Other·February 22, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a Federal Recertification Survey. Representing the Department of Public Health: HFEN, 14362 HFEN, 34273 HFEN, 40327 HFEN, 40623 HFEN, 40584 HFEN, 40911 The facility census was 93. The sample size was 23. Two (2) facility reported incidents #CA00620574 and #CA00620121 were investigated during the Recertification Survey. CA00620121 was substantiated without a violation of regulations. CA00620574 was not substantiated.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 02/15/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to notify the local Long-Term Care (LTC) Ombudsman (advocate) of the residents' transfer to the local emergency room (ER) for 5 of 23 sampled Residents, (Resident 16, Resident 26, Resident 78, Resident 88, and Resident 239). This failure had the potential for the LTC Ombudsman to not become aware, advocate for, and protect residents from being inappropriately transferred or discharged. Findings: In a concurrent interview and record review with the Health Information Manager (HIM) on 1/25/19 at 1:14 p.m., she presented a binder where she kept the transfer/discharge notices along with fax transmission reports she sent to the LTC Ombudsman every week. The HIM stated she notified the LTC Ombudsman by fax for all discharges from the facility, but not for transfers to the emergency room. In a subsequent interview and record review with the HIM on 1/25/19 at 4:30 p.m., she presented transfer/discharge notices for Resident 16, Resident 26, Resident 78, Resident 88, and Resident 239. The HIM explained, "These residents were transferred to the ER but came back [to the facility]." Resident 78 was transferred to the ER on 12/18/18; Resident 26 was transferred to the ER on 12/28/18; Resident 239 was transferred to the ER on 1/14/19; and Resident 88 and Resident 16 were transferred to the ER on 1/16/19. The HIM clarified she had not been notifying the Ombudsman when residents transfer to the ER and come back to the facility. The facility policy titled, "Transfer and Discharge" dated March 2017, indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "...'Transfer' is moving a resident from the Center to another legally responsible institutional setting...When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge...The Center sends a copy of the notice to the State Long-Term Care Ombudsman...The notice is provided at least 30 days before the transfer or discharge; the following are exceptions...When a resident's urgent medical needs require more immediate transfer...In these cases, notice must be given as soon as practical before or at the time of transfer or discharge..."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/15/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, clinical record review, and policy review, the facility failed to accurately administer medications to 1 of 23 sampled residents when Licensed Nurse (LN) 4 gave Resident 73's Celecoxib (medication used to treat pain or inflammation) with meals instead of one hour after meals as directed by the physician. This failure had the potential for Resident 73 to develop an upset stomach when the medication was not administered as prescribed by the physician. Findings: 1. On 1/24/19 at 7:21 a.m., Certified Nurse Assistants were observed passing out breakfast trays to residents on South Station. During a medication pass observation in South Station, on 1/24/19 at 7:56 a.m., LN 4 gave Resident 73 Celecoxib 200 milligrams (mg, unit of measurement) with breakfast. A review of Resident 73's clinical record revealed a physician's order dated 12/21/18, for Celecoxib Capsule 200 mg two times a day one hour after breakfast and dinner. The facility policy and procedure titled, "Medication Administration" dated June 2017, indicated, "...The nurse reviews each resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MAR [medication administration record] or TAR [treatment administration record] for ordered medications...and administers them per physician order..."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 02/15/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and policy review, the facility failed to ensure medications were secure in a census of 93, when: 1. Medications were left on a Resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bedside table, unattended; and, 2. The medication cart was left unlocked and unattended. These failures resulted in medications being accessible to unauthorized and unintended individuals. Findings: 1a. During a medication pass observation on 1/24/19 at 7:21 a.m., LN 4 left medications on top of Resident 26's bedside table; Resident 26 was in bed. LN 4 went outside Resident 26's room, and went down the hall to get a towel. In an interview with LN 4 on 1/24/19 at 8 a.m., she stated she should not have left the medications at the bedside. 1b. On 1/24/19 at 11:46 a.m., LN 6 placed medications on top of Resident 25's bedside table and went inside the bathroom to wash her hands; Resident 25 was sitting on the bed, waiting for LN 6 to come back and give her medications. LN 6 came out of the bathroom, wiped Resident 25's eyes with a tissue, went back to the bathroom to wash her hands, and left medications on top of Resident 25's bedside table. In an interview with LN 6 on 1/24/19 at 12:05 p.m., she stated she should not have left the medications unattended at the bedside. 2. During a medication pass observation on 1/24/19 at 8:12 a.m., LN 5 went inside the bathroom inside a resident room and left the medication cart unlocked and unattended. In an interview with LN 5 on 1/24/19, at 8:20 a.m., she stated she was supposed to lock the medication cart when it's unattended. LN 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE said, "I knew. I forgot to lock it [medication cart]." The facility policy and procedure titled, "Medication Administration" dated June 2017, indicated, "...The nurse locks the medication cart when not in use...Medications are not left at bedside...After Medication/Treatment Administration...The nurse...locks the medication cart..."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 02/15/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure proper FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infection control practices were maintained during resident care and medication pass for a census of 93 when: 1. Certified Nurse Assistant (CNA) 1 did not perform hand hygiene after repositioning Resident 85; 2. Licensed Nurse (LN) 6 entered an isolation room without a mask and did not wash her hands before starting treatment on Resident 45; and, 3. LN 6 did not perform hand hygiene before and after passing medications to Resident 80. These failures had the potential to spread infection in a vulnerable population. Findings: 1. During an observation on 1/22/19 at 12:27 p.m., CNA 1 was seen repositioning Resident 85 in bed using a draw sheet (a white linen placed between upper back and thighs used to move residents). CNA 1 did not perform hand hygiene before he left Resident 85's room and entered another resident's room. In an interview on 1/22/19 at 12:31 p.m., CNA 1 acknowledged he did not perform hand hygiene after he repositioned Resident 85. CNA 1 stated I should have washed my hands upon exiting the resident room. In an interview on 1/22/19 at 1:09 p.m., Licensed Nurse (LN) 1 confirmed all staff should wash their hands before and after resident care. LN 1 added it was the facility's practice to wash hands upon leaving a resident room. In an interview on 1/25/19 at 1:22 p.m., The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director of Nursing (DON) stated all staff were expected to perform hand hygiene before and after direct contact with each resident. The DON further stated all staff must wash their hands prior to leaving a resident room. 2. In an observation on 1/24/19 at 9:54 a.m., LN 7 went into a room without putting a mask on. There was a "Droplet Precaution" (precautions used when a resident has a lung, throat, or viral infection that can spread via tiny droplets in the air from the mouth or nose) sign posted on the room door which indicated putting a mask on prior to entering the room. The resident inside the room, Resident 45, was on droplet precautions because she tested positive for influenza. As LN 7 was talking to Resident 45 at the bedside, Resident 45 told LN 7 she had to put a mask on. LN 7 went back outside the room to grab a mask. In an interview with LN 7 on 1/24/19 at 10 a.m., she pointed to the precaution sign posted on the open door and said, "I didn't see that sign." After putting a mask on, LN 7 went back inside the room , approached Resident 45's bed, put on gloves, and proceeded to remove the dressing on Resident 45's left upper back to drain Resident 45's indwelling pleural catheter (catheter placed in the space just outside the lungs for the purpose of draining fluid). LN 7 did not wash her hands or performed hand hygiene prior to putting on gloves and removing Resident 45's dressing. When asked if she washed her hands, LN 7 removed her gloves, went to the bathroom, washed her hands, put FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555245 (X3) DATE SURVEY COMPLETED 01/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH PARK POST-ACUTE 2586 Buthmann Avenue Tracy, CA 95376 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE new pair of gloves on, and went back to finish removing Resident 45's dressing. 3. During a medication pass observation on 1/24/19 at 11:28 a.m., LN 6 positioned Resident 80's and his roommate's wheelchair so that she would be able to pull the privacy curtain around Resident 80 during medication administration. LN 6 did not perform hand hygiene after touching the residents' wheelchairs and before giving Resident 80 his medication. A review of facility document titled, "Handwashing/Hand Hygiene" updated March 2018 indicated, "This Center considers hand hygiene the primary means to prevent the spread of infections...Use an alcohol-based hand rub..., or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:...Before and after direct contact with residents; Before preparing or handling medications;...Before handling clean or soiled dressings, gauze pads, etc.;...After handling used dressings, contaminated equipment, etc.;...Before and after entering isolation precaution settings..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HGZC11 Facility ID: CA030000324 If continuation sheet 13 of 13