward in her chair more frequently, poor trunk control make the symptoms worse, while will assess in IDT [Interdisciplinary Team] improve the symptoms. These symptoms have occurred before . other history of unspecified convulsions A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 1/4/24, indicated Resident 1 has impaired function of both lower extremities and is fully dependent on staff assistance for transfers and repositioning in bed. MDS also indicated that Resident 1 had severely impaired mental status. A review of Resident 1 ' s fall risk assessment documentation titled Morse Fall Scale dated 1/17/24, indicated, Resident 1 was at high risk for falling. A review of Resident 1 ' s care plan record indicated the following care plans: - [Resident 1] had an actual fall on 2/15/24 with laceration to Right lateral forehead Date Initiated: 02/15/2024. - [Resident 1] is on the Fall Program Date Initiated: 02/16/2024. - Bed Mobility: [Resident 1] requires extensive assistance by (1-2) staff to turn and repositioning in bed. Date Initiated: 09/20/2018 Revision on: 06/23/2019. - Transfer: [Resident 1] is limited/extensive assist of (1-2) staff for transferring. Date Initiated: 09/20/2018 Revision on: 09/15/2020. - [Resident 1] has had an actual fall on 1/17/24 without injury. Date Initiated: 04/14/2019 Revision on: 01/17/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 7 of 8 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 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 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 - Few In an interview on 3/8/24 at 12:01 p.m. Certified Nursing Assistant (CNA 1) stated that on 2/15/24 she was assigned to take care of Resident 1. In the morning of that day, she used assistance from CNA 2 to transfer Resident 1 to a wheelchair using a full body lift. After moving resident over to the wheelchair, CNA 2 left the room to take care of her assigned residents, and CNA 1 remained in the room accommodating Resident 1 on the wheelchair without leg rests and without safety lap belt or straps. CNA 1 stated that it was important to use leg rests on a given wheelchair as it was giving Resident 1 additional support to prevent her from falling forward. CNA 1 was not able to find leg rests in the room and she stepped out of the room and walked over to the nurse ' s station looking for leg rests. While being out of the room CNA heard a noise from the room and rushed back as she was concerned that Resident 1 had significant leaning forward behavior while sitting. I know she [Resident 1] has been leaning . she may fall. CNA 1 came to the room and found Resident 1 on the floor with a bleeding cut on the forehead. CNA 1 called for help from the nurses. CNA 1 also stated that she was reluctant to ask for assistance from other CNA's for getting wheelchair leg rests or for monitoring Resident 1 while she searched for the leg rests because they were busy caring for other residents. During a concurrent observation and interview on 3/8/24 at 12:31 p.m. with CNA 2 in the hallway near Resident 1 ' s room, CNA 2 confirmed that she helped CNA 1 transferring Resident 1 from bed to the wheelchair on the morning of 2/15/24 prior to Resident 1 ' s fall incident, and she left the room before the incident occurred. CNA 2 also stated that Resident 1 had prior history of leaning forward on the wheelchair and had a few instances when she nearly fell. CNA 2 explained that Resident 1 required special Geri-chair that would position resident nearly horizontal to prevent tilting forward and falling. CNA 2 pointed at corner of the hallway where Resident 1 was laying in the Geri-chair positioned nearly horizontal (in laying rather than in sitting position) and stated that Resident 1 is much better (safer) in this newer chair. In an interview on 3/8/24 at 12:52 p.m. Licensed Nurse (LN 1) confirmed that Resident 1 had history of seizures and tilting forward behavior that existed prior to her fall on 2/15/24. LN 1 also stated that it would not be safe to use regular wheelchair for Resident 1 as she [Resident 1] would fall out. In an interview on 3/8/24 at 1:33 p.m. CNA 1 confirmed that on the morning of 2/15/24, prior to fall incident, Resident 1 was placed on a wheelchair that had some tilt back adjustment, but it was only small angle recline. CNA 1 stated that Geri-chair currently used by Resident 1 was provided after the incident and it reclines considerably farther, and it has a different (more stable) leg rest adjustment. A review of the facility ' s Policy and Procedure revised March 2018, titled, Falls and Fall Risk, Managing, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 8 of 8