Health inspection·March 27, 2025

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide a bed hold notice upon transfer to the hospital for 1 (Resident #47) of 2 sampled residents reviewed for hospitalization. Findings included: A facility policy titled, Bed-Holds and Returns, revised 10/2022, revealed, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation 1. All residents/representative are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these polices at least twice: a. a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). An admission Record indicated the facility admitted Resident #47 on 03/16/2022. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #47's Progress Note dated 01/03/2025 at 8:34 AM, revealed the resident was transferred to the hospital for further evaluation of blood in their urine and hallucinations. Resident #47's Progress Note, dated 01/08/2025 at 9:41 AM, revealed the resident arrived back in the facility. Resident #47's medical record revealed no evidence of a bed hold notice for when the resident transferred to the hospital on [DATE]; however, there was evidence to indicate on 01/08/2025, the Admissions Director left a message for Resident #47's family member regarding a bed hold and transfer notice (Resident #47's Progress Note dated 01/08/2025 at 12:16 PM, revealed the Admissions Director left a message for Resident #47's family member regarding bed hold and transfer notice this morning. Awaiting call back.). Page 1 of 10 555776 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0625 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/27/2025 at 12:42 PM, the Admissions Director stated bed hold/transfer was explained to a resident's family during the admissions process. Per the Admissions Director, if a resident transferred to the hospital, the resident's family would be asked if they would like to start a bed hold. The Admissions Director stated the bed hold notice should be completed prior to the resident leaving the facility. The Admissions Director stated she was not timely in issuing Resident #47s' bed hold notice. Residents Affected - Few During an interview on 03/26/2025 at 2:57 PM, the Director of Nursing (DON) stated the Admissions Director was responsible for sending out bed hold/transfer notices. According to the DON, the bed hold/transfer notice should be done immediately upon transfer. The DON stated waiting until after Resident #47's return to the facility on [DATE] to contact their family about the bed hold policy was not appropriate. Per the DON, the bed hold/transfer notice should have been sent or the family called when the resident left the faciity on [DATE]. The DON stated the Admissions Director should not have waited until Resident #47 readmitted to discuss bed hold/transfer options. During an interview on 03/27/2025 at 2:17 PM, the Administrator stated if a resident was their own responsible party, it would be difficult to get the notice of bed hold to the resident; however, if the resident had a responsible party, the notice should be given as soon as possible, but at least by the next day after transfer to the hospital. The Administrator stated the facility had an external marketer who could take the notice of bed hold to the hospital when a resident was their own responsible party. 555776 Page 2 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. 2. An admission Record revealed the facility admitted Resident #1 on 06/27/2024. According to the admission Record, the resident had a medical history that included atrial fibrillation, hypertension, and muscle weakness. The admission Record indicated the resident received diagnoses of bipolar disorder and anxiety disorder on 02/25/2025. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression and bipolar disorder. Resident #1's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASARR evaluation when the resident received a new mental illness diagnosis. During an interview on 03/25/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility thought the only time the resident needed a new PASARR included a new qualifying diagnosis. During a follow-up interview on 03/25/2025 at 1:38 PM, the DON stated the facility did not have an updated PASARR for Resident #1. Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when 2 (Resident #1 and Resident #2) of 3 sampled residents reviewed for PASARR were diagnosed with a new serious mental illness. Findings included: An undated facility policy titled, PASRR Completion Policy, revealed, The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. 1. An admission Record revealed the facility admitted Resident #2 on 05/22/2018. According to the admission Record, the resident had a medical history that included a diagnosis of spastic hemiplegic cerebral palsy. According to the admission Record, the resident received diagnoses of psychosis, manic episode, and depression on 12/06/2023. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses to include depression, bipolar disorder, and psychotic disorder. Resident #2's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASARR evaluation when the resident received a new mental illness diagnosis. During an interview on 03/25/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility thought the only time the resident needed a new PASARR included a new qualifying diagnosis. 555776 Page 3 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0644 During a follow-up interview on 03/25/2025 at 1:38 PM, the DON stated the facility did not have an updated PASARR for Resident #2. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555776 Page 4 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's onset of bilateral leg edema for 1 (Resident #15) of 1 sampled resident reviewed for care planning. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, specified, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, the comprehensive, person-centered care plan, e. reflects currently recognized standards of practice for problem areas and conditions. An admission Record indicated the facility admitted Resident #15 on 05/08/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy and essential hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/15/2025, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #15's Progress Note, dated 12/17/2024 at 7:47 PM, revealed the resident had edema in their bilateral legs. Resident #15's Progress Note, dated 03/11/2025 at 3:44 AM, revealed the resident reported pain and swelling in their right lower leg. The Progress Note indicated to address these symptoms, thrombo-embolic deterrent (TED) hose was prescribed to provide supportive care and alleviate discomfort. Per the Progress Note, the resident's condition would be monitored, and further evaluation would be conducted if swelling or pain persisted. Resident #15's Order Summary Report for active orders as of 03/25/2025, revealed an order dated 08/09/2024, that directed staff to monitor the resident for edema, ascites (a condition that occurred when fluid collected in spaces in the abdomen), abdominal distention related to weight gain every shift and notify the physician if present; an order dated 12/07/2024, that directed staff to monitor the resident for signs and symptoms of ascites and edema one time a day; and an order dated 03/13/2025, that directed staff to place TED hose/compression stocking on the resident in morning and remove at night, one time a day for swelling/edema to the right lower extremity. Resident #15's Care Plan Report, revealed no evidence of a care plan to address the resident's bilateral leg edema. During an interview on 03/26/2025 at 2:41 PM, Certified Nursing Assistant #4 stated Resident #15 complained their feet were swollen. During a telephone interview on 03/26/2025 at 6:25 PM, Registered Nurse #1 stated Resident #15 had pain or swelling in their leg a few months prior. 555776 Page 5 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/27/2025 at 11:03 AM, Licensed Vocational Nurse (LVN) #7 stated edema required a care plan and for any kind of care a resident required, it should be care planned. LVN #7 stated Resident #15 had swelling in their right ankle on 03/27/2025 and did not have a care plan to address their edema. During an interview on 03/27/2025 at 1:06 PM, the MDS Coordinator stated Resident #15 did not have a care plan that addressed their edema and a care plan should have been initiated when the monitoring for edema order was placed and when the TED hose was ordered. During an interview on 03/27/2025 at 11:19 AM, the Director of Nursing (DON) stated edema would require a care plan because it was an issue. The DON confirmed Resident #15 did not have a care plan to address their edema and needed one because it was issue that needed to be monitored and resolved. According to the DON, when the resident was found to have edema, a care plan should have been initiated by the nurse who assessed the resident to have edema. During an interview on 03/27/2025 at 1:19 PM, the Administrator stated he expected the staff to initiate care plan timely. 555776 Page 6 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to timely initiate antibiotic therapy for 1 (Resident #47) of 2 sampled residents reviewed for hospitalization. Residents Affected - Few Findings included: An admission Record indicated the facility admitted Resident #47 on 03/16/2022. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #47's Progress Note, dated 12/22/2024 at 12:18 PM, revealed the physician gave an order for a urinalysis with a culture and sensitivity. Resident #47's Lab Results Report revealed a urine culture with culture and sensitivity was collected on 12/20/2024 and the results were marked final and reported on 12/22/2024. Resident #47's Progress Note, dated 12/30/2024 at 11:32 AM, revealed the nurse practitioner (NP) started the resident on Bactrim DS (an antibiotic medication) two times a day for five days for a urinary tract infection. Resident #47's Order Summary Report, revealed an order dated 12/30/2024, for Bactrim DS oral tablet 800-160 milligrams, give one tablet by mouth two times a day for five days for a urinary tract infection. During an interview on 03/27/2025 at 9:34 AM, the Director of Nursing stated there was no reason she could find for the eight-day delay in obtaining an order for an antibiotic for Resident #47. During an interview on 03/27/2025 at 4:03 PM, the NP stated eight days was an excessive amount of time to start an antibiotic after a positive urinalysis with culture and sensitivity. 555776 Page 7 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards, specifically a space heater for 1 (Resident #1) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Electrical Safety for Residents, revised 01/2011, revealed, The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns and fire. The policy specified, 3. Portable space heaters are not permitted in the facility. An admission Record revealed the facility admitted Resident #1 on 06/27/2024. According to the admission Record, the resident had a medical history that included atrial fibrillation, hypertension, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an observation on 03/24/2025 at 1:01 PM, a free-standing space heater was noted in the middle of the floor of Resident #1's room. The space heater was plugged into the wall and there was a sign on the door of the resident's room that indicated to not put anything on the space heater, as it would be a fire hazard. During an observation of Resident #1's room on 03/25/2025 at 7:42 AM, the space heater was noted to be on and the resident was lying in bed. The facility incident log for the time frame 10/31/2024 to 03/25/2025, revealed no evidence to indicate a resident burn or injury related to a space heater. During an interview on 03/26/2025 at 2:17 PM, Registered Nurse (RN) #1 stated she was familiar with Resident #1, but did not know exactly how long the resident had the space heater in their room, but that it had been a while. RN #1 stated there was no air conditioning or heat vents in the resident's room, thus the space heater was there to help keep the resident warm during the winter months. RN #1 stated she was not aware of any residents that touched the space heater or been injured as the result of the space heater. Per RN #1, the sign on Resident #1's door about the space heater was a precautionary sign that made people aware of the space heater was there. RN #1 stated the space heater was placed in the resident's room by maintenance and it was not the resident's personal heater, that it belonged to the facility. During an interview on 03/26/2025 at 2:32 PM, RN #2 stated Resident #1 had had the space heater since winter because there was no heating unit in their room. RN #2 stated she was unaware of any incidents related to the space heater and the sign on the resident's door was hung by management to make staff aware the space heater was there and to watch it. During an interview o 03/26/2025 at 2:57 PM, the Director of Nursing (DON) stated the space heater had been in Resident #1's room for three weeks to a month and there had not been any incidents 555776 Page 8 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to it. The DON stated the sign on the resident's door about a fire hazard was placed there by Maintenance Director, who stated the space heater was allowed. According to the DON, she questioned if the space heater was allowed but was told it was a safe model and compliant with state regulations. During an interview on 03/26/2025 at 3:57 PM, the Maintenance Director stated he was told the facility was allowed to have space heaters as long as they met a few criteria, such as being made by an underwriter laboratory (UL) company, had a UL rating, were properly placed in a room, not near curtains or bedding, were oil-based instead of electric coil based, and the facility had proof of frequent checks of the heater. The Maintenance Director stated Resident #1 was in a room without a wall unit for air and/or heat. According to the Maintenance Director, when Resident #1 was too hot, the facility provided the resident a fan and when the resident was too cold, they provided the space heater. The Maintenance Director stated the regulations he based his decision to use the space heater for Resident #1 was a state regulation. Per the Maintenance Director, he was not aware he needed to follow the federal regulation and was not told space heaters were not allowed at all in skilled nursing facilities. During an interview on 03/27/2025 at 2:18 PM, the Administrator stated the Maintenance Director tried to do a lot of research to help meet Resident #1's needs, and thought he was doing a good thing. The Administrator stated the Maintenance Director thought the space heater was okay to have, since when the facility was part of the hospital, they were okay. The Administrator stated he expected space heaters to not be in a resident's room going forward. 555776 Page 9 of 10 555776 03/27/2025 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0773 Level of Harm - Minimal harm or potential for actual harm Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on interview and record review, the facility failed to timely notify the physician of laboratory results for 1 (Resident #47) of 2 sampled residents reviewed hospitalization. Residents Affected - Few Findings included: An admission Record indicated the facility admitted Resident #47 on 03/16/2022. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #47's Progress Note, dated 12/22/2024 at 12:18 PM, revealed the physician gave an order for a urinalysis with a culture and sensitivity. Resident #47's Lab Results Report revealed a urine culture with culture and sensitivity was collected on 12/20/2024 and the results were marked final and reported on 12/22/2024. Resident #47's Progress Note, dated 12/30/2024 at 11:32 AM, revealed the nurse practitioner (NP) started the resident on Bactrim DS (an antibiotic medication) two times a day for five days for a urinary tract infection. Resident #47's Order Summary Report, revealed an order dated 12/30/2024, for Bactrim DS oral tablet 800-160 milligrams, give one tablet by mouth two times a day for five days for a urinary tract infection. During an interview on 03/27/2025 at 9:34 AM, the Director of Nursing (DON) stated she could not find any documentation to indicate the physician was notified of Resident #47's laboratory results. During an interview on 03/27/2025 at 4:03 PM, the NP stated her expectation for the staff would be to call the provider with the results of the culture and sensitivity as soon as possible. The NP stated she was available 24 hours a day, as well as the other providers in the group. During a follow-up interview on 03/27/2025 at 12:23 PM, the DON stated she expected the staff to timely notify the physician with laboratory results. During an interview on 03/27/2025 at 2:17 PM, the Administrator stated he expected staff to timely follow through with physician notification of laboratory results. 555776 Page 10 of 10