Health inspection·June 12, 2024

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Pharmacist's Recommendations Pending from Last Month's Report for the timeframe 06/01/2024 to 06/11/2024, indicated, Resident #37 was currently on lorazepam 0.5 mg every eight hours as needed for anxiety and our regulation specify that we must have a specific duration for as needed anxiolytics. During an interview on 06/12/2024 at 8:37 AM, the Nurse Practitioner (NP) stated there should be a stop date within 14 days on PRN [pro re nata, as needed lorazepam, and the Pharmacist normally sent recommendations for a stop date if one was not included in the original order. The NP stated she did not know why there was not a stop date on Resident #37's PRN lorazepam order. During an interview on 06/12/2024 at 9:23 AM, the Pharmacist stated when she did medication reviews, she recommended to the physicians that PRN antianxiety medications needed a specified duration included in the order. The Pharmacist stated she recommended in March 2024 for the physician to add a duration or stop date to Resident #37's PRN lorazepam, but the physician had not yet responded to the recommendation. The Pharmacist stated she was in the facility on 06/11/2024 and again made a recommendation to the physician to add a stop date to Resident #37's PRN lorazepam because the regulation required a specified duration for a PRN psychotropic. The Pharmacist stated she told the facility to just call the physician because the physician was not responding to their recommendations. During an interview on 06/12/2024 at 10:54 AM, the Director of Nursing (DON) stated orders for PRN antianxiety medications required a stop date or duration to be included in the order per the regulations. The DON stated she knew there were orders for PRN antianxiety medications in use, but was not aware there was no specified duration included in the order and added that the recommendations for a stop date must have been overlooked until now. During an interview on 06/12/2024 at 11:00 AM, the Administrator stated she expected her staff to follow the policy on PRN psychotropic use and expected the physician to follow up on all pharmacy recommendations. 2. A Face Sheet revealed the facility admitted Resident #11 on 01/19/2024. According to the Face Sheet, the resident had a medical history that included chronic pain syndrome, spinal stenosis, and atrial fibrillation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #11's Care Plan Report, effective 01/19/2024 to present, indicated the resident had a diagnosis of anxiety manifested by restlessness and agitation. Resident #11's June 2024 Physician Order Sheet contained an order dated 03/25/2024 for Ativan (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety. The order did not include a stop/discontinue date. The Consultant Pharmacist's Medication Regimen Review, for Resident #11 for the timeframe 04/06/2024 to 04/17/2024, indicated, PRN psychotropic orders need a 14 day stop date. At that time physician will need to re-evaluate the continued need for the psychotropic. Duration greater than 14 days will need physician rationale. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555749 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Pharmacist's Nursing Recommendations for the timeframe 06/01/2024 to 06/11/2024, indicated, PRN psychotropic orders need a 14 day stop date. At that time physician will need to re-evaluate the continued need for the psychotropic. Duration greater than 14 days will need physician rationale. During an interview on 06/12/2024 at 9:23 AM, the Pharmacist stated when she did medication reviews, she recommended to the physicians that PRN antianxiety medications needed a specified duration included in the order. The Pharmacist stated she recommended in April 2024 for the physician to add a duration or stop date to Resident #11's PRN Ativan but the physician had not yet responded to the recommendation. The Pharmacist stated she was in the facility on 06/11/2024and again made a recommendation to the physician to add a stop date to Resident #11's PRN Ativan because the regulation required a specified duration for the PRN psychotropic. The Pharmacist stated she told the facility to just call the physician because the physician was not responding to their recommendations. During an interview on 06/12/2024 at 10:54 AM, the Director of Nursing (DON) stated orders for PRN antianxiety medications required a stop date or duration to be included in the order per the regulations. The DON stated she knew there were orders for PRN antianxiety medications in use, but was not aware there was no specified duration included in the order and added that the recommendations for a stop date must have been overlooked until now. During an interview on 06/12/2024 at 11:00 AM, the Administrator stated she expected her staff to follow the policy on PRN psychotropic use and expected the physician to follow up on all pharmacy recommendations. During an interview on 06/12/2024 at 11:45 AM, the Physician stated he used PRN antianxiety medications for 14 days but then reassessed the resident's need for the medication. The Physician stated Resident #11 was on PRN Ativan prior to admission so he kept the order in place due to the family's reluctance to change the resident's medication regimen. The Physician stated he reviewed the pharmacy recommendations each month and did not follow up on the recommendation to input a stop date on Resident #11's PRN Ativan due to the family's preference. The Physician stated it was not documented in the resident's chart that he chose to keep Resident #11 on the PRN Ativan with no stop date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555749 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, record review, and facility policy review, the facility failed to indicate the duration of an as needed antianxiety medication for 2 (Resident #11 and Resident #37) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, indicated, 12. Psychotropic medications are not prescribed or given on a PRN [pro re nata, as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. A Face Sheet revealed the facility admitted Resident #37 on 12/28/2022. According to the Face Sheet, the resident had a medical history that included diagnose of right femur fracture, major depressive disorder, and anxiety. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #37's Care Plan Report, effective 12/28/2022 to present, indicated the resident had a diagnosis of anxiety manifested by feelings of inability to breathe, and received ant-anxiety medications on an as needed basis. Resident #37's June 2024 Physician Order Sheet contained an order dated 02/21/2024 for lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every eight hours as needed for anxiety. The order did not include a stop/discontinue date. 2. A Face Sheet revealed the facility admitted Resident #11 on 01/19/2024. According to the Face Sheet, the resident had a medical history that included chronic pain syndrome, spinal stenosis, and atrial fibrillation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #11's Care Plan Report, effective 01/19/2024 to present, indicated the resident had a diagnosis of anxiety manifested by restlessness and agitation. Resident #11's June 2024 Physician Order Sheet contained an order dated 03/25/2024 for Ativan (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every six hours as needed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555749 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382 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 0758 anxiety. The order did not include a stop/discontinue date. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/12/2024 at 8:37 AM, the Nurse Practitioner (NP) stated there should be a stop date within 14 days on PRN lorazepam, and the Pharmacist normally sent recommendations for a stop date if one was not included in the original order. The NP stated she did not know why there was not a stop date on Resident #37's PRN lorazepam order. Residents Affected - Few During an interview on 06/12/2024 at 9:23 AM, the Pharmacist stated when she did medication reviews, she recommended to the physicians that PRN antianxiety medications needed a specified duration included in the order. During an interview on 06/12/2024 at 10:54 AM, the Director of Nursing (DON) stated orders for PRN antianxiety medications required a stop date or duration to be included in the order per the regulations. The DON stated she knew there were orders for PRN antianxiety medications in use, but was not aware there was no specified duration included in the order and added that the recommendations for a stop date must have been overlooked until now. During an interview on 06/12/2024 at 11:00 AM, the Administrator stated she expected her staff to follow the policy on PRN psychotropics. According to the Administrator, the Physician ordered the medications, and she was not aware the facility used PRN Ativan with no stop date or specified duration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555749 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382 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 Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff stored respiratory equipment per the facility policy when not in use for 1 (Resident #3) of 1 sampled resident reviewed for respiratory care. The facility also failed to ensure enhanced barrier precautions were utilized during the provision of wound care for 1 (Resident #33) of 12 sampled residents. Residents Affected - Few 1. A facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, specified, 8. Keep the oxygen cannulae and tubing used PRN [pro re nata, as needed] in a plastic bag when not in use. A Face Sheet revealed the facility admitted Resident #3 on 03/24/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with exacerbation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. The MDS revealed the resident used oxygen therapy. Resident #3's Care Plan Report, effective 03/24/2022 to present, revealed the resident had a diagnosis of COPD and respiratory failure with hypoxia and was at risk for impaired gas exchange. Interventions directed the staff to administer supplemental oxygen as ordered. Resident #3's June 2024 Physician Order Sheet, revealed an ordered dated 03/20/2024, for supplemental oxygen at three liters per minute per nasal cannula. During an observation on 06/11/2024 at 12:42 PM, Resident #3's oxygen tubing was seen resting on the concentrator and not in the empty bag attached to the concentrator. During an interview on 06/11/2024 at 1:13 PM, Licensed Vocational Nurse (LVN) #3 stated oxygen tubing should be placed in a plastic bag when not in use. During an interview on 06/11/2024 at 1:58 PM, CNA #4 stated oxygen tubing should be placed in a bag on the compressor unit when being stored. During an interview on 06/12/2024 at 9:30 AM, the Director of Nursing (DON) stated she expected oxygen tubing be stored in a bag by the concentrator when not in use. According to the DON, proper storage of the oxygen tubing was important to avoid infections. During an interview on 06/12/2024 at 9:32 AM, the Administrator stated it was her expectation that staff follow the policy regarding storage of respiratory care equipment. 2. A facility policy titled, Enhanced Barrier Precautions, revised 08/2022, indicated, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy indicated, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555749 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382 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 changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). A Face Sheet indicated the facility admitted Resident #33 on 11/14/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of malignant neoplasm of stomach and rhabdomyolysis. Resident #33's June 2024 Physician Order Sheet contained an order dated 06/06/2024, for wound honey topical paste to the resident's left lower back wound after cleaned with wound cleanser then cover with gauze island border dressing daily. During a concurrent observation and interview on 06/11/2024 at 1:07 PM, Licensed Vocational Nurse (LVN) #1 and Registered Nurse (RN) #2 provided wound care for Resident #33's wound on their left lower back. LVN #1 and RN #2 did not use EBPs while providing the wound care. LVN #1 indicated Resident #33 did not need EBP because the wound was small with no drainage. During an interview on 06/12/2024 at 7:20 AM, the Infection Control Prevention Officer (ICPO) indicated Resident #33 had a small area that kept opening and closing. The ICPO indicated if a wound required a daily dressing change, then EBP should be utilized. The ICPO stated staff should use EBP for Resident #33. The ICPO indicated she was not at the facility the previous week when the wound opened back up, but the nurse should have initiated the EBP set up because they knew if a daily dressing change was needed then EBP was required. During an interview on 06/12/2024 at 8:26 AM, LVN #1 stated she had been informed that EBP should have been used during the wound care that was provided on 06/11/2024. During an interview on 06/12/2024 at 10:49 AM, LVN #3 indicated EBP was utilized for residents with indwelling urinary catheter, dialysis access, peripherally inserted central catheter line, and wounds, to protect from body fluids. During an interview on 06/12/2024 at 11:18 AM, the Director of Nursing (DON) indicated any resident who had any type of wound or skin injury should have EBPs. The DON indicated EBP required a sign outside the room and personal protective equipment (PPE) cart outside the room. The DON stated the sign informed staff what PPE to wear. The DON stated staff should have utilized EBP during the wound care for Resident #33. The DON stated she expected EBP to be used for Resident #33's wound care and any resident who needed EBP. During an interview on 06/12/2024 at 11:32 AM, the Administrator indicated staff should have followed the policy for EBP during the wound care for Resident #33. The Administrator indicated she expected staff to follow the EBP policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555749 If continuation sheet Page 7 of 7