Health inspection·February 19, 2025

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that residents' medical care was supervised by a physician for one out of eight sampled residents (Resident 5) when the facility did not notify Resident 5's physician when Resident 5 refused blood draw and diagnostic test. Residents Affected - Few This failure had the risk for Resident 5's physician to not be aware about Resident 5's condition and for Resident 5 to not receive appropriate and timely treatment. Findings: A review of Resident 5's clinical record indicated Resident 5 was admitted January of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 5/13/24, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 5 had a severely impaired cognition. A review of Resident 5's care plan intervention, initiated 1/7/24, indicated, Observe and evaluate types of changes in cognitive status .decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed. A review of Resident 5's Clinical Physician Order, dated 4/29/24, indicated, CBC [complete blood countcommon blood test that measures the number and types of blood cells], CMP [comprehensive metabolic panel- a blood test that measures various substances in the body to assess overall health and detect potential medical conditions], Ammonia level [measures the amount of ammonia in your blood] R/T [related to] falls, R/O [rule out] abnormalities .one time only . A review of Resident 5's Clinical Physician Order, dated 4/29/24, indicated, Cervical spine (back of the neck) and right hand X-rays (2 views) r/t [related to] pain .one time only . A review of Resident 5's Progress Notes, dated 4/30/24, indicated, Spoke with resident's daughter [RP 5] to update on res [resident's] refusal to allow for blood draws and x-ray to rule out injuries and abnormalities, infections .Refused by resident. CBC, CMP, Ammonia level R/T falls, R/O abnormalities. Cervical spine (back of the neck) and right hand X-rays (2 views) r/t pain. Page 1 of 6 056238 056238 02/19/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0710 Level of Harm - Minimal harm or potential for actual harm A review of Resident 5's progress notes did not indicate that Resident 5's refusal for blood draw and X-ray test were communicated to his physician. During a phone interview on 2/11/25 at 1:27 p.m. with Responsible Party (RP) 5, RP 5 stated Resident 5 had lacked oversight of a physician during his stay in the facility. Residents Affected - Few During a concurrent interview and record review on 2/18/25 at 3:58 p.m. with the Director of Nursing (DON), Resident 5's clinical records were reviewed. The DON confirmed that there was no evidence that Resident 5's refusal for blood draw and X-ray were communicated to his physician. The DON stated the physician should be notified if the resident refused the ordered laboratory and diagnostic test. A review of the facility's policies and procedures (P&P) titled, Physician Services and Visit, dated 3/22/22, indicated, The Facility must ensure that all residents admitted to or accepted for care by the Facility are under the care of a physician selected by the resident or the resident's representative .A. Physician services include, but are not limited to: .i. The resident's Attending Physician participation in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the Facility .v. Providing written and signed orders for .care, diagnostic tests, and treatment of patients by others. A review of the facility's P&P titled, Physician Services and Visit, revised 12/21, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .aj. equal access to quality care . 056238 Page 2 of 6 056238 02/19/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Based on interview and record review, the facility failed to provide quality and timely laboratory services for one out of eight sampled residents (Resident 5) when Resident 5's laboratory tests ordered on l/8/24 and 2/16/24 were not done. This failure had the risk for the facility to be not aware about critical laboratory values of Resident 5 and for Resident 5 to not receive appropriate and timely treatment. Findings: A review of Resident 5's clinical record indicated Resident 5 was admitted January of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 5/13/24, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 5 had a severely impaired cognition. A review of Resident 5's care plan intervention, initiated 1/7/24, indicated, Labs [laboratory tests] as ordered and report results to MD [physician]. A review of Resident 5's Clinical Physician Order, dated 1/8/24, indicated, CBC [complete blood countcommon blood test that measures the number and types of blood cells], CMP [comprehensive metabolic panel- a blood test that measures various substances in the body to assess overall health and detect potential medical conditions], HBA1C [hemoglobin A1C- test is a blood test that measures your average blood sugar level over the past 2–3 months], VITAMIN D [measures the levels of vitamin D in your blood], TSH [Thyroid-Stimulating Hormone Test- used to measure thyroid hormone in the blood] and lipid panel [a blood test that measures the amount of fat in the blood] .one time only for labs until 1/8 A review of Resident 5's Clinical Physician Order, dated 2/16/24, indicated, CBC, CMP, HBA1C, VITAMIN D LEVEL .one time only until 2/16 . A review of Resident 5's progress notes did not indicate that the ordered laboratory test on 1/8/24 and 2/16/24 were done. During a phone interview on 2/11/25 at 1:27 p.m. with Responsible Party (RP) 5, RP 5 stated Resident 5's ordered laboratory tests were not being done. During a concurrent interview and record review on 2/18/25 at 3:58 p.m. with the Director of Nursing (DON), Resident 5's clinical records were reviewed. The DON confirmed that the facility did not have the results of Resident 5's ordered laboratory test on 1/8/24 and 2/16/24. The DON stated she did not know what happened, if the tests were done or why the facility did not have the results of the tests. The DON further stated all ordered laboratory tests should be done because it's a doctor's 056238 Page 3 of 6 056238 02/19/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0772 order and it would assess the patient's health status to know the needed treatment. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policies and procedures (P&P) titled, Physician Services and Visit, dated 3/22/22, indicated, The Facility must ensure that all residents admitted to or accepted for care by the Facility are under the care of a physician selected by the resident or the resident's representative .A. Physician services include, but are not limited to: .v. Providing written and signed orders for .care, diagnostic tests, and treatment of patients by others. Residents Affected - Few A review of the facility's P&P titled, Physician Services and Visit, revised 12/21, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .aj. equal access to quality care . 056238 Page 4 of 6 056238 02/19/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 153 residents when: Residents Affected - Some 1. A facility staff exited a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) and removed his used gloves and isolation gown in the hallway where staff and residents were passing by; 2. Two facility staff did not change their N95 mask respirator (a type of mask that filters up to 95% of particles in the air) upon exiting a droplet isolation precaution room; and, 3. A facility staff entered a droplet isolation precaution room and assisted a COVID19 positive resident without using eye protection. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of residents to germs, and may cause infection among residents, staff, and visitors. Findings: 1. During an observation on 2/18/25 at 11:28 a.m., Room (room number) had a red STOP sign posted on the wall, on the bottom of the room number which indicated, DROPLET PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .Make sure their eyes, nose and mouth are fully covered before room entry .Remove face protection before room exit. During an observation on 2/18/25 at 11:29 a.m. in room (room number), the housekeeping staff (HKS) came out of room (room number) wearing an N95 mask, gown and gloves. The HKS then removed his used gloves and isolation gown in the hallway. At the time the HKS removed his gloves and gown outside room (room number), there were residents and staff passing by in the hallway. During an interview on 2/18/25 at 11:33 a.m. with HKS, HKS stated he went inside Room (room number) to clean and that he was aware that the room was a droplet isolation precaution room. The HKS confirmed that he removed his used gloves and isolation gown in the hallway, outside room (room number). During an interview on 2/18/25 at 3:28 p.m. with the Infection Preventionist (IP), the IP stated that used gloves and gown should be taken off before getting out of the room to prevent spread of germs. A review of the facility's policies and procedures (P&P) titled, Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, dated 5/2023, indicated, 2. When caring for a resident with suspected or confirmed SARS-Cov-2 infection, personnel who enter the room of the resident will adhere to standard precaution s and use of NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection .c. Gloves: .3.Gloves are removed and discarded before leaving the resident room or care area .d. Gowns: .3. Gown is removed and discarded in a dedicated container for waste or linen before leaving the resident room or care area . 2. During an observation on 2/18/25 at 11:29 a.m. in Room (room number), HKS was cleaning the room 056238 Page 5 of 6 056238 02/19/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0880 Level of Harm - Minimal harm or potential for actual harm and Certified Nurse Assistant (CNA) 1 was observed assisting a resident in bed A. Both HKS and CNA 1 came out of the room and did not change their used N95 mask. During an interview on 2/18/25 at 11:33 a.m. with HKS, HKS confirmed that he did not change his used N95 mask after exiting room (room number). Residents Affected - Some During an interview on 2/18/25 at 11:40 a.m. with CNA 1, CNA 1 confirmed that she did not change her used N95 mask after exiting room (room number). During an interview on 2/18/25 at 3:28 p.m. with the IP, the IP stated that staff should remove and discard the used N95 mask after exiting an isolation room and should wear a new one. A review of the facility's P&P titled, Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, dated 5/2023, indicated, 2. When caring for a resident with suspected or confirmed SARS-Cov-2 infection, personnel who enter the room of the resident will adhere to standard precaution s and use of NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. a. Respirator: .2. Disposable respirators are removed and discarded after exiting the resident's room or care area and closing the door . 3. During an observation on 2/18/25 at 11:29 a.m. in Room (room number), CNA 1 was observed wearing an N95 mask, gloves, and gown and was assisting the resident in bed A. During an interview on 2/18/25 at 11:40 a.m. with CNA 1, CNA 1 stated she was aware that Resident in room (room number) bed A tested positive for COVID19. CNA 1 confirmed that she assisted the resident but did not wear face shield or any eye protection. During an interview on 2/18/25 at 12:15 p.m. with the IP, the IP stated resident in Room (room number) bed A tested positive for COVID19. During an interview on 2/18/25 at 3:28 p.m. with the IP, the IP stated that staff should wear face shield or eye protection when directly giving care to a resident who tested positive for COVID19. During an interview on 2/18/25 at 3:58 p.m. with the Director of Nursing (DON), the DON stated that staff should properly follow proper wearing and removal of personal protective equipment (PPE) such as N95 mask, gloves, gown and face shield or eye protection to prevent and control the spread of infection. A review of the facility's P&P titled, Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, dated 5/2023, indicated, 2. When caring for a resident with suspected or confirmed SARS-Cov-2 infection, personnel who enter the room of the resident will adhere to standard precaution s and use of NIOSH-approved N95 or equivalent or higher level respirator, gown, gloves, and eye protection .b. Eye Protection: 1. Eye protection (i.e. [in example], goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area . 056238 Page 6 of 6