Health inspection·September 10, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure two of 26 sampled residents (Resident 16 and Resident 11) and their responsible parties (RP- a person responsible for health care decisions) were informed of the residents' change of condition and medical appointments.This failure had the potential for the residents' RP not to be able to make an informed decision about the residents' healthcare.FindingsA review of Resident 16's admission Record, indicated she was admitted to the facility in 2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). The record also indicated Resident 16's son was the RP.During an interview on 9/8/25 at 12:19 p.m. with Resident 16's RP, RP stated Resident 16 was to be seen by an Ear, Nose and Throat specialist (ENT- a doctor specializing in conditions affecting the ears, nose, throat, sinuses, and parts of the head and neck.) for a follow up about her ear infections and had not been seen.A review of Resident 16's medical record indicated two ENT follow-up appointments were completed on 7/24/25 and 8/13/25. The medical record did not indicate the RP was notified of the follow-up ENT appointments or the treatment plan.A review of Resident 11's admission Record, indicated she was admitted to the facility in August 2025 with diagnoses including cerebral infarction (blood flow is interrupted to the brain, causing damage) and vascular dementia (cognitive decline caused by damage to the blood vessels in the brain).A review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/15/25, indicated Resident 11's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was three out of 15 with severe memory impairment.During an interview on 9/9/25 at 9:36 a.m. with Resident 11's RP, RP stated she was concerned about the lack of notification after Resident 11's fall on 8/23/25 which led to a right foot injury.A review of Resident 11's medical record indicated Resident 11's RP was not notified after a change of condition (COC- a document that indicates a change in resident health condition) on 8/25/25. The COC form indicated a call to the RP without a response. The medical record did not indicate a follow-up call to the RP or a contact with another family member.During a concurrent interview and record review on 9/9/25 at 2:15 p.m. with the Assistant Director of Nursing (ADON), Resident 16 and Resident 11's medical records were reviewed. ADON confirmed there were no RP notifications in the medical records regarding Resident 16's follow-up ENT appointments and Resident 11's COC. ADON stated her expectations were staff should have notified the RPs of appointments, treatment plans and changes in conditions in any resident.A review of the facility's policy titled, Informing Resident of Health, Medical Condition and Treatment Options, dated 2/2021, indicated, Every resident is informed of his or her total health status, medical condition and options for treatment and/or care. The policy further indicated, Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an on-going basis. If a resident has an appointed Residents Affected - Few Page 1 of 23 555180 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0552 representative, the representative is also informed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555180 Page 2 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interview, and record review, the facility failed to maintain privacy for one of 26 sampled residents (Resident 82), when Resident 82's urinary catheter (a tube left in the bladder to continuously drain urine into a collection bag) collection bag had no privacy cover. This failure decreased the facility's potential to maintain Resident 82's dignity.Findings:A review of Resident 82's admission Record, indicated she was admitted to the facility in August 2025 with diagnoses including acute cystitis (bladder infection) and neuromuscular dysfunction of the bladder (a condition in which the nerves controlling the bladder and urinary sphincter are damaged, leading to problems with urine storage and emptying).A review of Resident 82's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/3/25, indicated her Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 12 out of 15 with moderate memory impairment.A review of Resident 82's Treatment Administration Record, dated 9/25, indicated an order to monitor Resident 82's urinary catheter.During a concurrent observation and interview on 9/7/25 at 1:20 p.m. with Resident 82 in her room, Resident 82 was sitting in her wheelchair at her bedside table eating lunch. Resident 82's urinary catheter bag was attached beneath the seat. Resident 82 stated she never had a private cover for the urine collection bag since she was admitted and wanted to have one.During a concurrent observation and interview on 9/7/25 at 1:40 p.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 82's room, CNA 1 confirmed Resident 82 did not have a privacy cover for her urinary collection bag and stated she should have one.During an interview on 9/9/25 at 7:50 a.m. with the Infection Prevention Nurse (IP), IP stated urinary catheter bags should always be covered to maintain residents' privacy.A review of the facility's policy titled, Dignity, revised in 2/21, indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered . 555180 Page 3 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to protect and keep secure when not in use confidential resident health data and records for a census of 67 residents. This failure had the potential to expose and disclose personal and confidential residents' health information to unauthorized individuals.Findings:During a medication pass observation on 9/7/25 at 9 a.m., Licensed Nurse (LN) 4's computer screen was observed unlocked and accessible to residents and staff passing by when she left to clarify an order. During a medication pass observation on 9/7/25 at 9:08 a.m., LN 4's computer screen was again observed unlocked and accessible to residents and staff passing by when she left to enter a resident's room. During an interview on 9/7/25 at 1:21 p.m. with LN 4, LN 4 confirmed she left the computer unlocked and unattended when she went to clarify an order and again when she entered a resident's room. During an interview on 9/8/25 at 4:31 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to lock the cart and screen to hide residents' information so personal health information would not be exposed. A review of the facility's policy and procedure titled, Electronic Medical Records, revised in 3/14, indicated, Policy Interpretation and Implementation . 3. Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system. 4. The facility will make reasonable efforts to limit the use or disclosure of protected health information . Residents Affected - Some 555180 Page 4 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess one of 26 sampled residents (Resident 5), when the Minimum Data Set (MDS, a federally mandated assessment tool) inaccurately indicated Resident 5 had no pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).This failure had the potential to incorrectly recognize Resident 5's care needs.Findings:A review of an admission record indicated Resident 5 was admitted to the facility in November 2023 with a diagnosis of pressure ulcers. During an observation on 9/7/25 at 9:44 a.m. inside Resident 5's room, a wound vacuum assisted closure device (wound VAC, a negative pressure wound treatment that uses suction to help hard to heal wounds heal faster) was observed at the side of Resident 5's bed in continuous operation.A review of Resident 5's Order Summary Report, dated 7/10/25, indicated Resident 5 had treatment orders for two stage four pressure ulcers (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone at the base of the spine), one located on the sacrum (a triangular bone in the lower back) and the other one located on the left gluteal crease (horizontal line at the bottom of the left buttock cheek) and had the wound VAC.A review of Resident 5's MDS, dated [DATE], indicated no documented pressure ulcers in the skin condition MDS assessment.During a concurrent interview and record review on 9/9/25 at 1:44 p.m. with the MDS Coordinator (MDSC), Resident 5's MDS assessments, physician orders, treatment notes and Treatment Administration Record (TAR) were reviewed. MDSC confirmed Resident 5 had pressure ulcers since admission and stated the MDS assessment, dated 6/2/25, was inaccurately coded based on the TAR and treatment notes. During a concurrent interview and record review on 9/9/25 at 2:10 p.m. with the Nurse Consultant (NC), Resident 5's MDS assessments were reviewed. NC stated MDSC should have made sure assessments were documented accurately to ensure proper delivery of care to residents.A review of the facility's policy titled, Certifying the Accuracy of Resident Assessment, revised in 12/19, indicated, Any person . completing the MDS must . certify the accuracy of that portion of the assessment. Residents Affected - Few 555180 Page 5 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure professional standards were followed for three of 26 sampled residents (Resident 7, Resident 82 and Resident 85), when:1. A lidocaine (anesthetic used to treat pain) five percent (%, a unit of measurement) patch was applied to Resident 82's lower back without date, time and initials of the nurse applying it;2. Licensed Nurse 4 (LN 4) did not identify Resident 85 prior to medication administration;3. LN 4 did not wear gloves during preparation and administration of hazardous medication; and4. Nursing staff did not clarify overlapping PRN (as needed) pain medication orders. These failures had the potential to result in inappropriate medication administration, preventable medication errors, increased risk of adverse drug events, oversedation, and resident harm or death. Findings:1.During a medication pass observation on 9/7/25 at 8:12 a.m., the Assistant Director of Nursing (ADON) was observed applying a topical lidocaine patch to Resident 82's lower back. ADON applied the patch without signing and dating it.During an interview on 9/7/25 at 12:15 p.m. with ADON, ADON confirmed she was supposed to sign and date the lidocaine patch after applying it but did not do so because she did not have a marker.During an interview on 9/8/25 at 4:31 p.m. with the Director of Nursing (DON), DON stated nurses were expected to date and sign patches upon administration to ensure the patch was changed correctly and to prevent medication errors.A review of the facility's policy and procedure (P&P) titled, Transdermal Drug Delivery System (Patch) Application, dated 3/18, indicated, Procedures: Label patch with date and nurse's initials.2.During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed entering the room of Resident 85 and beginning medication administration without properly identifying the resident.During an interview on 9/7/25 at 9:36 a.m. with LN 4, LN 4 stated she missed identifying the resident prior to medication administration and normally she would ask their name and date of birth prior to giving medication.During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated nurses were expected to verify the identity of the residents prior to medication pass, and some ways to do that were to use the picture on the Medication Administration Record (MAR) and look at the name on the wall by resident's door.A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, The individual administering medication verifies the resident's identity before giving the resident his/her medications. The P&P further indicated, The individual administering medication checks the label three times to verify the right resident . Before giving the medication.3.During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed preparing and administering Resident 85's spironolactone (medication used to treat conditions such as high blood pressure, heart failure, fluid retention), a hazardous medication, without gloves.During a concurrent interview and record review on 9/7/25 at 9:26 a.m. with LN 4, the labeling on the bubble packet of Resident 85's medical record and spironolactone was reviewed. LN 4 confirmed Resident 85's medical record did not have any indication to alert staff that spironolactone was a hazardous drug. LN 4 confirmed the label on the bubble packet contained the word HAZAR to indicate it was hazardous.During an interview on 9/7/25 at 1:21 p.m. with LN 4, LN 4 stated she did not know spironolactone was a hazardous medication and required gloves when it was prepared and administered.During an interview on 9/8/25 at 1:09 p.m. with Consultant Pharmacist (CP), CP stated for spironolactone, gloves would be required for handling especially for staff that could be pregnant. CP also stated staff were made aware a drug was hazardous by the labels on the bottles and by his recommendation to have it added into charts.During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated she informed her staff on several occasions to never touch any medication. DON added she did not know spironolactone was hazardous, but she told staff to always have gloves on because you never know. DON further stated no one had Residents Affected - Some 555180 Page 6 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some told her spironolactone should be stored separately.A review of the facility's P&P titled, Storage of Medications, dated 11/20, indicated, Hazardous drugs are clearly marked and stored separately from other medications.4.During a concurrent interview and record review on 9/9/25 at 11:32 a.m. with DON, Resident 7's physician's orders were reviewed. Resident 7's medical record indicated the following physician's orders for pain management:-Acetaminophen (a mild pain medication) oral tablet 500 milligrams (mg, a unit of measurement). Give 500 mg by mouth every six hours as needed for pain not to exceed (NTE) three grams (g, a unit of measurement) of Acetaminophen (APAP) within a 24-hour period, ordered on 6/1/25, and-Hydrocodone-Acetaminophen (a more potent pain medication) tablet 5-325 mg. Give one tablet by mouth every six hours as needed for pain NTE 3 g of APAP within a 24-hour period, ordered on 6/22/25.DON confirmed Resident 7's physician's orders for Acetaminophen and Hydrocodone/APAP were both ordered as needed and stated nursing staff should have clarified the order with the physician to know when it was appropriate to administer each medication. DON further stated nursing staff should have clarified the order with the physician to include parameters (a pain scale) to know when to administer each medication.A review of the facility's P&P titled, Administering Medications, dated 4/19, indicated, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 555180 Page 7 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to accommodate the needs of one of 26 sampled residents (Resident 76), when Resident 76 was not given a shower as scheduled.This failure decreased the facility's potential to provide comfort to residents.Findings:A review of an admission record indicated Resident 76 was admitted to the facility in September 2025 with a diagnosis of right femur (thigh bone) and vertebra (backbone) fracture.During an interview on 9/7/25 at 9:24 a.m. with Resident 76, Resident 76 stated she felt uncomfortable because she had not taken a shower since her admission to the facility.A review of the facility's Skilled Nursing Shower Assignment, updated on 8/18/25, indicated Resident 76 was scheduled to have morning showers on Monday, Wednesday and Friday.During an interview on 9/10/25 at 9:45 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated residents were assisted with showers in the morning per their schedule. CNA 2 further stated CNAs must complete a shower tracking sheet and document it in the computer to let the Licensed Nurse (LN) know if the shower was given or refused by the resident.During a concurrent interview and record review on 9/10/25 at 10 a.m. with LN 1, Resident 76's shower schedule and the facility's shower tracking sheet binder were reviewed. LN 1 confirmed there was no documented shower sheet for Resident 76.During a concurrent interview and record review on 9/10/25 at 11:10 a.m. with the Director of Staff Development (DSD), Resident 76's progress notes and bathing task documentation were reviewed. DSD stated based on the notes Resident 76 did not refuse to take a shower the week before. DSD further stated the assigned CNA did not provide Resident 76 a shower.During an interview on 9/10/25 at 1:30 p.m. with the Administrator (ADM), ADM stated he expected CNAs to provide showers to residents as scheduled unless they refused. ADM further stated staff should prioritize the residents' physical needs to provide comfort and dignity.A review of the facility's policy titled, Bath, Shower/Tub, revised in 2/18, indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Residents Affected - Few 555180 Page 8 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper care of respiratory equipment was consistent with the facility's policy and professional standards of practice for one of 26 sampled residents (Resident 10), when Resident 10's nebulizer tubing and nasal cannula (a thin, flexible tube that goes around your head and into the nose and gives additional oxygen through the nose) were not changed after seven days.This failure decreased the facility's potential to provide safe respiratory care for Resident 10.Findings:A review of an admission record indicated Resident 10 was admitted to the facility in February 2024 with a diagnosis of respiratory failure with hypoxia (insufficient amount of oxygen in the body's tissues).A review of Resident 10's Order Summary Report, dated 7/30/25, indicated an order for oxygen via nasal cannula to keep oxygen saturation at 92 percent.During a concurrent observation and interview on 9/7/25 at 9:32 a.m. with Licensed Nurse 1 (LN 1) in Resident 10's room, a nebulizer machine with tubing/mouthpiece (a machine that turns liquid medicine into a fine mist) and a nasal cannula were observed by Resident 10's bedside table. LN 1 confirmed both tubings were last replaced on 8/28/25 as indicated by the label attached to it. LN 1 stated the tubings were not changed in seven days.During an interview on 9/10/25 at 10 a.m. with the Director of Nursing (DON), DON stated her expectation for staff was to adhere to the facility's policy regarding the proper use and maintenance of respiratory equipment for residents.A review of the facility's policy titled, Departmental Respiratory Therapy, revised in 11/2011, indicated, The purpose of this procedure is to guide . with respiratory therapy tasks and equipment including . medication nebulizers/Continuous Aerosol . Discard the administration set-up every seven (7) days. Residents Affected - Few 555180 Page 9 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to:1. Ensure nursing staff accurately documented the removal of controlled medications (those with high potential for abuse or addiction) during medication pass;2. Ensure accurate accountability and effective storage of controlled medication when random controlled medication audits for two out of two residents (Resident 14 and Resident 17) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps a record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; and,3. Demonstrate adequate safeguards were implemented to ensure chain of custody of controlled substances and limit their potential for diversion prior to final destruction. These failures resulted in the facility not having accurate accountability of controlled medications and increased potential for diversion, abuse or misuse of these medications.Findings: 1.During a concurrent interview and record review on 9/7/25 at 8:12 a.m. with Assistant Director of Nursing (ADON), Resident 82's physician's order for pain relief was reviewed. Resident 82's medical record indicated the following physician's order for pain management: -Oxycontin (a medication used for pain relief) oral tablet ER (extended release). Give 10 milligrams (mg, a unit of measurement) by mouth two times a day for pain management. Hold for sedation or respiratory rates (RR per minute) less than 12. Do not crush/chew, ordered on 9/8/25. During a medication pass observation on 9/7/25 at 8:12 a.m., ADON administered Oxycontin ER 10 mg tablet to Resident 82 but did not document the removal of the medication on the CDR prior to administration. During a concurrent observation and interview on 9/7/25 at 8:12 a.m. with ADON, ADON confirmed she did not document the removal of the medication on the CDR prior to the administration of the medication to Resident 82. ADON confirmed the process should be to sign on CDR prior to administration when she stated, We get it out, and we sign it when we pop it out. A review of the facility's policy and procedure (P&P) titled, Controlled Medications, dated 3/2018, indicated, . The licensed nurse administering the medication immediately enters the following information on the accountability record (CDR) and Medication Administration Record (MAR): date and time of administration, amount administered, signature of the nurse administering the dose. 2a. A review of Resident 14's medical records indicated the following physician's orders: -Valium (a highly potent medication usually prescribed for anxiety and muscle spasms) oral tablet five mg. Give 0.5 tablet by mouth two times a day for neuromuscular degenerative (progressive muscle weakness and loss of function) AEB (as evidenced by) repetitive physical movements (fidgeting and pacing), ordered on 4/21/25. -Valium oral tablet five mg. Give one tablet by mouth at bedtime for neuromuscular degenerative AEB repetitive physical movements (fidgeting and pacing), ordered on 4/21/25. A review of Resident 14's CDR and MAR, dated August 2025, indicated Valium five mg was removed from the medication cart on 8/31/25 at 8:02 p.m., but the respective administration was not documented on the MAR. During a concurrent interview and record review on 9/8/25 at 4:31 p.m. with Director of Nursing (DON), Resident 14's CDR and MAR for Valium were reviewed. DON confirmed the identified discrepancy and stated the withdrawal on 8/31/25 at 8:02 p.m. might have been accidentally documented on the incorrect CDR as the timing of the withdrawal coincided with the bedtime dose. 2b. A review of Resident 17's medical record indicated a physician's order for morphine sulfate (a highly potent pain relief medication) tablet 15 mg. Give 7.5 mg every four hours as needed for moderate to severe pain 4-10 (a scale used to measure intensity of pain), dated 6/8/25. A review of Resident 17's CDR and MAR, dated July 2025, indicated morphine sulfate 15 mg was removed from the medication cart on 7/21/25 at 6:10 a.m. but the respective administration was not documented on the MAR. During a concurrent 555180 Page 10 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interview and record review on 9/8/25 at 4:31 p.m. with DON, Resident 17's CDR and MAR for morphine sulfate were reviewed. DON confirmed the above identified discrepancy. A review of the facility's P&P titled, Controlled Medications, dated 3/2018, indicated, . The licensed nurse administering the medication immediately enters the following information on the accountability record (CDR) and Medication Administration Record (MAR): date and time of administration, amount administered, signature of the nurse administering the dose, completed after the medication is administered. A review of the facility's P&P titled, Controlled Substances, dated 4/2019, indicated, Upon administration: The nurse administering the medication is responsible for recording: name of the resident receiving the medication; name, strength and dose of the medication; time of administration; method of administration . Signature of nurse administering medication. 3. During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated the steps of drug destruction included: nurse on the floor would bring the CDR and controlled medication into her office upon discontinuation of orders or discharge of resident, nurse and DON both signed off on CDR after counting the controlled medication, DON put the controlled medication into a locked drawer in her office to which only she would have access to, Consultant Pharmacist (CP) would come into the facility once a month and both DON and CP counted the controlled medication and CP would note it in a notebook the DON kept in the office, the controlled medication would be locked back up into storage in incineration box (a form of disposal of controlled medication), and the medication would be kept there until final pick up. DON agreed there were not adequate safeguards in place to ensure the chain of custody of controlled substances limited the potential for diversion. During an interview on 9/8/25 at 10:56 a.m. with CP, CP stated he would try to come to facility monthly or every other month for the destruction of controlled medication. CP stated when controlled medication was removed from cart, the medication and CDR both went to the DON and were locked into storage in her office. CP further stated if there was an entire bubble pack of controlled medication and the CDR missing from the storage prior to his arrival, the only way it would be detected by him was if the DON would detect it and share that information. CP confirmed there was no system in place that allowed him to identify if controlled substances were diverted from the time they were locked in the DON's cabinet to the time he arrived at the facility for destruction. CP acknowledged and confirmed the process did not limit the potential for diversion because of lack of accountability and documentation for processing controlled medications for destruction. A review of the facility's P&P titled, Medication Destruction, dated 3/2018, indicated, Controlled medication destruction is done in the presence of a pharmacist and a registered nurse employed by the facility. The destruction is documented on a mediation disposal form or a controlled medication disposition log . Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until destroyed by the facility's RN and consultant pharmacist; or as otherwise directed by state law. 555180 Page 11 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 14.81 percent (%, a unit of measure) error rate when four medication errors out of 27 opportunities were observed during a medication pass for two of three Residents (Resident 82 and Resident 85). This failure resulted in medications not given in accordance with the prescriber's orders and increased potential to affect the residents' clinical conditions.Findings: 1. During a medication pass observation on 9/7/25 at 8:12 a.m., the Assistant Director of Nursing (ADON) was observed preparing and administering seven medications for Resident 82 which included: oxycontin (a medication given to treat pain) ER (extended release, a long acting formulation) 10 milligrams (mg, a unit of measurement), Nephro vitamins (Vitamin B-Complex with Vitamin C and Folic Acid, a collection of vitamins and minerals), Senokot 8.6 mg (a medication to relieve constipation), Lidoderm 5% patch (a topical patch applied to the skin that relieves pain), Clear lax (a powder mixed with water that helps relieve constipation and helps irregular bowel movements), calcium carbonate (helps neutralize excess stomach acid) 500 mg, ertapenem (an antibiotic; a medication that kills or inhibits the growth of bacteria, used to treat urinary infections). A review of Resident 82's medical record indicated physician's orders for: -Senna Plus oral tablet 8.6-50 mg (a dual action medication comprised of sennosides [derived from the senna plant, this ingredient irritates the lining of the bowel to stimulate muscle contractions and promote a bowel movement] and docusate sodium [an ingredient that increases the amount of water the stool absorbs, making it softer and easier to pass]). Give two tablets by mouth one time a day for bowel management and hold for loose stool, ordered on 9/7/25. During a concurrent interview and record review on 9/7/25 at 12:15 p.m. with ADON, Resident 82's physician's orders were reviewed. ADON confirmed the order was for Senna Plus oral tablet 8.6-50 mg ordered but she administered Senokot 8.6 mg. 2. During a medication pass observation on 9/7/25 at 9:26 a.m., Licensed Nurse 4 (LN 4) was observed preparing and administering medications for Resident 85 which included: carvedilol (a medication used to treat high blood pressure) 3.125 mg, Jardiance (a medication used to help kidney function) 10 mg, budesonide/formoterol (brand name Symbicort, a medication that is inhaled that helps with reducing inflammation in airway) inhaler. A review of Resident 85's medical record indicated the following physician's orders: -Carvedilol 3.125 mg one tablet to be given orally two times a day with meal, ordered on 9/3/25;-Jardiance 10 mg to be taken with meal. Give 10 mg orally one time a day for diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ordered on 9/3/25; and -Budesonide/formoterol (brand name Symbicort) 160-4.5 micrograms (mcg, a unit of measurement) actuation inhaler two puffs to be inhaled orally two times a day for chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause long term breathing problems) and to rinse mouth after use, ordered on 9/3/25. During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed administering carvedilol 3.125 mg to Resident 85 without food. LN 4 was also observed administering Jardiance 10 mg to Resident 85 without food. During a concurrent interview and record review on 9/7/25 at 9:26 a.m. with LN 4, LN 4 stated she did not know when Resident 85 last ate food and did not verify with Resident 85 prior to administration. LN 4 confirmed that the physician's orders for carvedilol 3.125 mg and Jardiance 10 mg both stated to give these medications with a meal. LN 4 confirmed that giving medication without meals as ordered could have potentially affected the efficacy of the medication and caused side effects. During an interview on 9/7/25 at 12:15 p.m. with ADON, ADON stated Resident 85 last ate approximately around 7:15 a.m. to 7:30 a.m. During an interview on 9/8/25 at 1:20 p.m. with Consultant Pharmacist (CP), CP stated administration of medication two hours after mealtime was not considered administration with food. CP stated medications ordered with a meal should be Residents Affected - Some 555180 Page 12 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered within 30 to 45 minutes of the mealtime. CP stated the potential outcome for administering medications ordered with a meal but given on an empty stomach could lead to stomach upset. CP further stated the absorption of some medications could be better with a meal. During a concurrent medication pass observation and interview on 9/7/25 at 9:26 a.m. with LN 4, LN 4 was observed administering one puff of Symbicort inhaler to Resident 85. LN 4 confirmed the physician's orders for Symbicort indicated to administer two puffs and stated she only administered one. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated, Medications are administered in accordance with prescriber orders, including any time frame. The P&P further indicated, The individual administering the medication checks the label three times . Before administering the medication. 555180 Page 13 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to:1. Ensure multi-dose medications with shortened expiration dates were labeled correctly after use with an open date;2. Ensure medications were securely stored within manufacturer's specifications; and3. Ensure safe storage and monitoring of over the counter (OTC) medications. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate storage that was left unsupervised and open to anyone in the facility.Findings: 1. During a medication pass observation on 9/7/25 at 9:26 a.m. with Licensed Nurse 4 (LN 4), Resident 85's inhalers Budesonide/Formoterol or Symbicort (a prescription inhalation medication used to treat chronic lung diseases) and Tiotropium or Spiriva Respimat (a prescription medicine used as a long-term once-daily maintenance treatment) were found to be unlabeled with an open date. During a concurrent medication cart audit of Cart 2 and interview on 9/7/25 at 12:49 p.m. with LN 2, three out of five Refresh Tears eye drops (OTC liquid eye medicine meant to provide moisture to eyes) did not have resident specific labeling. LN 2 confirmed that labeling was missing. A review of the facility's policy and procedure (P&P) titled, Medication Labels, dated 3/2018, indicated, Labels are permanently affixed to the outside of the prescription container. The P&P further indicated, If a label does not fit directly onto the product, for example eye drops, the label may be affixed to an outside container or carton, but the resident's name must be maintained directly on the actual product container . Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name. 2. During a concurrent medication cart audit of Cart 2 and interview on 9/7/25 at 12:49 p.m. with LN 2, budesonide inhalation suspension ampules (a liquid medication contained in small individual containers used to reduce inflammation and swelling in airways) 0.5 milligrams per milliliter (mg/ml; units of measurement) were not stored inside foil packaging. LN 2 reviewed the manufacturer's labeling and confirmed it indicated, Once the foil envelope is opened, use the vials within 2 weeks . LN 2 confirmed the ampules were not stored in foil packaging in accordance with the manufacturer's specifications. During a concurrent medication cart audit of Cart 2 and interview on 9/7/25 at 12:49 p.m. with LN 2, fluticasone furoate/vilanterol (a prescription dry powder inhaler used long-term to help with symptoms of various lung diseases) 100-25 micrograms (mcg, a unit of measurement) was identified without an opened date. LN 2 confirmed the inhaler did not have an opened date and stated it should have. A review of the facility's P&P titled, Medication Labels, dated 3/2018, indicated, Contents are not transferred from one container to another. The P&P further indicated, Each prescription medication label includes date dispensed . Expiration date of medication. A review of the manufacturer's labeling for budesonide ampules indicated, After opening the aluminum foil envelope, the unused ampules should be returned to the aluminum foil envelope to protect them from light. 3. During an observation on 9/8/25 at 9:25 a.m., the central supply room (a space where facility stored items such as medical equipment, and supplies in a secure locked area) was left with the door wide open and the room unattended. OTC medications were observed on the shelves unattended in the open room which was located next to resident rooms. During an interview on 9/8/25 at 9:35 a.m. with Staffing Coordinator (SC), SC confirmed the door to the central supply room where OTC medications were stored should not have been left unlocked and unattended. During an interview on 9/8/25 at 11:48 a.m. with the Administrator (ADM) and Director of Nursing (DON), ADM and DON confirmed the door to the central supply room 555180 Page 14 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0761 Level of Harm - Minimal harm or potential for actual harm should have been locked and secured. A review of the facility's P&P titled, Storage of Medications, dated 11/2020, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . Compartments containing drugs and biologicals are locked when not in use. Residents Affected - Some 555180 Page 15 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the recipe for three residents of a census of 67 (Resident 16, Resident 24, and Resident 85), when an unmeasured amount of milk was added to pureed (a very smooth, lump-free, and moist consistency similar to pudding, requiring no chewing and able to be swallowed easily) rice.This failure had the potential to add extra liquids to the rice serving and decrease the intake of nutrients.Findings:A review of Resident 16's admission Record, indicated she was admitted to the facility in 2023.A review of Resident 16's Order Summary Report, dated 8/25/25, indicated a fortified diet (added calories) order with a pureed texture and nectar thick consistency.A review of Resident 24's admission Record, indicated he was admitted to the facility in 2024 with a diagnosis of dysphagia (difficulty swallowing). A review of Resident 24's Order Summary Report, dated 9/8/25, indicated an order for a regular large portions diet with a pureed texture and thin liquids consistency. A review of Resident 85's admission Record, indicated she was admitted to the facility on [DATE] with a diagnosis of dysphagia.A review of Resident 85's Order Summary Report, dated 9/4/25, indicated a diet order with no added salt, consistent carbohydrate/controlled carbohydrate (CCHO - a diet for managing blood sugar), a pureed texture and nectar thick consistency.A review of the facility's lunch menu, dated 9/9/25, indicated the lunch menu consisted of curry lemon chicken, garlic rice, peas with onions, wheat roll, and ice cream.A review of the facility's recipe titled, Pureed (IDDSI Level 4 [International Dysphagia Diet Standardization Initiative-Level 4 consists of pureed foods and extremely thick drinks]) Starch (Rice .), dated 2024, indicated six to 12 ounces [(a unit of measure) 0.75 to 1.5 cups] of warm milk to be added to six servings of rice.During a concurrent observation and interview on 9/9/25 at 10 a.m. with [NAME] 2 (C2) and the Dietary Services Supervisor (DSS), lunch preparation for pureed food items was observed. C2 stated she was making six servings of rice, then measured six servings of cooked rice and put it in a blender. Heated milk was to be added in increments using a 1/3 cup scoop to obtain the desired pureed consistency. C2 added three unmeasured scoops of milk and stated she should have followed the recipe and measured the amount of added milk. DSS took the recipe binder from behind C2 and showed her the pureed recipe for rice.During an interview on 9/9/25 at 10:40 a.m. with the Registered Dietician (RD), RD stated C2 did not measure three of the scoops of milk added to the rice. RD further stated it was uncertain what the partial scoops added up to in total.A review of the facility's policy titled, Diet Orders, dated 2023, indicated, Diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services Department. 555180 Page 16 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to properly prepare and store food for a census of 67 residents, when:1. Stored food was found expired and unlabeled; and 2. The cool down procedure was not followed for cooked meat.This failure decreased the facility's potential to prevent foodborne illnesses among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/7/25 at 8:32 a.m. with the Assistant Dietary Manager (AsstDM), the following items were found:-In the dry storage: One unopened package of hamburger rolls, removed from freezer on 8/27/25, with a ‘use by' date of 9/3/25; one opened package of wheat bread, unlabeled and undated; two opened packages of pasta, opened on 9/1/24, with a ‘use by' date of 9/1/25. AsstDM stated the items were past their expiration dates and needed to be discarded.-In the walk-in refrigerator: 20 heads of celery with wilted leaves, with an expiration date of 9/4/25. AsstDM confirmed the celery was past the expiration date and should not be served to residents.During an interview on 9/7/25 at 8:44 a.m. with the Dietary Services Supervisor (DSS), DSS confirmed the food items in the dry storage and walk-in refrigerator were expired and stated it should not be served to residents. DSS further stated serving expired food could potentially cause foodborne illness among residents.A review of a facility document titled, Dry Goods Storage Guidelines, dated 2023, indicated opened and unopened bread should be stored on the shelf 5-7 days before discarding, and opened pasta could be stored safely for one year. A review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, indicated, All food will be dated - month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines . Dry food items which have been opened . will be tightly closed, labeled and dated . Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used.A review of a facility document titled, Produce Storage Guidelines, dated 2023, indicated celery was to be stored one week in the refrigerator before discarding.A review of a facility document titled, Storing Produce, dated 2023, indicated, Check boxes of fruit and vegetables for rotten, spoiled items . Throw away all spoiled items . Remove the wilted or spoiled portions of lettuce, celery, and other fresh vegetables in the refrigerator often so they don't cause the rest of the vegetable to spoil.2. During an observation on 9/7/25 at 9:25 a.m., [NAME] 1 (C1) was cutting turkey roasts on the meat slicer for the residents' lunch entree. During a concurrent interview and record review on 9/7/25 at 9:25 a.m. with C1 and DSS, the facility's document titled, Cool Down Log, dated 9/25, was reviewed. The log indicated the temperature at two hours in the cooling process of cooked meats should be 70 degrees Fahrenheit ( F - a temperature scale where water freezes at 32 F and boils at 212 F) or below. If the meat temperature was higher than 70 F, the meat was to be discarded. The log further indicated on 9/6/25 at the two-hour cool down time, [NAME] 1 (C1) documented the temperature of the turkey roasts was 80 F, and continued the cool down process. Both C1 and DSS stated 80 F was too high as a cool down temperature for the meat at the two-hour mark, and the turkey needed to be discarded. A review of the facility's P&P titled, Cooling and Reheating of Potentially Hazardous Food (PHF), dated 2023, indicated, Cooked PHF. shall be cooled and reheated in a method to ensure food safety. PHF food includes food of animal origin that is raw or heat-treated . [which] includes . meat, fish, poultry. The P&P further indicated, When cooked PHF food will not be served right away, it must be cooled as quickly as possible. The P&P specified the two-stage cool down method: Cool cooked food from 140 F to 70 F within two hours. Then cool from 70 F to 41 F or less in an additional four hours for a total cooling time of six hours . Corrective Action is to be taken when the cool down process is not done correctly: discard cooked, hot food immediately 555180 Page 17 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0812 when the food is above 70 F and more than 2 hours into the cooling process. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555180 Page 18 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly dispose garbage for a census of 67 residents, when a kitchen garbage dumpster was found to have two gaping, warped lids. This failure had the potential to produce unsanitary conditions for residents due to easy access for rodents and other pests.Findings:During a concurrent observation and interview on 9/7/25 at 9:46 a.m. with the Registered Dietician (RD) and the Maintenance Plant Director (PD), the kitchen dumpsters were observed. One garbage dumpster's lids were rounded and bowed, leaving a lengthy 3-inch (a unit of measure) gap between the lids and the top rim. RD stated it was a pest problem because rodents and insects had access inside the dumpster. PD stated he ordered a new dumpster but had no documentation of the order with the disposal company.A review of the facility's document titled, Garbage and Trash, dated 2023, indicated, Adequate, clean, vermin-proof areas must be provided for the storage of garbage . and that the lids are closed. Residents Affected - Some 555180 Page 19 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 67 residents, when:1.Multiple surfaces in the laundry room's clean area were found with an accumulation of a gray powdery substance;2.Resident 73's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mask was found on top of the nightstand without a bag;3.Resident 34's bathroom toilet contained a large, thick soiled dressing;4.Licensed Nurse (LN) 3 and LN 4 did not maintain fingernails in accordance with the facility's policy;5.Multi-resident medical equipment was not sanitized and disinfected in accordance with professional standards; and6.Single use Styrofoam tray used during med pass was not disposed after use.These failures had the potential to spread infection among residents, staff, and visitors.Findings: Residents Affected - Some 1.During an observation on 9/8/25 at 11:06 a.m. in the laundry room's clean area, an accumulation of gray powdery substance was found on a cart containing clean linens covered with pink mesh material, on a portable fan on the table where staff would fold clean laundry, and in the area behind the three dryers. During a concurrent observation and interview on 9/8/25 at 11:20 a.m. with Environmental Services Supervisor (EVS), the cart containing clean linens covered with pink mesh material, the portable fan on the table, and the area behind the three dryers were observed. EVS confirmed the accumulation of the gray powdery substance and stated it was neither clean nor good for residents and staff. EVS further stated they did not pay much attention to the accumulation of the gray powdery substance. A review of the facility's policy titled, Departmental (Environmental Services) – Laundry and Linen, dated January 2014, indicated, Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination . A review of the facility's policy titled, Cleaning and Disinfection of Environmental services, dated August 2019, indicated, Environmental surfaces will be cleaned and disinfected . 2. A review of Resident 73's admission Record, indicated Resident 73 was admitted to the facility in September 2025 with diagnoses including chronic obstructive pulmonary disease (a lung condition that causes long-term damage to the airways and lungs, making it difficult to breathe) and pulmonary embolism (a condition where a blood clot blocks a lung artery but does not immediately cause acute right heart strain or failure). A review of Resident 73's Order Summary Report, dated 9/10/25, indicated Resident 73 had an order for ipratropium-albuterol solution (a combination of two medications, both which help to relax the muscles in the airways and increase airflow to the lungs) to be inhaled via nebulizer every six hours. During an observation on 9/7/25 at 10:06 a.m. in Resident 73's room, a nebulizer mask was found on top of Resident 73's nightstand without a bag. During a concurrent observation and interview on 9/7/25 at 10:14 a.m. with Infection Preventionist (IP) in Resident 73's room, Resident 73's nebulizer mask was observed. IP confirmed the nebulizer mask was not in a bag and stated the nebulizer mask should always be inside a bag to prevent infection. 555180 Page 20 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy titled, Respiratory Therapy – Prevention of Infection, dated November 2011, indicated, Infection Control Considerations related to Medication Nebulizers . Store the circuit [complete nebulizer setup] in plastic bag . between uses. 3. A review of Resident 34's admission Record, indicated he was admitted to the facility in August 2025 with diagnoses including neutropenia (an abnormally low count of neutrophils, a type of white blood cell that is crucial for immunity), lung transplant, squamous cell carcinoma on the scalp (a cancer on the outer skin layer), and a pressure sore (an injury to the skin and underlying tissue resulting from prolonged pressure) of the sacral region (tailbone). A review of Resident 34's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 8/22/25, indicated his Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 11 out of 15 with moderate memory impairment. A review of Resident 34's Treatment Administration Record, dated September 2025, indicated Resident 34 had daily orders for dressing changes to his scalp cancer surgical site and tailbone pressure sore. A review of Resident 34's Order Summary Report, dated 9/10/25, indicated he was receiving mycophenolate mofetil to maintain immunosuppression (a medical treatment that represses the immune system, often prescribed to prevent rejection of transplanted organs) for his lung transplant. During a concurrent observation and interview on 9/7/25 at 10:10 a.m. with Resident 34, Resident 34 stated he was continent of bowel and bladder, and staff always assisted him to the toilet. The toilet in Resident 34's room had a large rectangular skin bandage, dated 9/5/25. The dressing had absorbed a large amount of toilet water and appeared cube-shaped, measuring approximately 4 x 3 x 3 inches (a unit of measure). During a concurrent observation and interview on 9/7/25 at 10:27 a.m. with LN 5, LN 5 stated it was unacceptable for a staff member to leave the soiled bandage in the toilet after assisting Resident 34. LN 5 further stated the nursing aide who cared for Resident 34 should have discarded it in a safe biohazard receptacle and this was an infection control issue. A biohazard waste bin was in Resident 34's room for such items. During an interview on 9/9/25 at 7:50 a.m. with IP, IP stated dressings should never be discarded in the toilet and the assistant caring for Resident 34 should have disposed of the soiled dressing in the biohazard disposal bin in the resident's room, not the toilet. IP further stated flushing the dressing down the toilet would clog the pipes and cause contaminated water to overflow, exposing Resident 34 to infectious microorganisms, knowing that Resident 34 was undergoing immunosuppressive therapy following a lung transplant, and any exposure to infectious organisms could be fatal. A review of a facility document titled, Infections-Clinical Protocol, revised in 3/18, indicated, The physician . and staff will identify infection transmission risks and (in conjunction with the Infection Preventionist) will implement relevant precautions. A review of the facility's policy titled, Infection Prevention and Control Program, revised in 10/18, indicated the infection prevention program provides . a safe, sanitary . environment and to help prevent the development and transmission of communicable diseases and infections. The policy further 555180 Page 21 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated to prevent infection, the facility should ensure staff are adhering to . proper techniques and procedures . following established general guidelines such as those of the Centers for Disease Control (CDC). 4. During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed preparing and administering medication with approximately one-inch-long acrylic fingernails on both hands. During a concurrent observation and interview on 9/8/25 at 8:42 a.m. with LN 3, LN 3 was observed preparing and administering medication with approximately one-inch-long acrylic fingernails on both hands. LN 3 stated she knew she was not supposed to have them. LN 3 further stated long fingernails could grow pathogens (a virus or other microorganism that can cause disease). During an interview on 9/8/25 at 9:56 a.m. with IP, IP stated artificial nails were not allowed. IP further stated she had an in-service for her staff and informed staff nails should not exceed tip of finger because of patient care, because it had the potential to scratch the residents. IP also stated short nails helped prevent the spread of infection. During an interview on 9/8/25 at 4:31 p.m. with Director of Nursing (DON), DON stated long nails were an infection control issue and no one should have had them, especially nurses and Certified Nursing Assistants (CNAs) because they performed direct patient care. A review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, indicated, Personnel with direct-care resident responsibility should maintain short, natural fingernails . Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities and is prohibited among those caring for severely ill or immunocompromised residents. A review of an undated article published by the CDC titled, Clinical Safety: Hand Hygiene for Healthcare Workers, indicated, Know when to clean your hands: Immediately before touching a patient . Immediately after glove removal . Maintain fingernail and jewelry safety: Natural nails should not extend past the fingertip. Do not wear artificial nails or extensions when having direct contact with high-risk patients . Germs could live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. 5. During a medication pass observation on 9/7/25 at 8:52 a.m., LN 4 was observed using Micro Kill 2 Germicidal wipes (used in healthcare settings to clean and disinfect hard, non-porous surfaces and equipment) to disinfect the blood pressure (BP) cuff and stethoscope (medical devices used to measure BP) without gloves after checking a resident's BP. During an interview on 9/7/25 at 1:27 p.m. with LN 4, LN 4 stated she was expected to wear gloves when using Micro Kill 2 Germicidal wipes to disinfect medical equipment after use on a resident, but she had not. During an interview on 9/8/25 at 9:56 a.m. with IP, IP stated staff were expected to wear gloves when cleaning medical equipment to protect their skin from harmful chemicals and also for infection control. During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated staff were expected to wear gloves when they touched a chemical wipe and the BP cuff was dirty after use and staff's hands were dirty 555180 Page 22 of 23 555180 09/10/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after touching it. DON further stated gloves were to help prevent cross contamination between the BF cuff and soiled hands. A review of an article published by the CDC titled, Cleaning and Disinfecting your Facility, dated 4/5/21, indicated, Use chemical disinfectants safely! Always read and follow the directions on the level of cleaning and disinfection products to ensure safe and effective use . Wear gloves for all tasks in the cleaning process. 6. During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed using a single use Styrofoam tray on her medication cart to prepare medication for Resident 85. LN 4 was then observed taking the medication on the tray into Resident 85's room and placing it on her bedside table. After administration of medication to Resident 85, LN 4 was observed putting the same single use Styrofoam tray back onto her cart instead of discarding it after use. During an interview on 9/8/25 at 9:56 a.m. with IP, IP stated the Styrofoam trays were not multi use and should have been thrown away immediately after its first use because of the possibility of spreading infection. IP then stated if a resident had C. Diff (clostridium difficile a bacterium that could cause inflammation of the colon and could be spread through contact of contaminated surfaces) then staff would have introduced that to the medication cart and that's how infection spreads. During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated not discarding the single use Styrofoam tray immediately after use would have created an infection control issue. A review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, indicated, Single-use items are disposed of after a single use. 555180 Page 23 of 23