Inspection·February 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had a severely impaired memory. During a observation on 2/26/25 at 12:20 p.m., Resident 14 was mumbling incoherently and unable to be interviewed. Resident 14's curtains did not reach around bed for privacy. Residents Affected - Some During a concurrent observation and interview on 2/26/25 at 12:23 with CNA 3, CNA 3 verified Resident 14's curtains did not reach around the bed for privacy . 4. Resident 16 was admitted to the facility in the fall of 2023 with diagnoses which included muscle weakness and need for assistance with personal care. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 was alert and oriented, able to make his needs known. During an observation on 2/24/25 at 10:40 a.m. in Resident 16's room, three slats were missing from the vertical blinds covering Resident 16's sliding door. One slat was broken half way down. During a concurrent observation and interview on 2/24/25 at 10:43 a.m. with Licensed Nurse (LN) 3, LN 3 verified three vertical blind slats were missing with another one broken in half. LN 3 stated, I'm not sure if it's been put in the log. [Resident 16 is] here mostly every day . During an interview on 2/25/25 at 9:07 a.m. with the Maintenance Supervisor (MS), MS stated, [Resident 31 and Resident 7's] curtains do not close . and verified multiple vertical blind slats were broken or missing. The MS stated, Housekeeping .should be checking that the curtains reach around the bed completely. If something is broken, they should put it in the maintenance log so I can fix it I don't always indicate in which room the slats were replaced. During an interview on 2/25/25 at 9:23 a.m. with the Environmental Services Manager (ESM), the ESM was asked about the curtains that did not reach around resident personal space. The ESM stated it would be embarrassing for someone to walk in on a resident who was being changed and not having curtains around them for privacy. During an interview on 2/27/25 at 7:37 a.m. with the Director of Nurses (DON), the DON stated, The residents should be offered privacy at all times during care . During a review of the facility policy and procedure (P&P) titled Quality of Life - Dignity, revised 2/24, the P&P indicated Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .Demeaning practices and standards of care that compromise dignity are prohibited . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 2 of 10 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 02/27/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to accommodate resident needs when one of 15 sampled residents (Resident 27) call light was not within reach. Residents Affected - Few This failure increased the risk that Resident 27's needs would go unmet. Findings: Resident 27 was admitted to the facility in fall of 2017 with diagnoses which included lung disease, muscle weakness, need for assistance, long term pain, the most advanced stage of eye disease that severe damage to the optic nerve, depression and anxiety. During a review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 2/6/25, the MDS indicated Resident 27 had moderate memory impairment and no impairment of her arms and legs. During a review of Resident 27's physician progress note (PPN), dated 2/6/25, the PPN indicated Resident 27 was on inhalers . [had] chronic pain .at high risk for .falls . During a review of Resident 27's care plan (CP) titled, [Resident 27] .is observed to have ability to use call light, gross and fine hand motor function intact, was dated 11/1/24. During a review of Resident 27's CP titled, [Resident 27 is at risk for falls ., dated 11/24, the CP indicated, Be sure The (sic) resident's call light is in reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . During a concurrent observation and interview on 2/24/25 at 1:42 p.m. with Resident 27, Resident 27's call light was on the chest of drawers behind the resident but she indicated she was unable to reach it to call staff. During a concurrent observation and interview on 2/24/25 at 1:44 p.m. with Certified Nurses Assistant (CNA) 1, CNA 1 verified the observation and said, No it's [call light] not in reach for her. It should be in reach. During an interview on 2/27/25 at 7:37 a.m. with the Director of Nurses (DON) , the DON was asked her expectations regarding the resident call lights and said, The call lights should be accessible at all times. During a review of the facility policy and procedure (P&P), titled Answering the Call Light, dated 9/24, the P&P indicated When the resident is in bed .be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 3 of 10 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 02/27/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm 2. Resident 19 was admitted to the facility in March of 2023 with diagnoses that included Diabetes (disease where the body has poor blood sugar control) and hyperglycemic-hyperosmolar coma (coma induced by severely elevated blood sugar levels). Residents Affected - Few A review of Resident 19's Order Details, dated 3/25/23, indicated, metFORMIN Oral Tablet 500 MG (Metformin HCL). Give 1 tablet by mouth two times a day for DM2 Twice a day with breakfast and dinner During an observation on 2/24/25 at 3:42 p.m. with LN 4, LN 4 administered metformin to Resident 19 without a meal or any observable snacks in the resident's room. During an interview on 2/25/25 at 3 p.m. with Resident 19, Resident 19 indicated she didn't have any snacks at her bedside and did not receive any food prior to her receiving her diabetes medications on 2/24/25 at 3:42 p.m. During an interview on 2/27/25 at 7:59 a.m., with the DON, the DON indicated diabetes medications should be given with food and her expectation from facility staff is to ensure food is available to resident to prevent hypoglycemia (low blood sugar levels). During a review of the facility's P&P titled, Administering Medications, revised April 2024, the P&P indicated, Medications are administered in accordance with the prescriber orders, including any required time frame .Medication administration times are determined by resident need and benefit, not staff convenience . Based on observation, interview, and record review, the facility failed to meet professional standards for two of 15 sampled residents (Resident 206 and Resident 19), when: 1. Resident 206's peripherally inserted central catheter's dressing (PICC, a long, thin tube that's inserted into a vein in the arm and ends in a large vein near the heart used to deliver antibiotics) was not changed per physician orders, 2. Resident 19 recieved metformin (a diabetes medication for blood sugar control) without food as ordered by the provider. These failures had the potential to result in a serious bloodstream infection for Resident 206 and upset stomach for Resident 19. Findings: 1. Resident 206 was admitted to the facility in February 2025 following joint replacement surgery to the left hip. Resident 206 was cognitively intact and her own responsible party, according to Resident 206's face sheet. During a review of Resident 206's physician orders, dated 2/10/25, the physician orders indicated, PICC .dressing change .every seven days. During a concurrent observation and interview on 2/24/25 at 12:26 p.m. with Resident 206 in Resident 206's room, the PICC dressing on Resident 206's right arm was dated 2/17/25. Resident 206 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 4 of 10 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 02/27/2025 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 0658 staff told her, It would be changed today. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 2/25/25 at 8:48 a.m. with Resident 206 in Resident 206's room, the PICC dressing on Resident 206's right arm was dated 2/17/25. Resident 206 reported her dressing had not been changed. It was also observed that Resident 206 was receiving an antibiotic infusion of ceftriaxone through her PICC. Residents Affected - Few During a concurrent observation and interview on 2/25/25 at 9:13 a.m. with Licensed Nurse 2 (LN 2) in Resident 206's room, LN 2 verified the date on the PICC dressing was 2/17/25. LN 2 stated, The order states to change .every seven days or if it's dirty. LN 2 stated physician orders were not followed and the dressing should have been changed Monday, 2/24/25. During a concurrent interview and record review on 2/26/25 at 12:33 p.m. with the Director of Nursing (DON), Resident 206's physician orders, dated 2/10/25, were reviewed. The physician orders indicated, PICC .dressing change .every seven days. The DON stated the (dressing change for Resident 206) was due on 2/24. The DON further stated changing the dressing past seven days is, .very dangerous .these are central lines .they go to the heart .the risk of infection is very high. The DON stated the nurse should have followed the physician orders. During a review of the facility's policy and procedure (P&P) titled, Midline Dressing Changes, dated April 2016, indicated, To prevent catheter-related infections .change midline catheter dressing .every 5-7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 5 of 10 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 02/27/2025 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 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 implement their medication storage policy when medications were not labeled with an opened date and an expired medication was available for use in the medication cart. These failures placed the residents at risk for receiving contaminated medications, medications with reduced potency or unpredictable results that could lead to complications over time. Findings: During a concurrent observation and interview on 2/25/25 at 10:09 a.m., with Licensed Nurse 5 (LN 5), medication cart two was found to contain the following unlabeled opened medications: 1. an inhaler of budesonide 160 mcg / formoterol fumarate dihydrate 4.5 mcg, 2. an inhaler of fluticasone furoate 200 mcg/vilanterol 25 mcg, 3. a vial of insulin lispro 100 units/ml. A review of the facility's document titled, Abridged List of Medications with Shortened Expiration Dates [ALMSED], undated, the ALMSED indicated, budesonide 160 mcg (micrograms, a unit of measurement)/formoterol fumarate dihydrate 4.5 mcg (drugs to aide in breathing) should be discarded three months (90 days) after opening. A review of the fluticasone furoate 200 mcg/vilanterol 25 mcg (drugs to aide in breathing) inhaler manufacturer box indicated to discard the product 42 days after opening. A review of the insulin lispro (medication to lower blood sugar) 100 units/ml (milliliter, a unit of measurement) vial manufacturer box indicated to discard the product 28 days after opening. During a concurrent observation and interview on 2/25/25 at 10:09 a.m., with Licensed Nurse 5 (LN 5), medication cart two also contained a bottle of expired cromolyn sodium 4% eye drops (eye drops for allergies) with an open date of 12/21/24. A review of the facility's document titled, Abridged List of Medications with Shortened Expiration Dates [ALMSED], undated, the ALMSED indicated, cromolyn sodium 4% eye drops should be discarded 60 days after opened. During a concurrent observation and interview on 2/25/25 at 10:09 a.m., LN 5 confirmed the three undated medications and an expired eye drops in the medication cart two. LN 5 indicated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 6 of 10 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 02/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some important to label medications with the opened date due to the possibility of decreased effectiveness past the manufacturer's recommended date. LN 5 also indicated expired medications should be disposed of. During a concurrent observation and interview on 2/25/25 at 4:10 p.m., with LN 6, medication cart one contained one opened unlabeled inhaler of fluticasone furoate 200 mcg/umeclidinium 62.5 mcg/vilanterol 25 mcg. LN 6 confirmed the inhaler was not labeled and should be, because it can expire. During an interview on 2/27/25 at 7:59 a.m., with the Director of Nursing (DON), the DON indicated she expected that facility staff to dispose of expired medications and staff to date and label medications that once opened. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, revised 4/19, the P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 7 of 10 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 02/27/2025 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. Resident 24 was admitted to the facility in January of 2025 with a diagnosis of intestinal obstruction. Residents Affected - Some A review of Resident 24's Order Details, dated 2/21/25, indicated, Contact precautions [precautions requiring staff to wear a gown and gloves when providing care] r/t [related to] C Diff . Resident 26 was admitted to the facility in April of 2024 with diagnoses that included fistula of intestine (an abnormal connection between two parts of the intestine or between the intestine and another organ or the skin) and history of urinary tract infection. During an observation on 2/26/25 at 12:15 p.m., Certified Nursing Assistant 4 (CNA 4) was observed leaving the room of Resident 24 after performing care and entering the room of Resident 26. CNA 4 then left Resident 26's room and entered Resident 206's room. CNA 4 did not wash her hands with soap and water during this observation. During an observation on 2/26/25 at 12:25 p.m. with CNA 4, CNA 4 confirmed it was required for staff to wash their hands for residents on contact precautions for a C Diff infection. During an interview on 2/26/25 at 12:53 p.m. with the Infection Preventionist (IP), the IP indicated staff were required to wash their hands with soap and water after leaving a room on contact precautions for C Diff. The IP indicated that was to prevent the spread of infection by the C Diff pathogen. During a review of the facility's Policy and Procedure (P&P) titled, Clostridium Difficile, undated, the P&P indicated, Steps toward prevention and early intervention include .Frequent hand washing with soap and water by staff and residents .When caring for residents with CDI [C Diff infection], staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR [alcohol-based hand rub, hand sanitizer that doesn't require running water] for the mechanical removal of C. difficile spores from hands. 3. Resident 1 was admitted to the facility in March of 2005 with diagnoses that included adult failure to thrive and dysphagia (difficulty swallowing). During a concurrent observation and interview on 2/24/25 at 10:21 a.m., with LN 2, Resident 1's gastrotomy tube (a tube placed into the gut to administer nutrition) feeding bottle was unlabeled. LN 2 confirmed the finding and indicated the bottle should be labeled since the bottles were only good for a certain amount of time once opened. During an interview on 2/27/25 at 7:59 a.m., with the DON, the DON indicated her expectation for staff was to label gastrotomy tube feeding bottles with the date, time, and rate of feed. During a review of the facility's P&P titled, Enteral Feedings, undated, the P&P indicated, On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 8 of 10 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 02/27/2025 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 diseases and infections when: Level of Harm - Minimal harm or potential for actual harm 1. Staff did not wear a gown when providing high contact care to one resident (Resident 206) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)], Residents Affected - Some 2. Staff didn't wash hands after providing care for a resident who had C Diff [Clostridium Difficile, bacteria that cause inflammation of the colon]; and 3.Tube feeding bottle was not labeled. These failures had the potential to contribute to the spread of infections for a facility census of 55 residents. Findings: 1. Resident 206 was admitted to the facility in February 2025 following joint replacement surgery to the left hip. Resident 206 was diagnosed with methicillin susceptible staphylococcus aureus infection (MRSA-a germ that is resistant to some antibiotics) and was admitted with a peripherally inserted central catheter (PICC-a long, thin tube that's inserted into a vein in the arm and ends in a large vein near the heart used to deliver antibiotics). Resident 206 was cognitively intact and her own responsible party, according to Resident 206's face sheet. During a review of Resident 206's care plan, dated 2/10/25, the care plan indicated, Use of enhanced barrier precautions for use of: indwelling medical device .PICC .related to risk of colonization with an MDRO. The care plan further indicated, Resident will have reduced risk of obtaining or spreading colonization with an (MDRO) during high-contact resident care activities. During a review of Resident 206's physician orders, dated 2/11/25, the physician orders indicated, Enhanced Barrier Precautions due to RUA (right upper arm) PICC. During a concurrent observation and interview on 2/25/25 at 9:22 a.m. in Resident 206's room with Certified Nursing Assistant 5 (CNA 5), CNA 5 was observed having physical contact with Resident 206, getting the resident up and changing her clothes without wearing a gown. An EBP sign was posted outside of Resident 206's room indicating, Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities .dressing .changing linens .providing hygiene .changing briefs or assisting with toileting. CNA 5 stated she had changed Resident 206's clothes, briefs, and bed linen without wearing a gown. CNA 5 stated, I think I was supposed to [wear gloves, gowns] when discussed the EBP sign that was posted outside the resident's room. During an interview on 2/25/25 at 9:35 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated CNA 5 was supposed to wear the gown during resident care for Resident 206. During an interview on 2/27/25 at 8:02 a.m. with Director of Nursing (DON), the DON stated residents on EBP had a sign placed in front of the resident's room along with a personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart. The DON stated the purpose of EBP was to prevent the spread of infection. The DON further stated she would expect a CNA to wear a gown and gloves for residents on EBP while assisting with dressing, changing briefs, and changing linens, without exception. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 9 of 10 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 02/27/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated 6/18/24, indicated, EBP include the use of glove and gown during high-contact care activities for residents .with indwelling medical devices. The policy further indicated, High-contact resident care activities include .dressing .providing hygiene .changing linens .changing briefs. In addition, the policy indicated, Indwelling medical device include .peripherally-inserted central catheters-PICCs. The policy further indicated, Post clear signage on the door or wall outside of the resident room .signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Event ID: Facility ID: 555184 If continuation sheet Page 10 of 10