Health inspection·October 15, 2024

F 0689 Resident 1 had a fractured (broken) left clavicle. Level of Harm - Actual harm A review of Resident 1 ' s clinical record titled, [ACUTE CARE HOSPITAL NAME] Progress Notes *New*, dated 9/10/24, at 9:06 p.m., by LN 5, indicated Resident 1 rolled out of bed and had complaints of pain scored at 10 out of 10 using the Numerical Rating Pain Scale (assessment tool 0 through 10; 0 = no pain and 10= the worst pain). Residents Affected - Few A review of Resident 1 ' s fall risk care plan, initiated on 8/29/22, indicated Resident 1 was at risk for falls related to her diagnosis of Parkinson's disease, weakness, urinary incontinence (unable to hold urine), use of antianxiety and antidepressant medications, history of falls, and required staff assistance with transfers and toileting. Interventions included fall mats at the bedside which was initiated on 9/1/2022. A review of Resident 1 ' s clinical record titled, Post Fall Evaluation, dated 9/10/24, at 4:42 p.m., indicated there was no fall mat in place at the time of the fall. A review of Resident 1 ' s clinical record titled, Interdisciplinary Team [IDT – a group of health care providers and other staff members that work together to discuss the care of Resident 1] Post Fall Meeting, dated 9/11/24, at 9:55 a.m., by LN 1, indicated Resident 1 rolled out of bed on 9/10/24, at 4:07 p.m. and sustained a fracture to her left clavicle, skin tears to the right and left side of her wrists, skin tears to the right index (finger next to the thumb) finger, a knot (bump) to the left side of her head, and complained of severe left shoulder pain that radiated (sent out) down to the elbow. At 4:45 p.m., Resident 1 was sent to [ACUTE CARE HOSPITAL NAME] for further evaluation. A review of Resident 1 ' s clinical record titled, [ACUTE CARE HOSPITAL NAME] Progress Notes *New*, dated 9/11/24, at 2:12 a.m., by LN 4, indicated Resident 1 returned to the facility from [ACUTE CARE HOSPITAL NAME] on 9/11/24, at 1:31 a.m. During a concurrent observation and interview on 10/16/24, at 11:50 a.m., in Resident 1 ' s room, Resident 1 had skin tears on her right hand that had steri-strips (thin, sticky bandages that are applied to the skin to help small cuts or wounds stay closed as they heal) in place, and a scabbed wound (a rough surface made of dried blood that forms over a cut or broken skin while it is healing) on her left fourth finger. There was no fall mat on either side of the bed. Resident 1 stated she was unsure how she fell out of bed on 9/10/24. During a concurrent observation and interview on 10/16/24, at 11:57 a.m., with LN 2, LN 2 stated Resident 1 required two staff members on each side of the bed when Resident 1 was turned and/or her brief was changed because Resident 1 was very fragile. LN 2 acknowledge there was not a fall mat at the bedside and that Resident 1 required a fall mat as part of her fall precaution interventions. During an interview on 10/15/24, at 12:05 p.m., with CNA 2, CNA 2 stated Resident 1 was a one person assist with brief changes and transfers (move from bed to wheelchair). CNA 2 stated she was unsure if Resident 1 needed a fall mat and was not sure where to look in Resident 1 ' s clinical record to verify if Resident 1 needed a one person or a two person assist with care needs. CNA 2 was unsure where to locate Resident 1 ' s care plan. During an interview on 10/15/24, at 12:10 p.m., with LN 3, LN 3 stated Resident 1 was a two person assist with brief changes (staff assistance to remove and replace an absorbent cloth or disposable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 2 of 5 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 10/15/2024 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 - Actual harm Residents Affected - Few products which is worn by humans who are incapable of, or have difficulty, controlling their bladder or bowel movements) and transfers because of her limited ability to assist with cares and because Resident 1 was very weak. During a phone interview on 10/15/24, at 12:36 p.m. with CNA 1, CNA 1 stated before Resident 1 ' s fall on 9/10/24, Resident 1 sometimes required a one person assist and sometimes required a two person assist with cares (depending on Resident 1 ' s strength on a given day). CNA 1 stated on the day of the fall, CNA 1 rolled Resident 1 ' s body away from her on the bed and then CNA 1 turned to grab the brief off of the nightstand. CNA 1 stated that was when Resident 1 fell out of bed. CNA 1 stated after the fall, Resident 1 declined in her physical ability to be helpful with her own cares. CNA 1 stated after the fall Resident 1 complained her head and shoulder hurt and Resident 1 was later transferred to [ACUTE CARE HOSPITAL NAME]. During a concurrent interview and record review on 10/15/24, at 1:20 p.m., with the Minimum Data Set (MDS - standardized assessment of Resident 1) Nurse, Resident 1 ' s clinical record titled, Section GG – Functional Abilities and Goals (a section of a comprehensive assessment that reviewed Resident 1's physical abilities), dated 6/30/24 and Section GG – Functional Abilities and Goals, dated 9/16/24, were reviewed. Section GG, dated 6/30/24 (before the fall), indicated Resident 1 required supervision or touch assistance (the helper provided verbal cues and/or touching/steadying assistance and the helper set up or cleaned up, but Resident 1 completed the activity) when she ate her meals. Resident 1 was dependent on staff when she rolled to the right and to the left (the helper did all the effort) and with all other ADLs. Section GG – Functional Abilities and Goals, dated 9/16/24 (after the fall), indicated Resident 1 was dependent on assistance when she ate her meals (the helper did all the effort and Resident 1 did none of the effort to complete the activity). Resident 1 remained dependent on staff when she rolled to the right and to the left and with all other ADLs. The MDS Nurse stated before the fall, Resident 1 was able to feed herself most of the time and after the fall she needed total assistance with eating. The MDS Nurse stated Resident 1 ' s care plan was supposed to be read and followed by all CNAs, Licensed Vocational Nurses (LVN), Registered Nurses (RNs), and the entire care team to guide them in how to specifically care for Resident 1. During an interview on 10/15/24, at 2:04 p.m., with the Occupational Therapist (OT), the OT stated before the fall, Resident 1 was able to feed herself independently more often than she was not able to feed herself independently and Resident 1 had started Occupational Therapy on 10/7/24 to increase independence with ADLs. The OT stated before the fall Resident 1 had use of both of her arms (Resident 1 was right-handed). The OT stated after the fall, Resident 1 had increased trouble with feeding and did not have use of her left arm (arm was in a sling; a device used to support and keep still (immobilize) an injured part of the body). The OT stated all health care professionals were supposed to read and follow Resident 1 ' s care plan to ensure safety during cares and treatments. A review of Resident 1 ' s clinical record titled, Occupational Therapy (exercises designed to increase independence with Activities of Daily Living (ADLs – brushing teeth, getting dressed, toileting, eating) Treatment Encounter Note(s), dated 10/11/24, at 2:24 p.m., by the Occupational Therapist (OT health care provider who assisted Resident 1 with Occupational Therapy), indicated Resident 1 attempted therapy and then immediately requested to lay back down in bed. A two-person assist (two health care providers assisted Resident 1) was used when Resident 1 was repositioned. Resident 1 ' s body movements led to pain (as evidenced by Resident 1 yelled out) and limited her functional activities. During a phone interview on 10/15/24, at 2:39 p.m., with the Medical Director (MD), the MD stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 3 of 5 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 10/15/2024 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 the facility should have provided the correct number of staff while providing cares to Resident 1 to ensure quality care was delivered. Level of Harm - Actual harm Residents Affected - Few During a follow-up interview on 10/15/24, at 2:50 p.m., with CNA 1, CNA 1 stated on 10/15/24, the Director of Staff Development (DSD) showed CNA 1 (for the first time) that the information regarding the amount of assistance Resident 1 required was located in Resident 1's care plan in the Electronic Heath Record ( a digital version of a patient's medical history that can be used to improve patient care) and in the [NAME] (a system that nurses used to organize and access resident ' s information for care planning). CNA 1 stated prior to 10/15/24, CNA 1 was unsure where to find information regarding the amount of assistance Resident 1 required during cares. CNA 1 stated after Resident 1 ' s fall, Resident 1 had a decline in her ability to feed herself. CNA 1 stated before the fall, Resident 1 used to call CNA 1 by name and after the fall Resident 1 did not recall CNA 1 ' s name. During a concurrent phone interview and record review on 10/16/24, at 12:27 p.m., with the Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR – a document that indicated when and what medication was administered to Resident 1), dated 9/24, was reviewed. The DON stated Tramadol (a government regulated pain mediation used to treat moderate pain (4 through 6 on the Numerical Rating Pain Scale) to severe pain (7 through 9 on the Numerical Rating Pain Scale) 50 milligrams (mg – unit of measurement) was ordered to be given every 6 hours following the fall on 9/10/24. The DON verified Resident 1 was given Tramadol 54 times for pain control in the month of September 2024. A review of Resident 1 ' s left clavicle fracture care plan, initiated on 9/11/24, in the section titled Interventions, indicated for Resident 1 to use a sling to her left arm at all times and was not supposed to put weight on the left arm. During a concurrent interview and record review on 10/15/24, at 3:25 p.m., with the DON, the following documents were reviewed: - Resident 1 ' s care plan related to ADL deficits, initiated on 8/30/22, - [Resident 1 ' s] [NAME], undated, - Certified Nursing Assistant Job Description, dated 10/20, - The facilities Fall and Fall Risk, Managing Policy and Procedure (P&P), dated 9/23, and - The facilities Care Plan, Comprehensive Person-Centered P&P, dated 3/22. The DON confirmed Resident 1 ' s ADL deficit care plan, initiated on 8/30/22, indicated Resident 1 ' s ADL interventions, also initiated on 8/30/22, included: extensive assistance by two staff members when Resident 1 was turned in bed and toileted. The DON confirmed Resident 1 ' s clinical record titled, [NAME], indicated Resident 1 required two staff members to assist Resident 1 when she was repositioned in bed, turned in bed, and with brief changes. A concurrent interview and record review with the DON continued with a review of the facility ' s document titled, Certified Nursing Assistant Job Description, indicated, . Duties and Responsibilities .review care plans daily to determine if changes in the resident ' s daily care routine have been made on the care plan The facility ' s P&P titled, Fall and Fall Risk, Managing, indicated, . 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 4 of 5 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 10/15/2024 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 - Actual harm Residents Affected - Few minimize complications from falling . The facility ' s P&P titled, Care Plan, Comprehensive Person-Centered, indicated, . The . team . develops and implements a . person centered care plan for each resident . After reviewing Resident 1 ' s ADL deficit care plan, Resident 1 ' s [NAME], the Certified Nursing Assistant Job Description, the Fall and Fall Risk, Managing P&P, and the Care Plan, Comprehensive Person-Centered P&P, the DON stated that CNA 1 should have used a two person assist to turn Resident 1 and two persons assist to change Resident 1 ' s brief. The DON stated Resident 1 ' s care plan was created to ensure Resident 1 received safe care from the healthcare team. The DON stated her expectation was that all the staff members would have read and followed Resident 1 ' s care plan. The DON verified Resident 1 ' s care plan, the CNA Job Description, and the above listed P&Ps were not followed. A review of the facility ' s undated educational power point titled, Lifting and Transferring, indicated, .WHEN CHANGING A RESIDENT-TIPS AND REMINDERS . Ensure there are appropriate staff to assist. For example, if the resident requires a 2 person assist, be sure to have 2 CNAs to assist . Ensure that all supplies are within reach, so you do not have to leave the resident ' s side. Always review the Care Plan or [NAME] prior to providing care to ensure proper plan of care is maintained . A review of the facility ' s P&P titled, Repositioning, dated 5/13, indicated, .check the care plan, . or the communication system to determine resident ' s specific positioning needs including Resident level of participation and the number of staff required to complete the procedure . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 5 of 5