Other·January 15, 2020

F000 INITIAL COMMENTS

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: Health Facilities Evaluator Nurse (HFEN), 40583 HFEN, 34273 HFEN, 37329 HFEN, 40911 HFEN, 42432 The facility census was 93. The sample size was 29.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 01/17/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, 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: NFMU11 Facility ID: CA030001535 If continuation sheet 1 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect one of 29 sampled residents' (Resident 79) rights when staff did not provide sugar, sugar substitute, or a drink replacement to Resident 79 upon her request. This failure placed Resident 79 at risk for psychosocial harm. Findings: According to the admission record, Resident 79 was admitted to the facility with Alzheimer's disease (a progressive brain disorder that affects memory and thinking skills) and diabetes mellitus (abnormally high blood sugar levels). A review of the Minimum Data Set (MDS, an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 2 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 assessment tool) dated 11/5/19 indicated Resident 79's Brief Interview for Mental Status (BIMS, evaluation of cognition) was coded as "4" which indicated Resident 79 had severe cognitive impairment. Resident 79 required extensive assistance with most activities of daily living and required encouragement and cueing with eating. During a dining observation in the Harmony Unit (a living section in the facility) dining room on 12/10/19 at 12:15 p.m., Resident 79 verbalized she wanted sugar in her iced tea. Certified nurse assistant (CNA) 1 put one packet of sugar in Resident 79's iced tea. Resident 79 tasted the iced tea and requested for more sugar. CNA 1 went outside the dining room to talk to Resident 79's nurse. Upon CNA 1's return to the dining room, she told Resident 79 the licensed nurse said she was only allowed one packet of sugar in her iced tea. Resident 79 repeatedly asked for more sugar and a drink replacement, and staff repeatedly told the resident they already put sugar in her iced tea. After a few minutes, CNA 2 noticed Resident 79 was not eating as she continued to request for more sugar in her iced tea. CNA 2 encouraged Resident 79 to eat but the resident refused, verbalized she just wanted to drink, and continued to request for more sugar in her iced tea. CNA 2 left to go to the kitchen and came back with a turkey sandwich. Resident 79 took a small bite of the sandwich and refused to eat any more of her meal. She continued to ask staff for more sugar in her iced tea and stated she did not want to eat any food. CNA 2 stirred Resident 79's iced tea as she reminded the resident another CNA already put sugar in her iced tea; CNA 2 encouraged Resident 79 to try her iced tea. Resident 79 tasted the iced tea and said, "It's not good. It needs more sugar." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 3 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 Staff did not offer sugar, sugar substitute, or another drink to Resident 79 until Resident 79 got up and ambulated back to her room. In an interview with licensed nurse (LN) 1 on 12/10/19 at 1 p.m., he stated Resident 79 was diabetic and was on a consistent carbohydrate diet (same amount of carbohydrates at each meal). LN 1 stated he assumed Resident 79 was only allowed one packet of sugar because she only got one packet of sugar in her meal tray. LN 1 added he will ask the dietary supervisor if Resident 79 can have more sugar. When asked about facility policy on resident's rights, LN 1 said, "It's her right to get sugar in her drink. It's her preference." In an interview with the interim director of nursing (DON) on 12/13/19 at 3:35 p.m., she stated staff should provide education to the resident about risks versus benefits of getting additional sugar, but the resident has the right to get their request.

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 01/17/2020 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 4 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect one of 29 sampled residents' (Resident 18) privacy when the director of staff development (DSD) left Resident 18's electronic treatment administration record (TAR) open and in full view of everyone, after she stepped away to do Resident 18's treatment behind the privacy curtain. This failure had the potential to result in unauthorized access to Resident 18's health information. Findings: According to the admission record, Resident 18 was admitted to the facility with dementia (a decline in mental ability). Resident 18 was dependent on staff for activities of daily living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 5 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 In an observation in the Harmony Unit (a living section in the facility) on 12/12/19 at 2:55 p.m., the DSD prepared to do wound care for Resident 18. After she gathered all her supplies, the DSD left the electronic TAR open and in full view of everyone, locked the treatment cart, and went inside the room, behind the privacy curtain, to provide care to Resident 18. In a subsequent interview with the DSD on 12/12/19 at 3:22 p.m., she said, "I thought I clicked on the 'walk away' button [privacy button]." During a review of the facility's policy and procedure titled, "Medication Administration General Guidelines" dated May 2016, indicated, "...During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse...Resident's health information needs to remain private. The pages of the MAR (medication administration record) notebook containing resident health information must remain closed or covered when not in direct use...Current medications, except topicals used for treatments, are listed on the resident's medication administration record (MAR). Topical medications used in treatments are listed on the treatment administration record (TAR)..."

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

F623 01/17/2020 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 6 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 7 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 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; (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, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 8 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 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, clinical record review, and facility policy review, the facility failed to notify the local long-term care (LTC) Ombudsman (a person who investigates and mediates resident problems and complaints in relation to the skilled nursing facility services) of residents transferred to the local acute care hospital for two of five sampled residents (Resident 55 and Resident 39). This failure placed Resident 55 and Resident 39 at potential risk of being denied appeal information and potential assistance from the LTC Ombudsman. Findings: A review of the clinical record for Resident 55 revealed the resident had a facility initiated transfer to the local emergency room on 9/25/19, and the local LTC Ombudsman was not provided a notice of the transfer until 12/12/19 at 5:05 p.m. A review of the clinical record for Resident 55 revealed the resident had a facility initiated transfer to the local emergency room on 9/30/19 and the LTC Ombudsman was not provided a notice of the transfer until 12/12/19 at 5:05 p.m. A review of the clinical record for Resident 39 revealed the resident had a facility initiated transfer to the local emergency room on 10/18/19 and the local LTC Ombudsman was not provided a notice of the transfer until FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 9 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 12/12/19 at 5:05 p.m. During a review of the facility's policy titled, "Notice of Proposed Transfer/Discharge," with a revision date of 1/20/18, indicated, "...7. The facility will notify the local LTC Ombudsman of all facility-initiated transfers/discharges ...b) The community will send a copy of the Notice of Proposed Transfer/Discharge of all facilityinitiated transfers and discharges to the LTC Ombudsman Program at the same time the notice is given to the resident or resident representative..." During an interview on 12/13/19 at 7:50 a.m., with the Administrator she indicated, "I think they might have missed a few," referring to the notices to the local LTC Ombudsman for Resident 55 and Resident 39. During an interview on 12/13/19 at 7:53 a.m., with the Medical Records Coordinator, she indicated, "They weren't faxed in a timely manner. Per policy we can fax them every 30 days. When you asked for the ones, I saw they hadn't been faxed and then I faxed them," referring to the notices for the local LTC Ombudsman for Resident 55 and Resident 39.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 01/17/2020 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 12) received services to prevent a decrease in lower FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 10 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 extremities range of motion (ROM, measurement of the amount of movement around a specific joint or body part). This failure potentially resulted in Resident 12 having an incorrect medical record and an inaccurate assessment. Findings: According to the admission record, Resident 12 was admitted to the facility in mid 2018 with dementia (a decline in mental ability) and with generalized muscle weakness. She was admitted to the facility for rehabilitation. According to the Annual Minimum Data Set (MDS, an assessment tool) dated 9/11/19, Resident 12 was able to verbalize her needs and required extensive assistance from staff for most activities of daily living. The MDS dated 9/11/19, indicated, Section C1000 - Cognitive Skills for Daily Decision Making was coded as "3" which indicated Resident 12 was severely cognitively impaired. The MDS dated 9/11/19, indicated, Section E0800 - Rejection of Care Presence & Frequency was coded as "0" which indicated Resident 12 did not reject care. During a review of the clinical record for Resident 12, the Admission Observation form completed on 6/8/18, indicated, "...Transfer activity: Manual lift from stretcher...Staff assist with transfer: 1 person facility staff physical assist...Range of motion functional limitations: None...Extremity weakness: None...Contractures (deformity and rigidity of the joint): None..." The Physical Therapy (PT) Initial Assessment dated 6/9/18, indicated Resident 12 was able to use a front wheeled walker for ambulation and was able to safely complete all functional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 11 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 transfers with moderate assistance. The PT Initial Assessment dated 6/9/18, indicated, "...Underlying Impairments...Range of Motion: Right LE (lower extremity) - WFL (within functional limits, which means a person's ability is outside of the normal range, but it is sufficient for activities of daily living)...Range of Motion Left LE - WFL..." The PT care plan dated 6/9/18, indicated, "...Discharge Plans: Home with Home health PT follow up...Current Level of Function: The patient [Resident 12] requires front wheeled walker and moderate assistance x 2 (26-75% with 2 people) for safe ambulation for 15 feet...The patient [Resident 12] is able to safely complete all functional transfers requiring moderate assistance (26-75% assist)..." A review of the Admission Minimum Data Set (MDS, an assessment tool) dated 6/15/18, indicated, Section G0400-Functional Limitation in Range of Motion was coded as "0" for lower extremity which indicated Resident 12 had no limitation in ROM in both lower extremities. A review of the subsequent MDS(s) dated 9/11/18 and 12/10/18, indicated, Section G0400-Functional Limitation in Range of Motion was coded as "0" for lower extremity which indicated Resident 12 still had no limitation in ROM in both lower extremities. A review of the PT Progress Note and Discharge Summary dated 12/31/18, received from the facility via fax on 12/30/19, indicated Resident 12 was discharged from PT with routine therapy aide (RTA or restorative nursing, nursing interventions provided to ensure maintenance of resident's highest level of function) for lower extremities ROM exercises. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 12 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 A review of the MDS dated 3/10/19, indicated, Section G0400-Functional Limitation in Range of Motion was coded as "0" for lower extremity which indicated Resident 12 had no limitation in ROM in both lower extremities. The Restorative Nursing Progress Note dated 3/5/19, received from the facility via fax on 12/30/19, indicated, "...[Resident 12] has been tolerating the omnicycle for [both] UE (upper extremities) and LE ROM exercises. No c/o (complains of) pain. A lot of encouragement given." The Restorative Nursing Progress Note dated 3/12/19, received from the facility via fax on 12/30/19, indicated, "...[Resident 12] has a lot of stiffness on [both] knees. Charge nurse aware. Has moderate pain when trying to extend leg. Unable to extend fully..." The care plan dated 3/14/19, specified Resident 12 had contractures and required restorative nursing. The care plan indicated, "...Problem: REQUIRES RESTORATIVE NURSING...Long Term Goal: WILL MAINTAIN CURRENT LEVEL OF FUNCTIONALITY...Approach: ...CONTRACTURE MANAGEMENT...ROM/EXERCISE...TRANSF ER TRAINING...Discipline: Restorative Nursing..." A review of bilateral knee x-ray results dated 3/20/19, received from the facility via fax on 12/30/19, indicated Resident 12 had moderate degenerative joint disease (DJD) of the left knee (the wearing down of the protective tissue at the ends of bones which occurs gradually and worsens over time) and had no acute bony abnormality of the right knee. There was no evidence found in the clinical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 13 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 record Resident 12 was referred to PT for reevaluation upon identification of both knee stiffness and/or lower extremity contractures. The Restorative Nursing Flowsheet for 6/1/196/30/19 indicated active and passive ROM exercises to both upper and both lower extremities were provided by routine therapy aides to Resident 12 once a day, three times a week. The restorative nursing weekly progress notes for 6/1/19-6/30/19 indicated Resident 12 had pain and was unable to fully extend both lower extremities. The restorative nursing weekly progress notes also indicated licensed nurses were made aware Resident 12 had pain and was unable to fully extend both lower extremities. The MDS dated 6/8/19, did not identify Resident 12's decline in function. The MDS indicated, Section G0400-Functional Limitation in Range of Motion was coded as "0" for lower extremity which indicated Resident 12 still had no limitation in ROM in both lower extremities. The licensed nurse Weekly Summary dated 6/18/19, indicated Resident 12 had contractures on both lower extremities. The Physician's Order dated 7/18/19, received from the facility via fax, indicated restorative nursing services for active and passive ROM to both lower and upper extremities of Resident 12 were discontinued. The Restorative Nursing Flowsheet for 7/1/197/23/19 indicated active and passive ROM exercises to both upper and both lower extremities were provided by routine therapy aides to Resident 12 once a day, three times a week until 7/20/19; the ROM exercises were discontinued on 7/23/19. The restorative nursing weekly progress notes for 7/1/19FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 14 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 7/23/19 indicated Resident 12 had pain and was unable to fully extend both lower extremities. The restorative nursing weekly progress notes also indicated licensed nurses were made aware Resident 12 had pain and was unable to fully extend both lower extremities. The licensed nurse Weekly Summary dated 9/10/19, indicated Resident 12 had contractures on both lower extremities. The MDS dated 9/11/19, did not identify Resident 12's decline in function. The MDS indicated, Section G0400-Functional Limitation in Range of Motion was coded as "0" for lower extremity which indicated Resident 12 still had no limitation in ROM in both lower extremities. The Restorative Nursing care plan, which listed contracture management and ROM exercises as interventions, was renewed on 11/25/19, but the restorative nursing services were not renewed and provided to the resident, as specified in the plan of care. There was no evidence the resident was referred to PT for reevaluation. The licensed nurse Weekly Summary dated 12/3/19, indicated Resident 12 had contractures on both lower extremities. In an observation in the Harmony Unit (a living section in the facility) activity/dining room on 12/10/19 at 11:04 a.m., Resident 12 was observed sitting in her wheelchair. Resident 12's wheelchair foot/leg rests were elevated and she had pillows under both knees. Resident 12 was observed in the dining room while she participated in the activity program; she kept both her knees bent and did not fully extend both her lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 15 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 In a subsequent observation and interview in the Harmony Unit with Resident 12 on 12/10/19 at 1:57 p.m., Resident 12 stated she had occasional pain on her thighs and her legs. When asked if she was able to fully extend both her legs, Resident 12 did not respond. Resident 12 kept both knees bent and did not fully extend both her lower extremities. In an interview with certified nurse assistant (CNA) 3 on 12/13/19 at 10:30 a.m., she stated Resident 12 was contracted on both lower extremities. She explained she had to dress Resident 12 first, before other residents, because she had to put Resident 12's pants on while the resident was in bed. CNA 3 added it was hard to put Resident 12's pants on once she was up in the wheelchair because Resident 12 could not move and extend her legs. CNA 3 stated Resident 12 was very contracted and could not bear weight on her lower extremities. CNA 3 verbalized staff used a mechanical lift to transfer Resident 12 in and out of bed and the wheelchair. In an interview with routine therapy aide (RTA) 1 on 12/13/19 at 10:48 a.m., she stated Resident 12 was no longer being seen for restorative nursing exercises and no longer have a physician's order for restorative nursing. RTA 1 added, she used to see Resident 12 for ROM exercises to both upper and both lower extremities, but Resident 12 was "too contracted and was hurting a lot." In a concurrent interview and record review with licensed nurse (LN) 2 on 12/13/19 at 11 a.m., she reviewed the clinical record for Resident 12 and verified there was no physician's order for restorative nursing program, but there was a care plan for restorative nursing. LN 2 said the restorative nursing care plan should be discontinued. LN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 16 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 stated Resident 12 was not contracted and was able to move both her lower extremities. In a concurrent interview and record review with resident assessment coordinator (RAC) 2 on 12/13/19 at 11:18 a.m., she reviewed the clinical record for Resident 12 and verified there was no physician's order for restorative nursing program, but there was a care plan for restorative nursing. RAC 2 stated the restorative nursing care plan has to be discontinued. In a concurrent interview and record review with RAC 1 on 12/13/19 at 1 p.m., she reviewed the clinical record for Resident 12. RAC 1 said, "I do not remember if [Resident 12] is contracted or not." RAC 1 stated contractures should be coded correctly in the MDS. RAC 1 explained when she assessed Resident 12 for the MDS and performed passive ROM on both her lower extremities, Resident 12 was able to move her legs with full ROM. In an observation by the Harmony Unit nurses station on 12/13/19 at 1:15 p.m., CNA 2 was assisting Resident 12 to position her legs onto the pillows on the elevated foot/leg rests in the wheelchair. Resident 12 was unable to fully extend her right leg and was unable to extend her left leg at all. CNA 2 was having a hard time positioning Resident 12's legs, so RTA 1 came over to help CNA 2 and Resident 12. RTA 1 explained to CNA 2 Resident 12 was unable to fully extend her legs because it hurts her. In a concurrent interview and record review with the director of rehabilitation department (DOR) on 12/13/19 at 2:30 p.m., she reviewed the PT Initial Assessment dated 6/9/18. She stated Resident 12 was evaluated for transfer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 17 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 training and her ROM on both lower extremities were within functional limitation upon admission to the facility. In a concurrent interview and record review with the interim director of nursing (DON) on 12/13/19 at 3:35 p.m., she was made aware of the above observations and interviews. She reviewed the clinical record for Resident 12. She said, "It could be [Resident 12] needs to be assessed by PT and need to be put on RNA [restorative nursing]." The DON explained reassessment of residents were done quarterly with the MDS or when there is a change of condition or a change in the resident's function or ability. After reassessment, Resident 12 should be referred to PT for evaluation. In an interview with LN 3 on 12/13/19 at 4:05 p.m., she stated when in her wheelchair, Resident 12 was able to move her lower extremities but has not seen her with her legs fully extended. In an interview with LN 4 on 12/13/19 at 4:15 p.m., he stated Resident 12 had contractures on both her lower extremities but was able to move her right leg more. LN 4 explained he worked with Resident 12 before, and both her lower extremities were already contracted. In an interview with LN 5 on 12/13/19 at 4:20 p.m., she stated, "As far as I can remember, she [Resident 12] has contractures on her lower extremities, just not sure which side."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/17/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 18 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: 2. Resident 22 was admitted to the facility with diagnosis of urine retention (inability to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 19 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 completely empty the bladder of urine). During initial visit on 12/10/19, at 8:46 a.m., Resident 22 had an intravenous catheter (a small, flexible tube placed into a vein for access to administer a medication) inserted at the back of her right hand and an intravenous (IV-through the veins) pole with a pump was observed in her room. In an interview with the licensed nurse (LN) 6 on 12/11/19, at 8:08 p.m., she stated, Resident 22 was receiving antibiotic (medications used to treat infections) medications intravenously because she had a urinary tract infection (UTIan infection involving the urinary system). LN 6 added, "Resident 22 had two more doses of antibiotics left." During a concurrent interview and Resident 22's clinical record review on 12/12/19, at 1 p.m., LN 2 stated, Resident 22's laboratory report dated 12/6/19, revealed abnormal results indicating a UTI. The physician order dated 12/6/19, indicated to administer ertapenem (Antibiotic medication to treat UTI) intravenously. The progress notes dated 12/7/19, revealed IV antibiotic was administered. Further review of Resident 22's clinical record revealed, there was no care plan indicating the resident had UTI and there was no care plan for antibiotic medication use. LN 2 stated, "I can't find the care plan for UTI." In a subsequent interview with the resident assessment coordinator (RAC) 1 on 12/12/19, at 3:11 p.m., she stated, there was no care plan for the UTI and IV antibiotic use. She further stated, "I agree, there was no care plan done." In an interview with the interim director of nursing (DON) on 12/13/19, at 2:51 p.m., she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 20 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 stated, as soon as the problem had been identified, the nurse should have initiated a care plan concerning the problem and initiated an intervention appropriate for the problem. Review of the facility policy titled, "Interdisciplinary Team/Care Plan Process" revised 12/23/14, indicated in pertinent parts, "...1. Care plans are reviewed and revised as needed: a. Upon identification of a medical change in condition; b. when there has been a significant change in the resident's status...; c. During the weekly summary process; d. No less than quarterly..." Based on staff interview and record review, the facility failed to develop a person-centered care plan which accurately described the care and services to be provided to each resident for 3 of 29 sampled residents (Resident 22, Resident 25, and Resident 62) when: 1. Resident 25 and Resident 62 were on scheduled voiding but did not have a care plan for scheduled voiding or for urinary and/or bowel incontinence; 2. Resident 22 was on antibiotic therapy for a urinary tract infection (UTI) but did not have a care plan for UTI and antibiotic use. These failures had the potential for Resident 22, Resident 25, and Resident 62 to receive inaccurate care and treatment. Findings: 1a. According to the admission record, Resident 25 was admitted with Alzheimer's disease (a progressive brain disorder that affects memory and thinking skills). The Admission Bowel/Bladder Observation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 21 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 form dated 10/1/19, indicated Resident 25 was frequently incontinent of stool and urine (lack of control over urination or defecation), was a candidate for toileting schedule/timed voiding, and a care plan will be initiated. A review of the Minimum Data Set (MDS, an assessment tool) dated 10/8/19, indicated Resident 25 required extensive assistance for most activities of daily living, was not on a toileting program, was occasionally incontinent of bladder, and was always continent of bowel. There was no care plan for a toileting program or for urinary and/or bowel incontinence found in the clinical record. In an interview with certified nurse assistant (CNA) 5 on 12/11/19 at 1:14 p.m., she stated Resident 25 was on a toileting schedule so she asked Resident 25 to go to the bathroom every two hours. 1b. According to the admission record, Resident 62 was admitted with dementia (a decline in mental ability). The Admission Bowel/Bladder Observation form dated 11/4/19, indicated Resident 62 was always incontinent of stool and urine, was a candidate for toileting schedule/timed voiding, and to continue with the plan of care. A review of the MDS dated 11/10/19, indicated Resident 62 required extensive assistance for most activities of daily living, was not on a toileting program, was frequently incontinent of bladder, and was occasionally incontinent of bowel. There was no care plan for a toileting program or for urinary and/or bowel incontinence found in the clinical record. In a concurrent interview and record review with resident assessment coordinator (RAC) 1 and RAC 2 on 12/11/19 at 2:20 p.m., they reviewed the clinical record for Resident 25 and Resident 62. They verified the above FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 22 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 mentioned Bowel/Bladder Observation forms and were unable to find a care plan for a toileting program or for urinary and/or bowel incontinence for the residents. RAC 2 stated the toileting program should be included in the care plan. In an interview with licensed nurse (LN) 1 on 12/11/19 at 2:40 p.m., he stated care plans were usually initiated by the admission nurse. LN 1 said, "Everything we do for the resident has to be care planned." During a review of the facility's policy and procedure titled, "Bowel and Bladder Program Incontinence Assessment and Intervention" revised 12/21/10, indicated, "In an effort to support resident dignity and self-esteem, each resident's elimination status is assessed and an appropriate plan and interventions are developed in a timely manner...Within seven (7) days of admission...the Bowel and Bladder Observation is completed by a licensed nurse...Once the assessment and plan are completed, the information on the type of plan and interventions are transferred to the resident care plan so that all caregivers are aware of the plan for the resident..."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 01/17/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 23 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop, revise and/or update 3 of 29 sampled residents' care plans (Resident 12, Resident 25, and Resident 62) after completion of a comprehensive assessment or the Minimum Data Set (MDS, an assessment tool). This failure had the potential for Resident 12, Resident 25, and Resident 62 to receive inaccurate care and treatment. Findings: 1a. According to the admission record, Resident 25 was admitted with Alzheimer's disease (a progressive brain disorder that affects memory and thinking skills). The Admission Bowel/Bladder Observation form dated 10/1/19, indicated Resident 25 was frequently incontinent of stool and urine (lack of control over urination or defecation), was a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 24 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 candidate for toileting schedule/timed voiding, and a care plan will be initiated. A review of the MDS dated 10/8/19, indicated Resident 25 required extensive assistance for most activities of daily living, was not on a toileting program, was occasionally incontinent of bladder, and was always continent of bowel. There was no care plan for a toileting program or for urinary and/or bowel incontinence found in the clinical record. In an interview with certified nurse assistant (CNA) 5 on 12/11/19 at 1:14 p.m., she stated Resident 25 was on a toileting schedule so she asked Resident 25 to go to the bathroom every two hours. 1b. According to the admission record, Resident 62 was admitted with dementia (a decline in mental ability). The Admission Bowel/Bladder Observation form dated 11/4/19, indicated Resident 62 was always incontinent of stool and urine, was a candidate for toileting schedule/timed voiding, and to continue with the plan of care. A review of the MDS dated 11/10/19, indicated Resident 62 required extensive assistance for most activities of daily living, was not on a toileting program, was frequently incontinent of bladder, and was occasionally incontinent of bowel. There was no care plan for a toileting program or for urinary and/or bowel incontinence found in the clinical record. In a concurrent interview and record review with resident assessment coordinator (RAC) 1 and RAC 2 on 12/11/19 at 2:20 p.m., they reviewed the clinical record for Resident 25 and Resident 62. They verified the above mentioned Bowel/Bladder Observation forms and were unable to find a care plan for a toileting program or for urinary and/or bowel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 25 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 incontinence for the residents. RAC 2 stated the toileting program should be included in the care plan. In an interview with licensed nurse (LN) 1 on 12/11/19 at 2:40 p.m., he stated care plans were usually initiated by the admission nurse. LN 1 said, "Everything we do for the resident has to be care planned." 1c. According to the admission record, Resident 12 was admitted with dementia (a decline in mental ability). Resident 12 required extensive assistance from staff for most activities of daily living as indicated on the MDS dated 9/11/19. In an interview with routine therapy aide (RTA) 1 on 12/13/19 at 10:48 a.m., she stated Resident 12 was no longer being seen for restorative nursing exercises and no longer had a physician's order for restorative nursing. RTA 1 added, she used to see Resident 12 for range of motion (ROM, measurement of the amount of movement around a specific joint or body part) exercises to both upper and both lower extremities, but Resident 12 was "too contracted (contracture - deformity and rigidity of the joint) and was hurting a lot." In a concurrent interview and record review with licensed nurse (LN) 2 on 12/13/19 at 11 a.m., she reviewed the clinical record for Resident 12 and verified there was no physician's order for a restorative nursing program, but there was a care plan for restorative nursing. LN 2 said the restorative nursing care plan should be discontinued. She explained resident assessment coordinators (RACs) update the care plans. In a concurrent interview and record review with RAC 2 on 12/13/19 at 11:18 a.m., she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 26 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 reviewed the clinical record for Resident 12 and verified there was no physician's order, but there was a care plan for restorative nursing. RAC 2 stated the restorative nursing care plan has to be discontinued. In a concurrent interview and record review with RAC 1 on 12/13/19 at 1 p.m., she verified Resident 12's ROM on both upper and lower extremities were assessed as part of the MDS on 9/11/19, but did not mention the need to revise or discontinue the restorative nursing care plan. Further review of the clinical record for Resident 12 revealed a restorative nursing care plan dated 3/14/19. There was no current physician's order for restorative nursing program. The MDS was completed on 9/11/19, but the care plan was not revised or updated. The most current weekly nursing summary was completed on 12/10/19, but the care plan was not revised or updated. The facility policy and procedure titled, "Interdisciplinary Team/Care Plan Process" revised 12/23/14, indicated, "Each resident will have a care plan that is initiated upon admission and is complete [sic] no later than seven days after the completion of the resident assessment instrument...Care plans are reviewed and revised as needed...Upon identification of a medical change in condition...During the weekly summary process..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/17/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 27 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement an intervention to reduce the risk of a fall for one of 8 sampled residents (Resident 40) when the call light was not within Resident 40's reach. This placed Resident 40 at risk for further falls. Resident 40 was admitted to the facility with diagnoses of muscle weakness and repeated falls. During the initial room visit on 12/10/19, at 10:49 a.m., Resident 40 was in bed and awake. Resident 40's call light was hanging on the wall. Resident 40 stated, he could use the call light when it's near him. He further stated, "I can't reach it (call light). It should be here next to me." In a subsequent interview with the certified nurse assistant (CNA) 7, she stated, "The call light is suppose to be with him." In an interview with CNA 3 on 12/11/19, at 2:49 p.m., she stated, call light should be answered immediately and must be kept within reach of the resident. In an interview with the licensed nurse (LN) 2 on 12/12/19, at 7:27 a.m., she stated, call light should be placed next to the resident. Review of Resident 40's clinical records, the fall risk assessment tool dated 10/14/19, revealed a fall risk score of 22 indicated, "a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 28 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 level of high fall risk." The progress notes dated 11/27/19, indicated a fall incident, "...pt (patient) stated " I was trying to get my...on top of the bedside drawer...reminded pt to use his call light for help...placed...call button with in reached [sic]..." The post-fall assessment dated 11/27/19, revealed measures to be taken to prevent falls included, "...Remind resident to call for assistance..." Review of Resident 40's care plan, dated 11/27/19, indicated, "...remind pt to call for help using his call light..." In an interview with the interim director of nursing (DON) on 12/13/19, at 02:51 p.m., she stated, "I expected the staff to make sure the call light is available for use and answered." Review of the facility policy titled, "Fall Prevention Program" revised 12/21/10, indicated, "...Residents will be provided an environment which will reasonably maximize safety while maintaining an optimal level of independence..."

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 01/17/2020 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 29 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement its policy on enteral tubes (tube inserted through the abdomen and used to administer nutrition or medication) for 1 of one sampled resident (Resident 18) when the tube irrigation syringe was not replaced after 24 hours. This failure had the potential for Resident 18 to develop complications from being administered medications and fluids from a contaminated tube irrigation syringe. Findings: According to the admission record, Resident 18 was admitted to the facility with dementia (a decline in mental ability). Resident 18 was dependent on staff for activities of daily living and received nutrition and medications through an enteral tube. On 12/10/19 at 10:27 a.m., Resident 18 was observed in bed, sleeping in her room. Resident 18 was receiving tube feeding formula via an enteral pump attached to a metal pole at the bedside. There was a tube irrigation syringe in a plastic bag hanging on the metal pole. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 30 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 tube irrigation syringe bag was dated 12/8/19. In a subsequent observation at the bedside of Resident 18 on 12/10/19 at 1:49 p.m., the tube irrigation syringe bag hanging on the metal pole was labeled 12/10/19. In an interview with licensed nurse (LN) 1 on 12/11/19 at 2:40 p.m. he acknowledged, on the morning of 12/10/19, the tube irrigation syringe bag for Resident 18 was dated 12/8/19. LN 1 stated, "I noticed it yesterday. I threw it [tube irrigation syringe] away as soon as I saw it and I told the night nurse about it." LN 1 explained the tube irrigation syringe was supposed to be changed by night shift every 24 hours. The facility policy and procedure titled, "Medication Administration Enteral Tubes" dated November 2017, indicated, "...Clean feeding syringe and return to bedside stand. Syringes are replaced after 24 hours..."

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 01/17/2020 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: 2. Review of Resident 193's clinical record indicated Resident 193 was admitted to the facility with diagnoses which included mechanical complication of internal right hip prosthesis (problems with his right hip), removal of internal fixation device (a device used to ensure bones remain in position during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 31 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 and after healing process), muscle weakness and unsteadiness on his feet, pain on the right hip, and pain on the right knee. During an observation on 12/10/19 at 8:15 a.m., Resident 193 was observed walking down the hallway using a walker as a medical assistive device from his room to the therapy room with another therapist. Resident 193 stated, "ow," and then stated he was in pain outside of his room to the surveyor and wanted to speak about the facility to the surveyor after physical therapy. There was a licensed nurse with the medicine cart a few feet away from the resident. A record review of Resident 193's medication administration record (MAR) indicated Resident 193 had a physician's order dated 12/7/19 for hydrocodone-acetaminophen 10-325 mg (Norco-a narcotic pain medication), 1 tablet oral PRN (as needed) for pain. The MAR indicated he had not received Norco until 11:17 a.m., on 12/10/19, after physical therapy had been completed. The MAR also indicated the resident had a pain level of 7 out of 10 (with a pain scale of zero meaning no pain, to 10, meaning the highest level of pain). During a review of Resident 193's care plan, created on 12/08/19, Resident 193 had the problem: potential for pain related to right hip revision. The interventions and approaches for this included: assess and evaluate type and intensity of pain .... As needed, and provide medications as ordered, and the resident had to be educated on a pain scale and their rating of discomfort so that Resident 193 can provide the nurse with this information for his plan of care. Review of Resident 193's physical therapy care plan indicated Resident 193 needed assistance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 32 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 with mobility, or walking, throughout the activity of walking or intermittently walking as far as 10 to 150 feet away from his room. During an interview with physical therapy (PT 1) on 12/12/19 at 10:00 a.m., PT 1 stated Resident 193 recently had surgery before coming to the facility and should have been assessed by the nurse for pain before any movement or therapy for Resident 193. PT 1 should have also asked the licensed nurse if Resident 193 needed any other type of pain medication as ordered by the physician before going to physical therapy. PT 1 then stated that the Residents in physical therapy have to complete balance and strengthening exercises, and this requires mobility and movement of the patient's body parts. During an interview with Resident 193 on 12/10/19 at 11:30 a.m., Resident 193 stated he received a prescription for the pain medication Norco (a type of medication given to alleviate pain) from the hospital. Resident 193 stated he was in pain while walking, and the facility staff only gave him a Tylenol (a type of pain medication). Resident 193 also stated he had requested "Norco" before walking because his pain was not relieved with Tylenol. Resident 193 also stated the facility staff did not have Norco at the time and they did not provide the Norco pain medication when he requested it before getting him up to walk to therapy, even though that was the medication he had requested. During a review of Resident 193's progress notes, dated 12/10/19 at 10:25 a.m., the facility did not receive confirmation to take the Norco 10/325 mg out of the e-kit (an emergency kit that provides medications in a facility's inventory when medications are needed to be given to Residents) until after therapy was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 33 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 completed on 12/10/19. During an observation on 12/12/19 at 8:50 a.m., Resident 193 was expressing verbal signs of pain such as "ow" in his room with CNA 5 in his room. LN 6 was at the end of the Resident hallway with a medication cart outside of the Resident's room. CNA 5 walked out of Resident 193's room and near the nurses' station, but did not communicate to LN 6 about Resident 193's pain or if Resident 193 had or needed any pain medication ordered by physician. During an interview with CNA 5 on 12/12/19 at 1:35 p.m., CNA 5 stated Resident 193 was "screaming" because of his knee, was uncomfortable, and said "ow." CNA 5 stated she did not notify LN 6 about 193's pain and should have told the licensed nurse about Resident 193's pain. During an interview with the LN 6 on 12/12/19 at 2 p.m., LN 6 stated therapy staff should have asked the nurse about Resident 193's pain levels, and if Resident 193 had received pain medication before walking the resident to therapy. LN 6 indicated she was not informed about Resident 193's pain level prior to resident 193 walking with physical therapy staff to his physical therapy session. LN 6 stated she did not assess Resident 193 prior to having him walk and participate in physical therapy at 8:15 a.m. on 12/10/19. There were no pain levels documented in the MAR prior to Resident 193 walking to therapy, and Norco was removed from the e-kit after Resident 193 had already completed physical therapy. LN 6 confirmed she did not get information about the Resident 193's pain level from the CNA on the morning of 12/12/19. During an interview with the interim Director of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 34 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 Nursing (DON) on 12/13/19 at 11:30 a.m., she stated nurses should, and are expected to assess residents for pain by obtaining an assessment about the Resident's current condition prior to physical therapy. Review of the facility's policy and procedure, dated 12/13/16, titled "Assessment - Pain management" indicated, "Licensed Nurses will assess the resident's level of pain as needed with changes of condition, administer medication according to doctors orders, and/or provide alternative interventions to enhance resident comfort and satisfaction as needed." Based on observation, interview, and record review, the facility failed to recognize and manage pain for two of 8 sampled residents (Resident 18 and Resident 193) when: 1. Resident 18 was not given pain medication prior to wound care dressing change for a Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) located on the sacrum (a large, triangular bone at the base of the spine). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 35 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 This failure caused Resident 18 unnecessary pain and signs of discomfort during the wound care dressing change. 2. Resident 193 was not assessed for pain levels prior to walking and physical therapy and Certified Nursing Assistant (CNA) 5 did not communicate to Licensed Nurse 6 (LN 6) about pain to LN 6. This failure caused Resident 18 to have pain and discomfort not alleviated while in the facility. Findings: 1. According to the admission record, Resident 18 was readmitted to the facility with dementia (a decline in mental ability) and a Stage IV pressure ulcer on the sacrum. Resident 18 required extensive assistance for most activities of daily living as indicated on the Minimum Data Set (MDS) dated 11/22/19. In a concurrent observation and interview at the bedside of Resident 18, on 12/12/19 at 2:55 p.m., the director of staff development (DSD) performed wound care dressing change on Resident 18's Stage IV pressure ulcer as the resident laid in bed. Certified nurse assistant (CNA) 3 assisted the DSD with the wound care dressing change. CNA 3 and the DSD positioned Resident 18 to her right side to be able to visualize and treat the pressure ulcer on her sacrum. Resident 18's pressure ulcer was a gaping wound and her sacrum was exposed. Resident 18 cried out and moaned as soon as the DSD started to clean her wound. When asked if she was in pain, Resident 18 said, "Yes." The DSD stated she asked Resident 18 if she needed pain medicine prior to the wound care dressing change and the resident said she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 36 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 was not in pain. Resident 18 continued to cry out throughout the whole wound care dressing change which lasted approximately 10 minutes. A review of the MDS dated 11/22/19, indicated, Section C1000 - Cognitive Skills for Daily Decision Making was coded as "3" which indicated Resident 18 was severely cognitively impaired and never/rarely made decisions regarding tasks of daily life. A review of the physician's order dated 11/16/19, indicated for Resident 18 to take tramadol (medication used to treat moderate to severe pain) 50 milligrams (mg, a unit of measure) twice a day at 9 a.m. and at 9 p.m. for pain control. The physician's order dated 11/15/19, indicated for Resident 18 to take 650 mg of acetaminophen (pain medication) every 6 hours as needed for mild pain. A review of Resident 18's pain care plan dated 11/16/19, indicated, "...Goal: PAIN WILL BE RECOGNIZED AND EFFECTIVELY TREATED TO PROMOTE COMFORT AND WELL BEING DAILY...Approach: ...ASSESS AND EVALUATE TYPE AND INTENSITY OF PAIN EVERY SHIFT AND AS NEEDED...MEDICATION(S) AS ORDERED..." In a concurrent interview and record review with the interim director of nursing (DON) on 12/13/19 at 3:35 p.m., she reviewed the clinical record for Resident 18. She verified Resident 18 gets tramadol twice a day for pain control and may take acetaminophen as needed for pain. The DON reviewed the medication administration record (MAR) and confirmed Resident 18 got tramadol 50 mg at 9 a.m. and at 9 p.m. on 12/12/19, but did not get any acetaminophen on 12/12/19. She stated the licensed nurse should assess the resident's pain prior to treatment by asking the resident, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 37 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 and by observing the resident's body language and facial expression. The DON said, "Expectation is staff could anticipate resident will have pain from treatment and give pain medication PRN [as needed]." The facility policy and procedure titled, "Assessment - Pain Management" revised 12/13/16, indicated, "Licensed Nurses will assess the resident's level of pain, administer medication, and/or provide alternative interventions to enhance resident comfort and satisfaction...Residents are assessed for pain management upon admission, each shift, and as needed...Shift-to-shift documentation of pain level will be completed using a numeric value on a scale of 0-10...If the resident is unable to state or point to the scale, use the Pain Assessment In Advanced Dementia (PAINAD) scale to document the body language observed and assign the correct 0-10 scale..."

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

F755 01/17/2020 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 38 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 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 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, interview, and facility policy review, the facility failed to implement their disposal of medications policy and procedures when a medication was not disposed in an appropriate container in one of 2 inspected medication carts. This failure could result in potential diversion and accidental exposure of wasted (contaminated) medications, including controlled drugs (drugs that are detrimental to health and regulated by a government), that were stored in the medication cart while waiting for final disposition. During an inspection of medication cart #2 at the Sequoia station (a living section in the facility), with licensed nurse (LN) 7 on 12/13/19, at 3:55 p.m., a white, round tablet was found inside the first drawer where overthe-counter medications were kept. When asked how would LN 7 dispose of the wasted medication, LN 7 demonstrated by putting the tablet in a pill crusher plastic bag and crushing the tablet with a pill crusher. LN 7 then opened the narcotic stoarage area and opened a larger FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 39 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 plastic bag that had been towards the back of all the narcotic bags. LN 7 took the crushed wasted tablet, that was still in the pill crusher plastic bag, and put the plastic bag into the larger plastic bag. LN 7 stated, she kept the crushed waster tablet in this, crushed the tablet with a pill crusher, opened the narcotic storage area, and towards the back of all the narcotic packs was another bigger plastic bag. LN 7 placed the crushed wasted tablet that was in the pill crusher plastic bag into this bigger plastic bag. LN 7 stated, she kept the crushed wasted tablet in this plastic bag. Upon further observation, this bigger plastic bag contained several crushed medications still in its individual pill crusher plastic bags. In a subsequent interview with LN 7 on 12/13/19, at 3:55 p.m., when asked how she would dispose of a wasted controlled drug, she replied, it would be the same process as she would had done with the wasted tablet. She added, she would crush the wasted narcotic in a pill crusher plastic bag and place it in the bigger plastic bag, that was kept in the medication cart, still in its individual pill crusher plastic bag. She further stated, there was no appropriate container in the medication room for disposal of wasted medications, including wasted controlled drugs. In an interview with the interim director of nursing (DON) on 12/13/19, at 4:20 p.m., she stated, the medication room at the Sequoia station should have a pharmaceutical waste bin (a special container to discard wastes that contain properties dangerous or harmful to human health or the environment) and discard the wasted medications, including wasted controlled drugs in the bin. She added, "I will take care of it, should have a bin in the Sequoia med [medication] room." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 40 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 Review of the facility policy titled, "Disposal of Medications" dated December 2012, indicated in pertinent parts, "...3. Methods of disposition of pharmaceutical hazardous and nonhazardous wastes are consistent with...standards of practice. The nursing care center will use an approved vendor for pharmaceutical waste disposal needs. 1...a. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container... 2...a...The appropriate method of controlled substance destruction...transfer medication to trash receptacle following destruction to unusable consistency...Mixing medications with undesirable substance, such as used coffee grounds or kitty litter...will further ensure the drugs are not diverted..."

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

F880 01/17/2020 §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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 41 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 §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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 42 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 §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 implement its hand hygiene program for one of 29 sampled residents (Resident 18) when certified nurse assistant (CNA) 3 did not remove her gloves and did not perform hand hygiene after touching Resident 18. This failure had the potential to spread infection to residents in a census of 93. Findings: According to the admission record, Resident 18 was readmitted to the facility with dementia (a decline in mental ability) and a Stage IV (fullthickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) pressure ulcer located on the sacrum (a large, triangular bone at the base of the spine). Resident 18 required extensive assistance for most activities of daily living as indicated on the Minimum Data Set (MDS) dated 11/22/19. In an observation in Resident 18's room on 12/12/19 at 2:55 p.m., CNA 3 assisted the director of staff development (DSD) with the wound care dressing change for Resident 18. CNA 3 and the DSD positioned Resident 18 to her right side then the DSD performed the wound care dressing change. After the wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 43 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 care dressing change, the DSD put all the soiled dressing in a plastic bag and told CNA 3 she will be back to assist in cleaning and repositioning Resident 18. CNA 3 left the bedside without removing her soiled gloves and without performing hand hygiene. She opened Resident 18's closet, took out a clean pad and incontinent brief, and then went back to Resident 18's bedside wearing the same pair of gloves. The DSD and CNA 3 changed Resident 18's incontinent brief and pad, and repositioned Resident 18 in bed. In an interview with CNA 3 on 12/12/19 at 3:15 p.m., she stated she was supposed to remove her gloves and wash her hands right after providing care to Resident 18, and before going in her closet to get clean briefs. CNA 3 said, "I forgot." In an interview with the DSD on 12/12/19 at 3:20 p.m., she said she noticed CNA 3 did not remove her soiled gloves and did not wash her hands when she left Resident 18's bedside. She stated CNA 3 should have removed her gloves and washed her hands after she assisted with the wound care dressing change. The facility policy and procedure titled, "Hand Hygiene Program" revised 12/29/18, indicated, "Hand hygiene shall be regarded by this organization as the single most important means of preventing the spread of infections...Handwashing of approximately 20 seconds must be performed under the following conditions: ...Before handling clean or soiled dressings...After handling used dressings, contaminated equipment...After handling items potentially contaminated with blood, body fluids, excretions, or secretions..." The Centers for Disease Control and Prevention (CDC) website entry titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 44 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 "Healthcare Providers - When to Perform Hand Hygiene?", last reviewed on 4/29/19 at https://www.cdc.gov/handhygiene/providers/ind ex.html, indicated, "...Clinical Indications for the Two Methods for Hand Hygiene...Use an Alcohol-Based Hand Sanitizer...After touching a patient or the patient's immediate environment...Immediately after glove removal..."

F926 SS=D Smoking Policies CFR(s): 483.90(i)(5)

F926 01/17/2020 §483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement its smoking policy in accordance with State regulations for 2 of 2 sampled residents (Resident 15 and Resident 30) when a staff allowed the residents to smoke within 20 feet of an entrance or a window. This failure had the potential to place nonsmoking residents at health risk from secondhand smoke in a census of 93. Findings: In a concurrent observation and interview on 12/13/19 at 11:20 a.m., Resident 15 and Resident 30 were observed smoking outside, next to a table which was pushed all the way to the outside wall of the dining room. The table was next to the door and windows to the main FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 45 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 activity/dining room. Activity Staff (ACT) 1 was sitting outside next to Resident 15 and Resident 30. It was raining outside. There was no ash tray next to the residents who were smoking. The ash trays were located near the table, located in the area labeled "smoking area". In an interview with Resident 15 and Resident 30, they said they were not in the designated smoking area because they did not want to smoke in the rain. In an observation on 12/13/19 at 11:30 a.m., the administrator went outside to the smoking patio and saw Resident 15 and Resident 30 smoking next to the main activity/dining room door and windows while being monitored by ACT 1. The administrator told Resident 15 and Resident 30, "This is not the smoking area." The administrator turned to ACT 1 and told her the residents have to be in the smoking area. Resident 15 and Resident 30 covered their heads and went to the designated smoking area. In an interview with ACT 1 on 12/13/19 at 1:05 p.m., she said, "I was not aware [Resident 15 and Resident 30] were too far back from the smoking area and were too close to the windows and door." ACT 1 clarified she was aware of the location of the designated smoking area but was unsure of what to do in the rain. She added, "I was trying to keep the residents from getting pneumonia." The facility policy titled, "Smoking" revised 12/23/14, indicated, "It is the policy of this community to protect the health, welfare, and comfort of residents, visitors, and employees from adverse effects of tobacco smoke...Residents and visitors may smoke only outside in designated areas and are prohibited from smoking within twenty (20) feet of any entrance..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 46 of 47 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: _______________ 555713 (X3) DATE SURVEY COMPLETED 12/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEADOWOOD A HEALTH & REHABILITATION CENTER 3110 Wagner Heights Road Stockton, CA 95209 (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 The California Government Code Section 7597 indicated, "(a) No public employee or member of the public shall smoke a tobacco product inside a public building, or in an outdoor area within 20 feet of a main exit, entrance, or operable window of a public building..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFMU11 Facility ID: CA030001535 If continuation sheet 47 of 47