Health inspection·January 21, 2025

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. Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) remained free of accidents and hazards when Certified Nursing Assistant (CNA) 1 gave Resident 1 a vape pen (also known as using an electronic cigarette - the act of inhaling an aerosol from a battery-powered device) that contained tetrahydrocannabinol (THC – the mind-altering compound of marijuana - a federally illegal drug that can cause increased heart rate and blood pressure, and confusion). This failure could have resulted in Resident 1 having an adverse reaction to the drug such as lung injury, confusion, and/or injury from the vape pen which could have been being laced with an unknown drug. Findings: A review of Resident 1 ' s clinical record titled, admission RECORD, indicated Resident 1 ' s diagnoses included anxiety (an emotion that could feel like dread or fear) and chronic obstructive pulmonary disease (COPD - a chronic lung disease that made it difficult to breathe). A review of Resident 1 ' s clinical record titled, N Adv – Smoking and Safety, (smoking assessment) dated 12/4/24, at 1:54 p.m., indicated Resident 1 did not use marijuana or vape products. A review of Resident 1 ' s clinical record titled, Nursing Note, dated 12/14/24, at 6:38 p.m., by Licensed Nurse (LN) 1 indicated, .Resident [Resident 1] informed a staff member that she had taken some puffs of a vape she was given, but it is not hers. She gave the vape to the staff member and apologized. Resident [Resident 1] told the writer she was unsure if there was THC in the vape . A review of Resident 1 ' s clinical record titled, Care Plan, (a document that contained Resident 1 ' s specific problems, goals, and interventions) dated 12/14/24, indicated Resident 1 was continuously on two liters (L – unit of measurement) of supplemental (additional) oxygen via nasal canula (a device that gives additional oxygen through a thin, flexible tube that goes around the head and into the nose). A review of Resident 1 ' s clinical record titled, Care Plan, dated 12/14/24, indicated Resident 1 used a vape pen with possible THC and was monitored for 72 hours for adverse reactions. During an interview on 1/21/25, at 9:40 a.m., with LN 2, LN 2 stated CNA 1 was not supposed to share a personal vape pen with Resident 1. LN 2 further stated the vape pen could have been laced (a drug or drink mixed with another substance) with an unknown substance and could have caused illness or Page 1 of 3 056132 056132 01/21/2025 Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few injury. LN 2 stated CNA 1 should have told a LN about Resident 1 ' s anxiety, and the nursing staff could have then tried relaxation techniques, changed Resident 1 ' s environment, or called the physician for a medication order. During an interview on 1/21/25, at 10 a.m., with CNA 2, CNA 2 stated the residents in the facility were not permitted to smoke marijuana via a vape pen or any other form of the drug. During an interview on 1/21/25, at 10:30 a.m., with CNA 3, CNA 3 stated CNA 1 used to be a hard worker, however; in the last few months CNA 1 had not produced quality work. CNA 3 further stated vape pens that contained THC were not permitted at the facility. CNA 3 stated CNA 1 should have used relaxation techniques with Resident 1 to try and calm down her anxiety, and if that was not effective, CNA 1 should have informed the LN. CNA 3 further stated the LN could have completed an assessment and then called the physician for a medication order. During an interview a record review, on 1/21/25, at 10:40 a.m., with the Administrator (ADM), the ADM provided an internet photo of the vape pen CNA 1 gave Resident 1. The ADM stated Resident 1 told CNA 1 that she was feeling anxious and wished she had a joint (marijuana – THC) or a drink of alcohol. The ADM further stated CNA 1 gave Resident 1 a vape pen and stated, this should help. The ADM stated she called CNA 1 on 12/16/24 and CNA 1 admitted to giving Resident 1 a vape pen. The ADM further stated she knew the vape pen contained THC because the vape pen had a photo of a marijuana leaf. During an interview on 1/21/25, at 12:47 p.m., with Resident 1, Resident 1 stated CNA 1 gave her a vape pen after Resident 1 stated she was feeling anxious. Resident 1 further stated she smoked the vape pen one time and then gave it back to nursing staff the next day. During an interview on 12/21/25, at 1:10 p.m., with the Physician Assistant (PA), the PA stated he was made aware (after the fact) that CNA 1 had given Resident 1 a vape pen that contained THC. The PA stated he told nursing staff to get that pen out of the facility and that Resident 1 could not have THC. PA instructed nursing staff to monitor for adverse effects of the THC such as altered mental status (confusion) and respiratory difficulty. A review of the facility ' s document titled, CNA/HHA/CHT Report of Misconduct, dated 12/14/24, indicated, .[CNA 1] gave a resident [Resident 1] a vape pen with THC in it for the resident to smoke . During a joint concurrent interview and record review on 1/21/25, at 2 p.m., with the ADM and the Director of Nursing (DON), the facility ' s Policy and Procedure (P&P) titled, Smoking Policy – Residents, dated 8/22, was reviewed. The P&P indicated, .15. Staff members and volunteer workers are not permitted to purchase and/or provide any smoking items for residents .Electronic Cigarettes 1. Electronic cigarettes .are considered a risk for residents related to: a. potential health effects for the smoker, such as respiratory illness or lung injury which may present with symptoms of breathing difficulty, shortness of breath, chest pain .c. overdose by ingestion .d. explosion or fire caused by the battery . The ADM and the DON acknowledged the P&P was not followed when CNA 1 shared her THC vape pen with Resident 1. During a follow up joint concurrent interview and record review on 1/21/25, at 2:05 p.m., with the ADM and DON, the record titled, Drug-Free Workplace Policy, dated 11/19, and signed by CNA 1 on 2/1/23, was reviewed. The Policy indicated, .Illegal Drugs (Including Marijuana) The possession, .distribution or use of illegal drugs (defined as any drug or drug-like substance whose sale, use or 056132 Page 2 of 3 056132 01/21/2025 Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249

F 0689 Level of Harm - Minimal harm or potential for actual harm possession is unlawful in federal, state, and /or local laws) is inconsistent with the Company ' s objective of operating in a safe and efficient manner. Accordingly, no .employee shall use, or have in his or her possession, illegal drugs (including marijuana) during working hours or on Company property at any time. The ADM and the DON acknowledged the P&P was not followed when CNA 1 brought a vape pen with THC to the facility and shared the pen with Resident 1. Residents Affected - Few 056132 Page 3 of 3