Inspection·March 6, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s medical record, nurses note, dated, 1/27/24, authored by LVN C, indicated, Resident 1 showered. During an interview with LVN C, on 3/5/24 at 4:00 p.m., LVN C was queried about the central line catheter policy and procedure regarding who can change a central line dressing. LVN C responded, she believes RNs administer all IV ' s and change central line dressings in the facility. LVN C queried about her nurses note written on 1/27/24 where it indicated, Permacath minimal bleeding noted around catheter, dressing done. LVN C queried if she changed the dressing. LVN C responded that she reinforced the dressing. LVN C queried if she notified MD G about the blood around the Permacath site. LVN C stated she doesn ' t believe she notified MD G. LVN C queried as to what dressing was over the tip of the Permacath catheter and could see the insertion site of the Permacath. LVN C responded, a gauze was around the Permacath catheter tip. LVN C queried as to how the facility can assess the insertion site if there is a bloody gauze over the tip of the catheter. LVN C, stated, she looks on the dialysis communication transfer form to see if the dressing has been changed, if the dressing is not noted as being changed on the dialysis communication form, then I do not know if the site has been assessed. LVN C queried if Resident 1 was showering with his Permacath. LVN C responded, yes, she knew Resident 1 was taking showers. During an interview with the LVN A on 3/5/24 at 2 p.m., LVN A queried if she ever changed the dressing on Resident 1 ' s Permacath. LVN A stated, she had not changed the dressing but did look at the dressing to see if it needed to be reinforced. LVN A queried if Resident 1 had taken showers with the Permacath. LVN A stated, yes, Resident 1 had been taking showers. During an interview with the Infection Preventionist LVN F, on 3/7/24 at 1:30 p.m., LVN F queried if the Permacath Central Line Policy indicated that Residents could shower with a Permacath. LVN F responded, she thinks she remembers the policy indicates the resident cannot shower with the Permacath. LVN F queried as to who can change a central line dressing. LVN F states, she knows that RNs are the only ones who can change a central line dressing. LVN F queried how she would know that Facility H is changing the dressing after a dialysis treatment. LVN F stated, she believes Facility H writes it on their Transfer Form. LVN F queried if she has completed staff in services on Infection Prevention, End Stage Renal Disease and Dialysis. LVN F stated, she has not. During a review of Resident 1 ' s medical record, Dialysis Transfer Form, dated 2/3/24, Dialysis Transfer Form observed to have no information about the Permacath site or that the dressing had been changed from Facility H post dialysis treatment. During a review of Resident 1 ' s Care Plan, dated 1/23/24, indicated, On admission, Resident 1 is at risk for unavoidable bleeding and infection from right upper chest Permacath due to End Stage Renal Disease with Hemodialysis; Risk of any occurrence of unavoidable bleeding and infection from dialysis central line site will be reduced through appropriate interventions. Document monitoring of dialysis site every shift and as needed for any evidence of nursing changes in condition to include (but not limited to): bleeding, vital signs, access site patency, breathing patterns/breath sounds, level of consciousness, low blood pressure, diaphoresis, paleness, Notify physician of any changes. During a review of Resident 1 ' s medical record, Change of Condition Form, dated 2/5/24, authored by RN B, indicated, Resident 1 had thrown up 2 times this early morning, feels dizzy around 9:00 a.m., not eating food or drinking, lethargic and less verbal, blood pressure 90/60, temperature 101 degrees, pulse 109 per minute, oxygen 87 % (percent oxygen in the blood), and respirations 26 per minute. Called 911 and sent Resident 1 to hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 2 of 3 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s medical records, Nurses noted, dated 2/8/24, authored by RN I, indicated, Follow up made from hospital, Resident 1 still on medical treatment from central line infection. Informed that he has a new central line in place. During a review of the contract between the facility and Dialysis Facility H, signed 2/14/23, indicated, Center Obligations, (c) If requested by Facility, Center may in its sole discretion, agree to provide instructional materials and an annual in-service training for Facility staff relating to the care of dialysis patients at no charge to Facility. Center makes no representations or warranties respecting the training described above, and center shall not be responsible for the acts of Facility ' s staff in connection with their care of Facility ' s patients including without limitation, the designated resident. During a review of Facility H ' s Permacath Central Venous Catheter Policy, revised October 2022, indicated, Education of patients with catheters that require a dressing should include the following: Sponge bath only, keep dressing site clean and dry, observe for signs and symptoms of infection and report any signs and symptoms of infection. During a review of the facility ' s policy and procedure titled, Facility Assessment 2024, dated 2024, indicated, the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operation and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility ' s resident population, including, but not limited to, both the number of residents and the facility ' s resident capacity. Included in the list of facilities current diagnosis but not limited to is, End Stage Renal Disease and Sepsis. All residents are assessed prior to admission to assure that the facility can provide adequate care for the acuity of the Resident based on their diagnosis, health needs and the acuity of the other resident in the facility. The Facility must also provide staff competencies that are necessary to provide the level and types of care needed for the resident population. All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. During a review of the facility ' s policy and procedure titled, End stage Renal Disease Care of Resident, revised September 2010, indicated, Residents with End-Stage Renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: The nature and clinical management of ESRD (including infection prevention and nutritional needs); the type of assessment data that is to be gathered about the resident ' s condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD. During a review of the facility ' s policy and procedure titled, Hemodialysis Access Care revised, September 2010, indicated, Central Line Catheter, Care Immediately Following Dialysis Treatment, If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. Care of Central Dialysis Catheters: The central catheter site must be kept clean and dry at tall times. Bathing and showering are not permitted with this device. During a review of CDC National Standards, Guidelines for the Prevention of Intravascular Catheter-Related Infections dated 2011, # 6 Catheter Site Dressing Regimens 3) Replace catheter site dressing if the dressing FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 3 of 3