Health inspection·December 4, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was protected from neglect when physician notification regarding her change of condition (COC, a significant shift in someone's physical, mental or functional state, requiring attention) was delayed. This failure resulted in Resident 1 to experience delays in care and required hospitalization for an unmanaged fever, altered level of consciousness (sudden changes in condition, awareness or consciousness (your subjective awareness to yourself and the world)) and sepsis (a life-threatening blood infection). Cross reference F761.A review of Resident 1's admission record indicated she was admitted to the facility in May 2025 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness), and peripheral venous insufficiency (a condition where the valves in the leg veins are damaged causing blood to pool in the lower legs instead of flowing back to the heart). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/26/25, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 14, which indicated she had minimal cognitive impairment (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's progress notes, type, Respiratory Therapy Note, dated 11/18/25 at 10:49 a.m., indicated, Resident had a resting hear [heart] rate [the number of times the heart beats each minute while the person is awake, calm, and not moving] of 117 [117 beats per minute (bpm); normal heart rate is between 60 to 100 bpm] and was constantly shaking and complaining of being cold nurse was notified.A review of Resident 1's progress notes, type, Nursing Notes, dated 10/18/25 at 1:40 p.m., Licensed Nurse 1 (LN 1) indicated, Resident has elevated temperature at 100.2 F [Fahrenheit, a temperature scale; normal temperature is 98.6 F] this shift. Tylenol [acetaminophen, a medication to treat mild to moderate pain] PRN [as needed] given.A review of Resident 1's progress notes, type, Respiratory Therapy Note, dated 11/18/25 at 3:42 p.m., indicated, Resident has an spo2 [peripheral (referring to outer areas like hands/feet) oxygen saturation, measures the percentage of oxygen-carrying hemoglobin in your blood; normal range is between 95% to 100%] of 87% on room air. Resident placed on 2L [liters, a unit of measurement; volume of oxygen] of oxygen spo2 on oxygen 92%. Resident shaking with fever of 103.6 [ F] nurse notified.A review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation, a communication technique used in healthcare to facilitate clear and concise information) form dated 10/18/25 at 5:05 p.m., indicated, The change in condition, symptoms, or signs observed and evaluated is/are: fever.Resident temperature was 103 F 30 mins [minutes] ago, cooling measures started, fluids pushed, then rechecked. Fever now 104.6 F.This started on: 10/18/25.Since this started it has gotten: Worse [check marked].Mental Status Evaluation: Altered level of consciousness.Summarize your observations and evaluation: Resident noted to be febrile [having or showing symptoms of a fever], shaking, and not responding normally to baseline. Charge nurse called MD Page 1 of 6 555490 555490 12/04/2025 Meadowood Nursing Center 3805 Dexter Lane Clearlake, CA 95422

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [medical doctor] and received order to send out to ER [emergency room] for further eval [evaluation] and treatment.Primary Care Clinician [MD] notified: 10/18/25 at 5:05 p.m.A review of Resident 1's undated document, titled, SNF (skilled nursing facility)/NF (nursing facility) to Hospital Transfer Form, indicated Resident 1's date of transfer was 10/18/25 at 5:04 p.m.A review of [name of hospital] document titled, History and Physical Examination, dated 11/18/25 at 11 p.m., indicated, 74 y/o [year old] female in via EMS [Emergency Medical Service] from [name of skilled nursing facility] with fever, altered mental status.admission status: Fever, Sepsis. During a phone interview on 11/13/25 at 1:17 p.m. with LN 2, she stated she could not recall the date Resident 1 had a COC; however, she recalled Resident 1 with a golf ball sized spot of redness to her upper left leg the night before. LN 2 further stated the following day she was informed in hand-off (a report given between off and on coming staff regarding resident updates) from the AM (morning) staff that the redness had worsened and was down to her [Resident 1] knee. LN 2 confirmed Resident 1 had a fever that developed in the morning. LN 2 stated, It would have been appropriate to send her out [to the hospital] earlier. LN 2 confirmed the expectation for reporting a COC was to notify the MD as soon as the COC was assessed. LN 2 stated, If a fever is left untreated you can have a seizure and become unresponsive.During an interview on 11/13/25 at 2:53 p.m. with Resident 1, she stated in mid-October she had a day where she was really out of it and was sent to the hospital.During a phone interview on 11/14/25 at 12 p.m. with Certified Nurse Assistant 1 (CNA 1), she confirmed she assisted Resident 1 the day she developed the fever. CNA 1 verified Resident 1's COC happened in October 2025 during AM shift. CNA 1 stated Resident 1 was flushed (redness and warm) in the face and really out of it. CNA 1 confirmed Resident 1 had redness to the left leg that worsened throughout the AM shift. CNA 1 stated herself and another LN assessed Resident 1's left leg. CNA 1 stated she informed Resident 1's assigned nurse [the LN assigned to care for Resident 1 that day] and she [the LN] did not appear to be concerned. CNA 1 further stated, I told the nurse again, and she again didn't seem bothered by it [Resident 1's COC]. During an interview on 12/04/25 at 12 p.m. with the Director of Staff Development (DSD), she verified a fever is considered a COC and expected the MD to be notified right away. The DSD further stated, Yes, it was a pretty high fever. The DSD confirmed Resident 1's fever should had been reported to the MD earlier in the day if it [the fever] presented earlier in the day. The DSD stated, Neglect is failing to provide care that is necessary, and referenced necessary care as medication administration, grooming, bathing, and any type of monitoring. The DSD further stated, It could be considered neglectful that the MD was not phoned earlier, because necessary care was neglected to be done.During a concurrent interview and record review on 12/04/25 at 12:53 p.m. with the Director of Nursing (DON), she confirmed Resident 1's progress notes dated 10/18/25 at 10:49 a.m., 1:40 p.m., and 3:42 p.m. The DON stated, Most definitely, a fever is considered a COC. The COC should have been done at the AM shift. The DON verified there was no evidence that the redness to Resident 1's left leg was documented in Resident 1's medical record. The DON stated, I would definitely expect that [the redness to the left leg] to be documented. The DON confirmed it was unacceptable that the MD was not contacted until the PM (evening) shift. The DON stated if a fever is left untreated, They can go septic and die. The DON stated she considered this [the delay in reporting] negligence. The DON further stated, Because at 1049 (10:49 a.m.) we had a HR (heart rate) of 117. The patient [Resident 1] was shaking and complaining of being cold. This is going on until 5 p.m. That is six hours of just giving Tylenol and oxygen. What does that do for an infection? The DON stated six hours could be the difference between life and death. A review of the facility's policy and procedure (P&P) titled, Abuse and Neglect- Clinical Protocol, dated 2001, indicated, Neglect as defined.the failure of the facility, its 555490 Page 2 of 6 555490 12/04/2025 Meadowood Nursing Center 3805 Dexter Lane Clearlake, CA 95422

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.A review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's attending physician or physician on call when there has been.significant change in the resident's physical/emotional/mental condition.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 555490 Page 3 of 6 555490 12/04/2025 Meadowood Nursing Center 3805 Dexter Lane Clearlake, CA 95422

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 interview and record review, the facility failed to ensure professional standards of nursing practice were followed for a census of 89 residents when:1: One resident's (Resident 1) medication was left by her bedside unattended by staff without a physician order for self-administration of medications,2: An undisclosed number of residents' medications were pre-prepared (a type of workaround, described as a delay between preparation and administration of a medication or the preparation of multiple medications for different residents) prior to administration, and;3: The Director of Nursing (DON) allowed the administration of pre-prepared medications to residents; fully aware they were unlabeled and had been pre-prepared. These failures increased the facility's potential for medication errors and for residents to experience a delay in care and treatment.1. A review of Resident 1's admission record (Facility demographic) indicated she was admitted to the facility in May, 2025, with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness), and peripheral venous insufficiency (a condition where the valves in the leg veins are damaged causing blood to pool in the lower legs instead of flowing back to the heart). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/26/25, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 14, which indicated she had minimal cognitive impairment (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's order summary report, order date range 10/1/25-10/31/25, indicated two tablets of acetaminophen (a medication used to relieve mild to chronic pain and reduce fever)325 mg(milligrams) per tab, was to be administered to Resident 1 by mouth every four hours as needed for pain ranging from one to ten (a pain scale where zero signifies no pain and ten is the worst pain experienced during a person's lifetime). This summary report did not indicate medications could be left by Resident 1's bedside for self-administration of medications. A review of Resident 1's care plan did not indicate Resident 1 was capable of self-administration of medications. A review of Resident 1's Medication Administration Record (MAR) dated October, 2025, indicated, acetaminophen tablet 325 mg give 2 tablets by mouth every 4 hours as needed for pain [1-10 pain scale].start date 8/1/25, was administered on 10/18/25 at 1:26 p.m. by Licensed Nurse 1 (LN 1). A review of Resident 1's progress notes, type, Nursing Notes, dated 10/18/25 at 1:40 p.m., documented by LN 1 indicated, Resident has elevated temperature at 100.2 F [Fahrenheit, a temperature scale; normal temperature is 98.6 F] this shift. Tylenol [acetaminophen] PRN [as needed] given.A review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation, a communication technique used in healthcare to facilitate clear and concise information) form dated 10/18/25 at 5:05 p.m., indicated, The change in condition, symptoms, or signs observed and evaluated is/are: fever.Resident temperature was 103 F 30 mins [minutes] ago, cooling measures started, fluids pushed, then rechecked. Fever now 104. 6 F.A review of [name of hospital] document titled, History and Physical Examination, dated 11/18/25 at 11:00 p.m., indicated, 74 y/o [year old] female in via EMS [Emergency Medical Service] from [name of skilled nursing facility] with fever, altered mental status [sudden changes in condition, awareness or consciousness].admission status: Fever, Sepsis [the body's extreme, life-threatening response to an infection].During an interview on 12/04/25 at 12 p.m., with the Director of Staff Development (DSD), she stated she assessed Resident 1 on the evening of 10/18/25 (prior to being transferred to a hospital) and Resident 1 was found slumped (having the head low and shoulders forward) over and shivering. The DSD stated she observed Resident 1's Tylenol in a cup on Resident 1's bedside table. The DSD confirmed Resident 1 did not take the Tylenol that was prepared for her to treat her fever. The DSD Residents Affected - Some 555490 Page 4 of 6 555490 12/04/2025 Meadowood Nursing Center 3805 Dexter Lane Clearlake, CA 95422

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated Resident 1's temperature was approximately 104 F from a previous reading of approximately 103 F ( which indicated an increase in fever).During an interview on 12/04/25 at 12:20 p.m. the DON stated medications could not be left by residents' bedsides. The DON stated, They [Licensed Staff] are expected to stay there with them [residents] to take their medications. They [Licensed Staff] are not allowed to leave them [residents] because anybody could take their medications. The DON further stated residents could choke or drop their medications and not actually take them [when left unattended by their bedside]. The DON confirmed that Licensed Staff were expected to ensure residents were taking the medications they were handed by Licensed Staff. During a review of the facility policy and procedure (P&P) titled, Self-Administration of Medications, dated 2021, the P&P indicated, If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.During a review of the facility P&P titled, Administering Medications, dated 2019, the P&P indicated, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.2. During an interview on 11/13/25 at 1:40 p.m., the DSD stated on 9/16/25 at approximately 9:30 p.m. she observed pre-popped (medications that had been removed from the original, labeled package and pre-prepared in medication cups for resident administration) medications in the medication cart in Hall 4. The DSD confirmed she did not know what the medications were and could not recall who they were for. The DSD stated there were approximately five to six medication cups with unidentified medications in them. The DSD further stated, It's absolutely not standard practice (actions and behaviors all licensed nurses are expected to perform competently) to prepare medications like that [to pre-pop]. Medications should be prepared for administration right when you are prepared to give them, and prepared one resident at a time. The DSD verified it was dangerous to pre-pop medications and stated mistakes could be made very easily. The DSD further stated, It's a medication error waiting to happen. During an interview on 12/03/25 at 3:50 p.m., LN 4 stated on 9/16/25 she was dismissed from her shift because she had a difficult time staying awake during medication pass (a time when medication is administered). LN 4 stated the DON came to the facility and brought her to the ER (emergency room). LN 4 denied pre-preparing medications for administration. LN 4 stated another LN was asked to take over her medication cart on 9/16/25 after she left the facility. 3. During the interview on 12/03/25 at 3:50 p.m., LN 4 stated that during a second occasion, which was a Sunday [referring to 10/12/25] she phoned the DON and informed her she could not stay awake again. LN 4 stated another nurse (Licensed Nurse 3 [LN 3]) took over her medication cart in Hall 4 and they were instructed by the DON for LN 3 to oversee LN 4's administer her residents' medications prior to her [LN 4] leaving the facility and they did as instructed. LN 4, however, did not disclose the reason the DON had instructed LN3 to observe her (LN 4) administer medications prior to leaving the facility. During an interview on 12/04/25 at 9:45 p.m. LN 3 stated that on 9/16/25 during PM shift (evening) she observed pre-popped (pre-prepared) medications in LN 4's medication cart in Hall 4. LN 3 stated she did not know what the medications were and could not confirm which residents they were for. LN 3 stated that again, on 10/12/25 at approximately 10:29 a.m. she observed LN 4 falling asleep at her medication cart in Hall 4. LN 3 stated she contacted the DON and was instructed to take over the medication cart from LN 4. During the interview, LN 3 stated she again observed pre-popped medications in LN 4's medication cart on 10/12/25, after LN 4 was, for the second time, observed falling asleep on her cart. LN 3 stated she refused to take over the medication cart due to it containing pre-prepared medications and notified the DON about it. 555490 Page 5 of 6 555490 12/04/2025 Meadowood Nursing Center 3805 Dexter Lane Clearlake, CA 95422

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some According to LN 3, the DON responded by instructing her to supervise LN 4 administer her residents' pre-prepared medications prior to leaving the facility. LN 3 confirmed she supervised LN 4 during her medication pass, and observed her administered her pre-prepared medications, as instructed by the DON. LN 3 confirmed she did not know what the medications were and could not confirm which residents they were for. LN 3 stated pre-preparing medications could lead to medication errors.During an interview on 12/04/25 at 12:20 p.m., the DON confirmed she was aware of the pre-popped medications in LN 4's medication cart in Hall 4 on 9/16/25 and 10/12/25. The DON stated on 9/16/25 medications were pre-popped in medication cups and placed inside residents individually labeled boxed spots in the medication cart. The DON further stated, I saw it with my own eyes, and verified that she could not be certain residents received the correct medications. The DON stated she believed she stayed with LN 4 and observed her medication pass prior to taking her to the ER. The DON confirmed on 10/12/25 she instructed LN 3 to take over LN 4's medication cart when she was dismissed from her shift. The DON stated she was informed of pre-popped medications in LN 4's medication cart and she confirmed she instructed LN 3 to complete medication pass with LN 4 (in which LN 4 administered pre-prepared medications). The DON stated, In hind-sight (understanding a situation only after it has happened or developed), it might not have been the best decision for [LN 4] to continue to give the pre-popped medications. The DON confirmed it was not standard practice to pre-pop medications, and further stated, You don't know what you are giving- it could result in medication errors.A review of the facility policy and procedure (P&P) titled, Administering Medications, dated 2019, the P&P indicated, Medications are administered in a safe and timely manner.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.A review of the facility P&P titled, Medication Labeling and Storage, dated 2023, indicated, Medications and biologicals are stored in the packaging, containers, or dispensing systems in which they are received.The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe.manner. 555490 Page 6 of 6