Health inspection·January 21, 2025

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 2 of 3 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 01/21/2025 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 3 of 3