Health inspection·August 14, 2025

F 0580 treatment significantly.specific instruction to notify the Physician/Nurse Practitioner of changes in the resident's condition . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that a safe discharge plan was in place for one of two sampled residents (Resident 1) when:1. The facility did not notify and document that the Ombudsman (acts as an independent and impartial resource to help individuals and groups resolve issues and complaints, often within a larger organization or government agency), Adult Protective Services (APSprograms that promote the safety, independence, and quality-of-life for vulnerable adults who are, or are in danger of, being abused, neglected by self or others, or financially exploited, and who are unable to protect themselves), the police department, and Resident 1's Responsible Party (RP) were contacted upon his Discharge Against Medical Advice ([NAME]- when a patient leaves a hospital or healthcare facility before their doctor recommends they be discharged ) from the facility.2. The Medical Director (MD) did not receive notification from the facility that Resident 1 was attempting to leave the facility.3. The MD was not made aware of potential changes in behavior during Resident 1's stay in the facility.4. An elopement care plan (a proactive strategy to prevent residents in care facilities from leaving unsupervised, especially those with dementia or other cognitive impairments) was not created after Resident 1 was readmitted to the facility; when he had a history of leaving the facility during his initial admission on [DATE].These deficient practices had the potential to result in poor continuity of care and could lead to adverse health outcomes for Resident 1.Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including: need for assistance with personal care, unspecified dementia/ unspecified severity with other behavioral disturbance (an umbrella term for a decline in mental abilities severe enough to interfere with daily life. It affects memory, thinking, and behavior, and is not a normal part of aging), and suicidal ideations.During a review of Resident 1's clinical record titled, Nurses Notes, dated 7/11/25, at 9:37 PM, indicated, .[Resident 1] arrived via ambulance with 2 attendants .Resident is alert and oriented .he doesn't understand the situation .Resident started questioning me on whether or not the doors were locked and if he could go outside. Stated to resident that its getting dark .When resident saw EMT's [sic] he started yelling take me with you .resident became irate for some reason and stated he was leaving. Headed for the door. Didn't try to physically stop him as he was getting very aggressive in language and posture. Followed him out door, trying to convince resident to come back inside .Told my CNA [certified nursing assistant] to back off and let him go, it wasn't worth getting hurt. Came inside and called 911 .Received call our from maintenance supervisor that he is following the resident he saw leave the facility grounds. Maintenance stated policespotted [sic] them and started questioning resident .Police came to facility and told me that they were putting him [Resident 1] on a hold .During a review of Resident 1's clinical record titled, Nurses' Progress Note, dated 7/15/25, at 3:36 PM, indicated, .admission Note: Resident arrived from [local hospital] .Resident is alert and oriented .with episodes of confusion .Elopement Evaluation Score .High Risk .During a review of Resident 1's clinical record titled, [facility name] History and Physical, dated 7/16/25, the record indicated, .This is a medically complex patient, he has a baseline cognitive impairment and dementia, he is a poor historian.he is at high risk for decline and worsening due to his poor functional status as well as his cognitive impairment.Psychiatry exam indicated that Resident 1 has a baseline cognitive impairment and is unable to participate in the exam.During a review of Resident 1's clinical record titled, Social Service Assessment Admission/Readmission, dated 7/17/25, the record indicated, .Resident 1 and Resident Representative/Family will participate in discharge planning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safety concerns with Resident 1 preferred discharge plan indicated Resident 1 would need HH (Home Health), DME (Durable Medical Equipment) and caregiver for a successful discharge.During a review of Resident 1's clinical record titled, Nurses Note, dated 7/17/2025, the record indicated, .Resident 1 packed his belongings, put them in his walker, walked to the desk to tell staff that he is leaving. Licensed Nurse stated to Resident 1 to wait a moment to sign the [NAME] form. Resident 1 signed and Licensed Nurse pointed him to the door.During a phone interview on 7/29/25, at 1:49 PM, with Resident 1's RP, the RP stated that the facility did not notify her when Resident 1 left the facility. The RP further stated Resident 1 needed to be at the facility due to his severe dementia. The RP stated that a representative from a hospital contacted her on 7/18/25 to inform her that Resident 1 was no longer residing at the facility and had been admitted to the hospital. The RP further stated how upset she was that the facility did not notify her of Resident 1's [NAME] and was concerned that Resident 1 was left homeless overnight from 7/17/25 to 7/18/25.During a phone interview on 8/15/25, at 11:04 AM, with Licensed Nurse (LN) 3, LN 3 stated that Resident 1 was readmitted to the facility on [DATE] and he helped to perform the readmission assessment along with LN 1. LN 3 further stated that based on his assessment, Resident 1 was not safe to be discharged against medical advice ([NAME]) due to his behaviors of being very aggressive, yelling, having impaired cognition, and having dementia. LN 3 stated Resident 1 was alert and able to make needs known but he had cognitive issues and behavioral problems. LN 3 further stated that if a resident attempted to leave against medical advice (AMA), his expectation was to follow protocol by notifying the Ombudsman, contacting APS, and completing the SOC-341 (a form used to report suspected dependent adult/elder abuse in California).During a concurrent interview and record review on 7/30/25, at 11:43 AM, with the Social Services Director (SSD), an undated facility provided document titled, [facility name] AMA tracker, was reviewed. The SSD confirmed that the APS, Ombudsman, and the local police department were not notified of Resident 1's [NAME]. The SSD stated that it was a lapse in the facility's protocol. The SSD further stated that it was important to involve the other agencies because it could give additional support to ensure the residents' safety. The SSD stated that if the proper agencies are not aware, they would not be able to help in these types of cases.During an interview on 7/30/25, at 11:51 AM, with the Administrator (ADM), the ADM stated that APS and the Ombudsman were not notified regarding Resident 1's [NAME]. The ADM further stated that Resident 1 preferred to live on the streets and be homeless.During an interview on 7/30/25, at 12:24 PM, with the Director of Nursing (DON), the DON confirmed that the RP was the responsible party for Resident 1. The DON further confirmed that they had missed notifying Resident 1's RP, the Ombudsman, APS, and the police department regarding Resident 1's [NAME]. The DON stated that the entire notification process should always be used for the safety of the residents.During a review of an undated facility policy and procedure (P&P) titled, Transfer and Discharge (including AMA), the P&P indicated, .The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both.Notify Adult Protection Services, or other entity as appropriate.During a review of the facility's P&P titled, Transfer and Discharge Planning, revised on 8/20, the P&P indicated, .The Facility will determine if a referral to Adult Protective Services or other state agency responsible for investigating abuse and neglect is necessary. If indicated, the referral to Adult Protective Services or other state agency will be made at the time of discharge.2. A review of Resident 1's [facility name] Decision Making Capacity, signed by the MD, dated 7/16/25, the first box was checked that indicated, .Yes, Resident is Capable of Understanding Rights, Responsibilities, and Informed Consent .A review of Resident 1's [facility name] History and Physical, signed by the MD, dated 7/16/25, indicated, .This is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medically complex patient, he has a baseline cognitive impairment and dementia, he is a poor historian.he is at high risk for decline and worsening due to his poor functional status as well as his cognitive impairment.Psychiatry exam indicated that Resident 1 has a baseline cognitive impairment and is unable to participate in the exam.During a concurrent interview and record review on 8/14/25, at 1:38 PM, with the MD, Resident 1's clinical record titled, .History and Physical, dated 7/16/25, and Resident 1's .Decision Making Capacity, dated 7/16/25, were reviewed. When questioned the capacity for Resident 1 to make his own decisions if the H&P indicated Resident 1 had a cognitive impairment, the MD stated that the documentation is not jiving and appeared to reflect a wrong determination. The MD explained that Resident 1 was able to understand basic information but had more difficulty with comprehending complex information. The MD described Resident 1 as borderline, with the ability to understand simple matters but not complex medical information. The MD stated that during Resident 1's [NAME] event, he could not recall personally speaking to any of the LNs. The MD further stated that he just received notification that Resident 1 left already or was leaving. The MD stated that he could not recall speaking with Resident 1 regarding his plan to leave [NAME]. The MD further stated that it would have been much safer for Resident 1 if he had been given the opportunity to speak with him. The MD stated that he expected the LNs to offer Resident 1 the opportunity to speak with him so he could have explained the risks, benefits, and alternative options for a safe discharge.During a review of the facility's P&P titled, Transfer and Discharge Planning, revised on 8/20, the P&P indicated, .If the resident/representative wishes to be discharged to a setting that does not appear to meet the resident's post-discharge needs or appears unsafe, the Facility will treat this request similarly to a refusal of care.The Facility will discuss and document the risks/implications of being discharged to a location not equipped to meet the resident's needs with the resident/representative.The Facility will attempt to determine why the resident/representative is choosing that location.The Facility will document that other more suitable options were presented and discussed with the resident/representative but that the alternate locations were refused.During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 4/25, the P&P indicated, .The nurse will notify the resident's Attending Physician/Physician On-Call/Nurse Practitioner when there has been a(an).discharge without proper medical authority.3. During a review of Resident 1's Progress Notes, dated 7/16/25, the Progress Notes indicated, .Resident has done nothing except lay facing the wall in his bed. Refused to eat. Refused Covid booster. Refused all medications. Will continue to monitor. Call light in reach.During a review of Resident 1's Progress Notes, dated 7/17/25, the Progress Notes, indicated, .Resident noted very aggressive behavior. He took the medicine from the nurse and pretending he is going to take while he tried to sit on the edge of the bed. He lead forward and throw away all his medicine under the night stand and under the bed. Re-direct the resident. Will continue to monitor.During an interview on 8/14/25, at 1:07 PM, with LN 2, LN 2 stated Resident 1's behavior on 7/17/25 was very aggressive as she carefully entered the room to check and was able to validate the actions of Resident 1. LN 2 confirmed that she did not notify the MD and that she should have done so. LN 2 stated that informing the MD could have led to a further evaluation of Resident 1, including the ordering of possible laboratory tests.During a concurrent interview and record review on 8/14/25, at 11:11 AM, with the DON, Resident 1's Progress Notes, were reviewed. The DON confirmed that Resident 1 was exhibiting aggressive behaviors, was refusing his medications, and was also refusing to eat. The DON stated that LNs should have notified the MD if there were behavioral changes occurring for Resident 1. The DON further stated that if Resident 1 was refusing to eat or take his medications, that those were other reasons to inform the MD. The DON explained that notifying the MD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would have provided guidance on what actions to take with Resident 1.During an interview on 8/14/25, at 1:38 PM, with the MD, the MD stated that he could not recall any LNs notifying him about Resident 1's refusal to eat, refusal to take medications, or his aggressive behaviors. The MD further stated that he was available 24 hours a day and 7 days a week. The MD stated that he would have liked the facility to have notified him about Resident 1 so he could have discussed some medical options with him.During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 4/25, the P&P indicated, .The nurse will notify the resident's Attending Physician/Physician On-Call/Nurse Practitioner when there has been a(an).significant change in the resident's condition.need to alter the resident's medical treatment significantly.specific instruction to notify the Physician/Nurse Practitioner of changes in the resident's condition .4. During a review of Resident 1's clinical record titled, Nurses Notes, dated 7/11/25, at 9:37 PM, indicated, .[Resident 1] arrived via ambulance with 2 attendants .Resident is alert and oriented .he doesn't understand the situation .Resident started questioning me on whether or not the doors were locked and if he could go outside. Stated to resident that its getting dark .When resident saw EMT's [sic] he started yelling take me with you .resident became irate for some reason and stated he was leaving. Headed for the door. Didn't try to physically stop him as he was getting very aggressive in language and posture. Followed him out door, trying to convince resident to come back inside .Told my CNA [certified nursing assistant] to back off and let him go, it wasn't worth getting hurt. Came inside and called 911 .Received call our from maintenance supervisor that he is following the resident he saw leave the facility grounds. Maintenance stated policespotted [sic] them and started questioning resident .Police came to facility and told me that they were putting him [Resident 1] on a hold .During a review of Resident 1's clinical record titled, Nurses' Progress Note, dated 7/15/25, at 3:36 PM, indicated, .admission Note: Resident arrived from [local hospital] .Resident is alert and oriented .with episodes of confusion .Elopement Evaluation Score .High Risk .During an interview on 8/14/25, at 10:26 AM, with the Minimum Data Set (MDS) Nurse, the MDS stated that Resident 1's history of dementia and previous instance of leaving the facility during his first admission on [DATE], along with a high elopement risk score, were all indications that an elopement care plan should have been made. The MDS further stated that based on Resident 1's high elopement risk score, a care plan should have already been in place. The MDS explained that an elopement care plan is important in order to provide appropriate interventions.During a concurrent interview and record review on 8/14/25, at 10:46 AM, with LN 1, Resident 1's Electronic Health Record (EHR) was reviewed. LN 1 stated she did the readmission assessment for Resident 1 on 7/15/25 along with LN 3. LN 1 further stated that based on her clinical assessment, Resident 1 demonstrated confusion and had an inability to answer questions accurately. LN 1 confirmed that she stood by her documentation that Resident 1 was confused. LN 1 further stated that based on her assessment, Resident 1 required an elopement care plan as part of the baseline care plan. LN 1 confirmed that an elopement care plan was not made for Resident 1. LN 1 stated that an elopement care plan was important to ensure staff knew how to appropriately provide care for Resident 1, particularly given his confusion and desire to leave the facility.During a concurrent interview and record review on 8/14/25, at 11:11 AM, with the DON, Resident 1's Electronic Health Record (EHR) was reviewed. The DON stated that she expected the LNs to chart thoroughly so that anyone reviewing the clinical record would have a clear picture of Resident 1. The DON further stated that proper documentation was important to provide Resident 1 with the appropriate level of care. The DON confirmed that no elopement care plan had been developed for Resident 1. During a phone interview on 8/15/25, at 11:04 AM, with LN 3, LN 3 stated that Resident 1 was readmitted to the facility on [DATE]. LN 3 further stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that Resident 1 should have had an elopement care plan created because of his high risk for elopement and having a diagnosis of dementia as well as a history of leaving AMA. LN 3 explained that if a resident was a high risk for elopement, especially with dementia, staff would implement interventions such as assigning a sitter or 1:1 direct supervision, applying a WanderGuard, (a security system designed to protect residents in healthcare facilities, particularly those with memory care needs, from wandering out of designated safe areas) and providing 24-hour monitoring for 3 days to ensure safety. LN 3 stated that all shifts were responsible for working together to develop a care plan. LN 3 further stated that an elopement care plan was important to ensure Resident 1's safety.During a review of the facility's P&P titled, Elopements and Wandering Residents, dated 4/16/21, the P&P indicated, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. Event ID: Facility ID: 555105 If continuation sheet Page 7 of 7