Health inspection·January 14, 2022

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the bedside drawer on his left side. The eye drop bottle appeared old, the name of the medication was covered with a yellow sticker and was unreadable. The medication bottle did not indicate when it was opened. When Licensed Staff B asked Resident 7 if he was using the eye drop Resident 7 shook his head side to side. During an interview with Licensed Staff A on 1/13/22 at 2:54 p.m., when asked how staff would know if Resident 7 was getting the eye drops, Licensed Staff A stated licensed nurses had been giving the eye drops lately since Resident 7 cannot self-administer with one hand due to right hand paralysis During an interview and concurrent record review with Licensed Staff C on 01/14/22 at 3:40 p.m., Licensed Staff C verified there was no care plan specific to self-administration, indicating how staff should monitor Resident 7 to ensure safe, proper administration of eye drop medication. During a clinical record review for Resident 7, the IDT (Interdisciplinary Team) Care Plan Review dated 9/30/21 indicated, IDT acknowledges [Resident 7] is fully capable of understanding the importance of eye drops and is fully capable of self-administration. During a clinical record review for Resident 7, the Medication Administration Record (MAR) did not indicate Resident 7 self-administered the following eye drops from January 1, 2022 to January 14, 2022: 1) Refresh tears solution. Instill 1 drop in right eye every 4 hours as needed for dry eyes. 2) Olopatadine HCL 0.1 %. Instill 1 drop in both eyes every 12 hours as needed for allergy. 2. During a clinical record review for Resident 39, the Face sheet indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis of Dementia (memory disorders, personality changes, and impaired reasoning), psychosis and legal blindness (visual impairment). During a clinical record review for Resident 39, the MDS, dated [DATE], indicated Resident 39 had a total BIMS score of 15 out of 15 (Brief Interview for Mental Status--a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13-15 is cognitively intact, 08-12 is moderately impaired, and 00-07 is severe impairment). During a clinical record review for Resident 39, the LN-Self Administration of Medication - Initial Evaluation dated 6/15/20 electronically signed by one licensed staff indicated the IDT members approved Resident 39 to self-administer her own eye drops. The record did not indicate which IDT members had approved Resident 39 to self-administer the eye drops . During a clinical record review for Resident 39, the Doctor's Progress Note, dated 12/6/21, indicated Resident 39 had bilateral absolute glaucoma (eye disease that can cause vision loss. Absolute glaucoma is the end stage of glaucoma, the eye has no vision). The Doctor's Progress Note indicated, [Resident 39] does not have the ability to make informed decisions due to [Resident 39's] dementia. During a clinical record review for Resident 39, the MDS dated [DATE], indicated Resident 39 exhibited short-term and long-term memory problems. The MDS also indicated Resident 39 had episodes of rejecting evaluation or care (e.g., blood work, taking medications, ADL assistance) necessary to achieve Resident 39's goals for health and well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 2 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0554 During a clinical review for Resident 39, the Medication Administration Record (MAR) for January 2022 indicated Resident 39 self-administered the following eye medications: Level of Harm - Minimal harm or potential for actual harm 1) Brimonidine Tartrate Solution 0.2%. Instill 1 drop in both eyes in the morning for Glaucoma. Residents Affected - Few 2) Erythromycin Ointment 5 mg/gm. Instill 0.25 inch in both eyes at bedtime for legal blindness. 3) Latanoprost Solution 0.005%. Instill 1 drop in both eyes at bedtime for Glaucoma. 4) Pred Forte suspension 1%. Instill 1 drop in both eyes in the morning for Glaucoma. 5) Timoptic Solution 0.5%. Instill 1 drop in both eyes in the morning for Glaucoma. During an observation and concurrent interview with Licensed Staff A on 1/12/22 at 9:30 a.m., four empty packages of different eyedrop medication for Resident 39 were found on top of the medication cart drawer. Licensed Staff A stated Resident 39 self-administered her own eye drops and kept the medication with her. During a clinical record review and concurrent interview Management Staff F on 1/12/22 at 2:53 p.m., the LN-Self Administration of Medications - Initial Evaluation dated 6/15/20 indicated Resident 39 can correctly administer eye drops or eye ointments according to proper procedure. Management Staff F stated they would periodically assess resident based on change in the resident's status. During an interview and concurrent observation of with Licensed Staff D on 1/12/22 at 3:09 p.m., Licensed Staff D stated Resident 39 kept her eye drops in her pouch or in her locked cabinet. Licensed Staff D asked Resident 39 if she had been using her eye drops and if she could tell how she uses the eye drops. Resident 39 stated, todo esta bien (everything is okay). Licensed Staff D stated she observed Resident 39 administer her own eye drops a couple of years ago but not recently. When asked how Resident 39 would know which eye drop to instill first, Licensed Staff D stated she did not know. During an interview with Licensed Staff A on 1/13/22 at 2:52 p.m., Licensed Staff A stated Resident 39 would let her know when she self-administered her eye drops. Licensed Staff A stated they put a tape around the eye drops bottle so Resident 39 would know which medication to instill first. Licensed Staff A stated Resident 39 knew she had to wait five minutes in between eye drops. During an interview with Licensed Staff J on 1/14/22 at 2:54 p.m. Licensed Staff J stated Resident 39 had an MDS assessment completed back in December, but the care plan for self-administration of medication as well as the assessment for self-administration of medication were not done. Licensed Staff J stated she was not aware this was an issue at the time she was completing the assessment. During a phone interview with Management Staff F on 1/14/22 at 3:33 p.m., Management Staff F stated nurses would initially observe and assess resident during eye drop administration to make sure resident was administering the medication correctly. She stated the doctor agreed that Resident 39 can safely administer her own eye drops and this was documented in Resident 39's record. Management Staff F stated the care plan for self-administration of medication should be created at the time the assessment has been completed. During an interview and concurrent record review with Licensed Staff C on 1/14/22 at 3:40 p.m., Licensed Staff C verified there was no care plan for self-administration of medication indicating how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 3 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 39 was monitored for proper hand hygiene and proper administration of eye drops. Licensed Staff C stated, care plan does not change the care provided to the resident. We provide care according to doctor's order. When asked about the purpose of creating a care plan, Licensed Staff C stated, care plan reflects the care provided to the resident. Despite reassurances by Licensed Staff C, The facility provided no documentation indicating Resident 39's physician had approved the resident may self-administer her own eye drops. Review of the Facility policy and procedure titled Self-Administration of Medication revised in 5/2021 indicated, It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed medications. Procedures indicated: - If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. - The resident's cognitive, communication, visual and physical ability to carry out this responsibility will be evaluated. - Interdisciplinary Team may include Medical Director or Primary Care Physician, the Director of Nursing Services and other Nursing Representative, and Social Services. - Nursing will be responsible in monitoring self-administered doses in the resident's medication record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 4 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide respiratory care and service in accordance with professional scope of practice to one resident (Resident 149) who received oxygen therapy. This failure resulted in unlicensed staff working outside their scope of practice, and had the potential to result in Resident 149 receiving an inappropriate amount of oxygen. Residents Affected - Few Findings: During a concurrent observation and interview on 1/10/22, at 11:37 a.m., Resident 149 was observed sitting on a wheelchair with oxygen via mask that was switched by Unlicensed Staff E from oxygen concentrator (medical device that gives oxygen) to oxygen tank with a flow rate of three liters-per-minute. Resident 149 stated CNAs (Certified Nursing Assistant) usually switch his oxygen from concentrator to tank. Unlicensed Staff E stated she switched oxygen administration from concentrator to tank whenever the resident needed to go out of the room. During an interview on 1/13/22, at 2:40 p.m., Licensed Staff A stated the applicable standard of practice required licensed nurses to switch oxygen administration from a concentrator to an oxygen tank. Licensed Staff A stated it would be a problem if CNAs administered oxygen therapy because they did not know how much oxygen flow rate to administer, and it would affect resident's breathing. During an interview on 1/12/22, at 8:42 a.m., Management Staff F stated licensed nurses were responsible to switch oxygen therapy from concentrator to tank because it was a treatment and CNAs should not be changing tubing or switching them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 5 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure a medication error rate below 5%, when the manufacturer specifications for administration of medication for 2 of 25 medications administered during an observed medication pass was not followed. This failure resulted in a 8% medication error rate, and had the potential to result in administration of subtherapeutic (e.g., lower than that prescribed to treat a disease effectively) doses of medication. Residents Affected - Some Findings: 1. During an observation on 1/11/22 at 9:11 a.m. in Resident 30's room, Licensed Staff A instructed Resident 30 prior to medication administration of Asmanex HFA (help control and prevent asthma) to breath deep, hold for 10 seconds and breath out. Licensed Staff A puffed the inhaler and removed the inhaler from Resident 30's mouth right away with no wait time. Resident 30 held her breath for a few seconds with open mouth and breathed out through her mouth. Review of the medication insert for Asmanex HFA indicated, when you have finished breathing in, hold your breathe as long as you comfortably can, up to 10 seconds. Then remove the inhaler from your mouth and breathe out through you nose, while keeping your lips closed. During an interview with Licensed Staff A on 1/11/22 at 2:20 p.m. Licensed Staff A stated she was not aware that she had to leave the inhaler in Resident 30's mouth for at least 10 seconds. She stated she was not aware that Resident 30 was supposed to breath out thru her nose and not her mouth. Review of the Facility policy and procedure titled Administering Medications through Metered Dose Inhaler revised in 10/2010 indicated in procedure #14: - Instruct the resident to inhale deeply and hold for several seconds. - Remove the mouthpiece from the mouth and instruct the resident to exhale slowly through pursed lip. 2. During an observation on 1/11/22 at 11:24 a.m., in Resident 27's room, after checking Resident 27's blood sugar, Licensed Staff G stated Resident 27's blood sugar level was 261 and prepared 10 units of Novolog insulin injection according to doctor's order for administration. Resident 27 was turned on his left side and kept still during the procedure. Licensed Staff G injected the insulin to Resident 27's right arm and pulled out the needle right after with no wait time. Review of the medication insert for Novolog (Aspart insulin injection) indicated under step 11, insert the needle into your skin. Push down the plunger to inject your dose. The needle should remain in the skin for at least 6 seconds to make sure you have injected all the insulin. During an interview with Licensed Staff G on 1/11/22 at 12:38 p.m. Licensed Staff G stated she was aware that she was supposed to leave the needle in the skin at least 6 seconds after injecting the insulin to make sure Resident 27 got all the insulin. She stated she did not leave the needle because Resident 27 started getting agitated and looked uncomfortable. Review of the Facility policy and procedure titled Insulin Administration revised in 9/2014 indicated in steps in the procedure #19, Depress the plunger and remove the needle after approximately five (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 6 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0759 (5) seconds. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 7 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews, and record review, the facility did not ensure that 2 of 2 refrigerated vaccines (Influenza and Pneumococcal) were stored at the temperature required to maintain their overall safety and effectiveness. This had the potential to reduce the effectiveness of vaccines stored at the facility for administration to residents residing at the facility. Findings: During an observation and concurrent interview with Licensed Staff B on 1/11/21 at 2:31 p.m., the glass thermometer in the medication room refrigerator indicated a temperature of 36°F (degrees Fahrenheit, a temperature scale). Inside the refrigerator had three boxes of influenza vaccine, a vial of pneumococcal vaccine, a vial of tuberculin and a vial of insulin. The vials for influenza and pneumococcal vaccine indicated to be stored between 36°F to 46°. Licensed Staff B stated licensed nurses checked the med room refrigerator once a day. During a record review and concurrent interview with Management Staff F on 1/11/21 at 2:48 p.m., the Medication Room Fridge Temperature Log indicated, Refrigerator Temperature Range should be less than 41°F. The temperature log indicated the refrigerator temperature was below 36°F on the following dates: 28°F on January 1, 2022 28°F on January 2, 2022 26°F on January 3, 2022 34°F on January 6, 2022 34°F on January 8, 2022 34°F on January 9, 2022 34°F on January 10, 2022 Management Staff F stated she did not know temperature for the medication room refrigerator should be maintained between 36°F to 46°F and did not know temperature for refrigerated vaccines should be checked twice a day. The Centers for Disease Control and Prevention advised to never freeze refrigerated vaccines and to check and record min/max temperature at the start of the workday. For thermometer that does not display min/max temperatures, check and record current temperature at a minimum of 2 times a day (at start and end of workday). (Vaccine Storage and Handling Resources, CDC). Review of the Facility Policy and procedure titled Storage of Medication revised in 8/2014 indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Procedure indicated, Medications requiring refrigeration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 8 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0761 are kept in a refrigerator at a temperature between 2°C (36°F) and 8°C (46°F) with a thermometer to allow temperature monitoring. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 9 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection prevention and control practices for two residents (Resident 21 and Resident 16) when: Residents Affected - Some 1. Licensed Staff did not perform proper hand hygiene during wound care. 2. Facility staff placed a meal tray for lunch on an unsanitized bedside table with a quarter-filled urinal on it. These failures created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in serious illness. Findings: 1. During an observation on 1/14/22, at 9:19 a.m., Licensed Staff G was observed performing Resident 21's wound care. Licensed Staff G was observed donning (put on) gloves, cleansed the left buttock wound, then doff gloves (remove), and went to the bathroom and took clean pairs of gloves without performing hand hygiene. Then Licensed Staff G went back to Resident 21's bedside and sanitized her hands, don gloves and applied the Calmoseptine (medication) and dressing to the left buttock and doff gloves. Licensed Staff G did not sanitize her hands after doffing gloves and touched the microphone on her neck/chest area to call for assistance. Licensed Staff G threw away the soiled dressing and treatment supplies used for wound care. Licensed Staff G brought the unused dressing and placed it on top of the treatment cart and sanitized her hands. Then Licensed Staff G went to the nursing station and brought the unused dressing and placed it on the table and stated, it was clean, and proceeded to wash her hands. Licensed Staff C saw the unused dressing and threw it in the trash bin. During an interview on 1/14/22, at 9:32 a.m., Licensed Staff G was asked about hand hygiene practices during wound care, and she stated she should have sanitized her hands after doffing gloves and when she switched from contaminated area to clean area to prevent cross-contamination. Licensed Staff G was asked about their process for unused dressing, and she stated she was supposed to toss it, but she did not do it. A review of facility's INFECTION PREVENTION-HAND HYGIENE policy and procedure undated, it indicated, 4. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; k. After handling used dressings, contaminated equipment, etc.; m. After removing gloves; 6. The use of gloves does not replace hand washing/hand hygiene . 2. During a clinical record review for Resident 16, the Face sheet (A one-page summary of important information about a resident. It includes resident identification, past medical history, allergies, insurance status, or other pertinent information) indicated Resident 16 was admitted to the facility on [DATE] with a diagnosis of Quadriplegia (paralysis from the neck down, including the trunk, legs, and arms) and Need for assistance with personal care. During an observation on 1/10/22 at 10:20 a.m., Resident 16 was in bed with his head of bed elevated, asleep. There was an empty urinal on top of his bedside table near his water pitcher. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 10 of 11 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview with Licensed Staff G on 1/10/22 at 10:22 a.m., Licensed Staff G stated Resident 16 had limited range of motion (how far you can a joint or a muscle move or stretch) to both of his upper extremity and wanted his urinal on top of his bedside table for easy reach. Licensed Staff G stated it was okay to leave the urinal on top of the bedside table. She stated staff should put away the urinal before serving Resident 16 his meal tray. Residents Affected - Some During an observation on 1/10/22 at 12:36 p.m., Unlicensed Staff K did not sanitize the bedside table prior to serving Resident 16 his meal tray. Unlicensed Staff K served Resident 16 his meal tray while a quarter-filled urinal was still on top of the bedside table. During an observation on 1/11/22 at 11:15 a.m. Resident 16 was in bed, eyes closed, his water pitcher and empty urinal was on top of the bedside table. During an observation on 1/11/22 at 12:29 p.m., Unlicensed Staff H did not sanitize the bedside table prior to serving Resident 16 his meal tray. Unlicensed Staff H served Resident 16 his meal tray while a quarter-filled urinal was still on top of the bedside table. Unlicensed Staff H emptied the urinal and placed it back on top of the bedside table. During an interview with Unlicensed Staff H on 1/11/22 at 2:08 p.m. Unlicensed Staff H stated she disinfected Resident 16's bedside table prior to passing his meal tray. She stated Resident 16 wanted his urinal on his table because he cannot reach it if it's placed on the bedrail. When asked Unlicensed Staff H if she asked Resident 16 if she could put away the urinal while Resident 16 eats, Unlicensed Staff H stated' [Resident 16] wanted it on his table. Unlicensed Staff H stated it was unsanitary to have both meal and urinal on the table. During an interview with Unlicensed Staff I on 1/14/22 at 8:18 a.m. Unlicensed Staff I stated he would empty and put away Resident 16's urinal and clean the table with either warm cloth or bleach before serving Resident 16 his meal tray. During an interview and concurrent record review with Licensed Staff C on 1/14/22 at 3:47 p.m. Licensed Staff C stated the expectation from CNAs was to ask Resident 16 if they could remove the urinal and disinfect the table before serving his meal tray. She stated cross contamination was a potential problem when the urinal and meal tray are kept close to each other. Licensed Staff C stated Resident 16 was educated and made aware of the risks and benefits of keeping his urinal with his meal tray on the bedside table but cannot force him not to do it. Licensed Staff C stated she will provide a copy of the documentation discussed with Resident 16. Licensed Staff C verified the care plan for ADL Self Care Performance had a new intervention created on 1/11/21 indicating, Resident often insists on keeping his urinal on his bedside table with his meal tray or other items. Risks vs benefits explained along with ongoing education regarding infection control. Licensed Staff C verified there was no specific care plan addressing Resident 16 keeping his urinal on his bedside table with his meal tray. Licensed Staff C provided no documentation indicating the content of discussions with Resident 16 regarding the risks and benefits of keeping a filled urinal on the bedside table with meals, despite reassurances of the same. Review of the Facility policy titled Infection Control - Environmental Cleanliness not dated indicated, It is the policy of the facility to ensure that appropriate infection and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 11 of 11