Good Samaritan Rehab And Care Center

F-F761 Expired Medications. The ADM was again asked for a QAPI plan initiated prior to the current survey week, and the DON provided document titled, QUALITY ASSURANCE/ACTION PLAN, which was signed and dated 1/21/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0865 During a review of the facility's policy and procedure titled, FACILITY QUALITY ASSESSMENT & ASSURANCE AND QUALITY ASSURANCE IMPROVEMENT PROGRAM, dated 10/01/94, indicated, .is Level of Harm - Minimal harm or maintained in accordance with the Federal Requirements, all applicable State regulations .The function of potential for actual harm such program will be the responsibility of the QAA [specifies who attends the QAPI meetings and how often] and QAPI committee .In coordination with QAA/QAPI Program governing body, the facility administrator is Residents Affected - Few responsible to oversee the Quality Improvement [QI] Program in order to meet the needs, goals and objectives of the resident population that it serve[s] and meet the QI Standards of Care established through

the QAPI Program .to work systematically in order to identify, analyze and evaluate quality issues .

Review of an undated facility document titled, QAPI Written Plan: Introduction, indicated, .The QAPI plan will guide your organizations performance improvement efforts .The QAPI regulation requires a written plan . Your written plan will be made available to a state agency, federal surveyor, or CMS upon request .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 49823 potential for actual harm Based on observation, interview, and record review, the facility failed to provide an environment free from the Residents Affected - Few risk of infection for a census of 81 when staff refilled an empty soda bottle from the water dispenser at Nurse Station #3 with the water dispenser spout touching the mouth of the soda bottle.

These failures resulted in the potential for the spread of infection to residents, visitors, and staff in the facility.

Findings:

During a concurrent observation and interview, at Nursing Station #3, on 2/18/25, at 3:45 p.m., Medical Records Assistant (MR) 2 filled an empty plastic soda bottle with water from the resident water dispenser with the bottle mouthpiece touching the spout of the resident water dispenser. MR 2 confirmed that she refilled the empty plastic soda bottle with water from the resident water dispenser at the nurses' station with

the mouth of the bottle touching the spout of the resident water dispenser. MR 2 stated that it was not acceptable to refill the soda bottle from the resident water dispenser with the mouth of the empty plastic soda bottle touching the spout of the resident water dispenser. MR 2 stated that the risk was if she was ill, the residents who drank water from the dispenser would be ill, too.

During an interview on 2/21/25 at 12:45 p.m. with the facility Director of Nursing (DON), the DON stated that

the water dispensers at the nurses' stations were cleaned every 24 hours and filled with fresh water. The DON stated that disposable cups were provided for drinking water next to the water dispensers. The DON stated that if staff used the drinking water for personal use, staff used the drinking cups or their personal refillable containers. The DON stated that if staff used their personal refillable containers, staff should not allow their personal reusable water containers to touch the spout of the water dispenser while refilling their personal containers. The DON stated that the risk was contamination (introducing germs into or on areas that are normally clean or sterile) and potential spread of infection (growth of germs in the body). The DON confirmed that facility policy was not followed.

A review of an undated facility policy and procedure (P&P) titled, The Infection Control Program, indicated, . Policy: It is the policy of this facility to establish an Infection Control Program designed to provide a safe, sanitary and comfortable environment for residents and staff, visitors and the general public and to help prevent the development and transmission of disease and infection .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 50778 potential for actual harm Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- Residents Affected - Few a federally mandated program that includes a set of practices to ensure antibiotics are used appropriately) was followed for one of two sampled residents (Resident 42) on an antibiotic when:

1. Resident 42 developed signs and symptoms of a Urinary Tract Infection (UTI-an infection of the urinary system) and the facility's ANTIBIOTIC STEWARDSHIP GUIDELINE (a set of rules for identifying infections in long-term care facilities) used as part of ASP was not initiated for Resident 42;

2. The Infection Preventionist (IP) was not aware Resident 42 was prescribed antibiotics and did not add Resident 42 to the ANTIBIOTIC STARTS TRACKING log, the MONTHLY SURVEILLANCE REPORT FORM, or the ANTIBIOTIC LOG; and

3. An antibiotic time-out (an active reassessment of an antibiotic prescription 48-72 hours after the medication's first dose) was not done for Resident 42.

These failures had the potential to contribute to unsafe antibiotic use and monitoring in the facility for a census of 81 and placed Resident 42 at higher risk of antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections).

Findings:

Review of Resident 42's PHYSICIAN ORDERS, dated 2/7/25, written by Medical Doctor (MD) 1, indicated, . New order for UA [urine analysis (UA test) is a medical examination of the urine to detect potential health issues] stat d/t [due to] resident c/o [complaint of] burning sensation during urination .6:40 PM .urine specimen collected [a sample of urine that's collected for analysis in a lab] .

Review of Resident 42's PHYSICIAN ORDERS, dated 2/11/25, written by MD 1, indicated, .Ciprofloxacin [antibiotic medication] 500 mg [a unit of measurement] Q [every] day X [for] 5 days for UTI .

Review of a facility document titled, MONTHLY SURVEILLANCE REPORT FORM, dated 2/25, indicated four residents were tracked for signs and symptoms of infection for the month of February. Further review indicated Resident 42 was not listed on the form.

Review of a facility document titled, ANTIBIOTIC STARTS TRACKING, dated 2/25, indicated four residents were started on antibiotics for the month of February. Further review indicated Resident 42 was not listed on

the form.

Review of a facility document titled, ANTIBIOTIC LOG, dated 2/25, indicated five residents were started on antibiotics. Further review indicated Resident 42 was not listed on the form.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0881 During a concurrent interview and record review on 2/21/25 at 9:28 AM with the Infection Preventionist (IP),

the IP stated ASP guidelines were used as a tracking system for residents with signs and symptoms of Level of Harm - Minimal harm or infectious disease. During a review of the IP's ASP binder, the IP acknowledged Resident 42 was not listed potential for actual harm on a spreadsheet titled MONTHLY SURVEILLANCE REPORT FORM, dated 2/2025. The IP confirmed Resident 42 was not listed on the tracking spreadsheets titled, ANTIBIOTIC STARTS TRACKING and Residents Affected - Few ANTIBIOTIC LOG for February of 2025. The IP stated she was not aware Resident 42 was on antibiotics for

a UTI in February of 2025 and she should have been listed on the forms so Resident 42 could have been tracked on both spreadsheets for antibiotic use. The IP stated the nurse should have filled out the form ANTIBIOTIC STEWARDSHIP GUIDELINE for Resident 42 when Resident 42 initially complained of signs and symptoms of a UTI and placed the form in the binder located in the nursing station for the IP to retrieve to add Resident 42 to ASP tracking forms. The IP confirmed Resident 42 did not have the ANTIBIOTIC STEWARDSHIP GUIDELINE form initiated for her regarding her UTI that was diagnosed in February of 2025. The IP acknowledged antibiotic time-outs were not included on any of the facility's ASP forms and was not done for Resident 42 or the other residents listed on the form. The IP stated, an antibiotic time-out should have been conducted on day three from the start of antibiotic treatment to ensure effectiveness of the medication ordered and to notify the MD if new orders were needed. The IP further explained this process helped to ensure correct antibiotic treatment was used for susceptible organisms (bacteria that cannot grow

in the presence of a specific drug), to prevent spread of infectious disease, and provide timely treatment to decrease duration of infection. The IP acknowledged antibiotic time-outs were not being conducted on residents receiving antibiotics in the facility and stated they should be conducted for the residents on the residents being tracked as part of the ASP. The IP stated if not following the facility's ASP policy and guidelines could lead to the facility not implementing an ASP program to its fullest effect and could lead to residents taking antibiotics for longer than necessary and not the shortest duration.

A review of the facility's undated policy and procedure titled, ANTIBIOTIC STEWARDSHIP POLICY AND PROCEDURE, indicated, .Purpose .improving the use of antibiotics in healthcare to protect our residents and reduce the threat of antibiotic resistance .Components of this policy were developed by using evidence-based practice [a systematic approach to clinical decision-making that integrates the best available research] guidelines and are aligned with the Core Elements of Antibiotic Stewardship for Nursing home, published by the Centers for Disease Control and Prevention (CDC) .This facility will incorporate all seven (7) core elements .Utilize antibiotic-use and other data to ensure that Antibiotic Stewardship Policy Procedures and other best practices are followed .how to quantify [express or measure the quantity of] and assess appropriateness of antibiotics prescribed and how to identify adverse outcomes .Nurses will utilize the approved antibiotic stewardship guideline algorithm in identifying signs and symptoms specific to different systems .Antibiotic 'time-out.' At 72 hours after antibiotic initiation .each resident will be reassessed for consideration of antibiotic need, duration, selection, and de-escalation potential [a process whereby the delivery of effective initial antibiotic treatment is achieved while avoiding unnecessary antibiotic use] . completion of an antibiotic time-out must be recorded in the resident record .What will be measured/tracked . Antibiotic starts .Days of therapy .Antibiotic use .Stewardship actions .Outcomes .A monthly ASP Tracking Report will be compiled .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0881 Review of an online document published by the Centers for Disease Control and Prevention (CDC) in 2015 titled, Core Elements of Antibiotic Stewardship for Nursing Homes, indicated, . Antibiotics are among the Level of Harm - Minimal harm or most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home potential for actual harm receiving one or more courses of systemic antibiotics [antibiotics that are taken to treat infections throughout

the body] when followed over a year . studies have shown that 40-75% of antibiotics prescribed in nursing Residents Affected - Few homes may be unnecessary or inappropriate .Harms from antibiotic overuse are significant for the frail and older adults receiving care .These harms include risk of serious diarrheal infections from Clostridium difficile (a bacteria that causes diarrhea and inflammation of the colon-the longest part of the large intestines, which is an organ in the digestive system) increased adverse drug events (harm caused by appropriate or inappropriate use of a drug) and drug interactions (a change in the way a drug acts in the body when taken with certain other drugs), and colonization (when bacteria are present on or inside a person's body, growing and multiplying, but without causing any noticeable symptoms or illness) and/or infection with antibiotic-resistant organisms . Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use .This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections . practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic

review process, also known as an antibiotic time-out, for all antibiotics prescribed . Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices .

(https://www.cdc.gov/antibiotic-use/media/pdfs/core-elements-antibiotic-stewardship-508.pdf)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 50598 potential for actual harm Based on observation, interview and record review, the facility failed to maintain equipment in safe operating Residents Affected - Many condition when:

1. The can opener was found with layers of metal shavings and food particles; and

2. The dishwashing machine remained below manufacture required temperature of 120 degrees.

These deficient practices had the potential to compromise food safety for the 81 residents receiving food from the facility.

Findings:

1. During the initial kitchen tour on 2/18/25 at 8:45 AM, in the presence of [NAME] (CK) 1, the can opener was found with paint chipped off, food debris, and layer of metal shavings behind the blade. CK 1 confirmed

the findings.

During an interview with the Registered Dietician (RD) on 2/21/25, the RD stated the can opener should be cleaned regularly. The RD stated, there was a cleaning schedule for the staff to follow. The RD stated the can opener was dirty and for all of the metal build up staff had been taught to use a wired brush to clean the can opener properly. The RD stated, this did not meet her expectations and posed a risk to the residents as

a can opener in this condition could harbor pathogens that could be unsafe for the residents.

2. During a concurrent observation, interview and record review with the Certified Dietary Manager (CDM) and RD on 2/18/25 at 1:10 PM, after observing three complete dishwashing cycles it was found that the temperature on the machine did not exceed/reach 120 degrees. The CDM stated the reason for the temperature difference was because it was a low temperature washing machine. On the dishwashing machine was manufacture requirements and recommendations. The CDM confirm the minimum required temperature per manufacturer guldens was 120 Fahrenheit. The RD placed a handheld thermometer in a part of the dishwasher that allows external access during washing cycles. The handheld thermometer would not go above 117 degrees Fahrenheit during a full cycle of dish washing.

During an interview with the RD on 2/21/25, the RD stated the chlorine works to sanitize the dishes at 120 degrees Fahrenheit at least and it had to be at 120 degrees Fahrenheit for safety. If not at 120 degrees Fahrenheit this poses a risk to the residents. No, the condition of the dishwasher did not meet my expectations. At 120 degrees Fahrenheit the dishes are not hygienically sanitized as that is completely necessary.

During an interview with the Maintenance Supervisor (MS) on 2/21/25 at 3:34 PM, the MS stated the dishwashing machine needed to be calibrated to the correct temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0908 Review of the FDA 2022 Food Code, under section 4-202.15, Tilted Can Openers Indicated, .Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they Level of Harm - Minimal harm or can no longer be adequately cleaned and sanitized. Can openers must be designed to facilitate replacement. potential for actual harm (https://www.fda.gov/media/164194/download)

Residents Affected - Many Review of the FDA 2022 Food Code, under section 4-501.15 , Titled Warewashing Machines, Manufacturers' Operating Instructions indicated, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved.

Review of the FDA 2022 Food Code, under section 4-501.110 titled. Mechanical Warewashing Equipment, Wash Solution Temperature indicated, The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed. The temperatures vary according to the specific equipment being used. (https://www.fda.gov/media/164194/download)

Review of the FDA 2022 Food Code, under section 4-601.11, .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, version 1/23, indicated, (A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch. (B) The Food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . (https://www.fda.gov/media/164194/download)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51375

Residents Affected - Some Based on observation and interview, four rooms (rooms 5, 18, 22, and 45) in the facility did not meet the required 80 square feet per resident.

This failure placed the residents in rooms 5, 18, 22, and 45 at potential risk to impede their care and highest possible level of functioning due to smaller than required square footage.

Findings:

During an observation with the Maintenance Supervisor (MS), the following measurements were obtained for rooms 5, 18, 22, and 45.

a. room [ROOM NUMBER], a 3-bed room, measured 237.37 square feet, rather than the required 240 square feet.

b. room [ROOM NUMBER], a 3-bed room, measured 235.58 square feet, rather than the required 240 square feet.

c. room [ROOM NUMBER], a 3-bed room, measured 233.21 square feet, rather than the required 240 square feet.

d. room [ROOM NUMBER], a 2-bed room, measured 142.85 square feet, rather than the required 160 square feet.

a. During a concurrent observation and interview with the MS, on 2/20/25, at 9:30 AM, the MS confirmed room [ROOM NUMBER] measured at 21 feet 5 inches x 11 feet 1 inch (237.37 square feet) for a 3-bed room, leaving 79.1 square feet per resident, less than the 80 square feet per resident required.

During a concurrent observation and interview with Resident 40 in room [ROOM NUMBER], on 2/20/25, at 10:11 AM, Resident 40 stated that there was plenty of room and she was able to get the care that she needed without any issues.

b. During a concurrent observation and interview with Resident 24 in room [ROOM NUMBER], on 2/18/25, at 11:30 AM, Resident 24 stated that he had no issues with the room or his care. Resident 24 stated the room had adequate space to keep his wheelchair in the room without hindering workable areas or access to the residents residing in the room.

During a concurrent observation and interview with the MS, on 2/20/25, at 9:40 AM, the MS confirmed room [ROOM NUMBER] measured at 14 feet 3 inches x 17 feet (242.25 square feet), with a free-standing closet measuring 4 feet x 20 inches (6.67 square feet), leaving a total of 235.58 square feet for a 3-bed room or 78. 5 square feet per resident, less than the 80 square feet per resident required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0912 During a concurrent observation and interview with Resident 34 in room [ROOM NUMBER], on 2/20/25, at 10:14 AM, Resident 34 stated that there was enough space in the room and that staff could get around with Level of Harm - Potential for no problems to provide care to him. He further stated that he was happy with the room. minimal harm c. During a concurrent observation and interview with the MS, on 2/20/25, at 9:35 AM, the MS confirmed Residents Affected - Some room [ROOM NUMBER] measured at 14 feet 3 inches x 16 feet 10 inches (239.88 square feet), with a free-standing closet measuring 4 feet x 20 inches (6.67 square feet), leaving a total of 233.21 square feet for

a 3-bed room or 77.7 square feet per resident, less than the 80 square feet per resident required.

During a concurrent observation and interview with Resident 16 in room [ROOM NUMBER], on 2/20/25, at 10:12 AM, Resident 16 stated that the room was big enough and that there was enough room for her to get care with no issues.

d. During a concurrent observation and interview with the MS, on 2/20/25, at 9:30 AM, the MS confirmed room [ROOM NUMBER] measured at 14 feet 2 inches x 10 feet 1 inch (142.85 square feet), leaving a total of 71.4 square feet per resident, less than the 80 square feet per resident required.

During a concurrent observation and interview with Resident 288 in room [ROOM NUMBER], on 2/20/25, at 4:37 PM, Resident 288 stated that he did not have any problems moving around the room, even though it was a little smaller than other rooms. Resident 288 further stated that he could transfer into and out of the wheelchair without problems. Resident 288 added he could walk with the wheelchair to the bathroom and around the room without trouble.

During an interview with licensed nurse (LN) 3, on 2/20/25, at 10:22 AM, LN 3 stated that he had provided treatments and care to the residents in the smaller rooms with no issues. LN 3 further stated there was enough room for him to safely provide care.

During an interview with certified nursing assistant (CNA) 3, on 2/20/25, at 10:23 AM, CNA 3 stated that he had provided direct care in the smaller rooms. CNA 3 stated there was more than enough space for him to safely provide care to the residents and had no issues.

During an interview with CNA 2, on 2/21/25, at 9:35 AM, CNA 2 stated she could take care of each resident

in the rooms without any problems related to room space. CNA 2 further stated that she can move between beds and around each bed without difficulty. CNA 2 added the smaller rooms did not impact daily tasks.

During an interview with LN 2, on 2/21/25, at 9:42 AM, LN 2 stated that the small room sizes did not have any negative effects on care provided to the residents.

During an interview with the Administrator (ADM), on 2/21/25, at 12:17 PM, the ADM confirmed the room sizes of rooms 5, 18, 22, and 45. The ADM stated there were not any complaints from residents or staff that

the room spaces were too small or that they were unable to accommodate the resident needs.

Room waiver was recommended to continue, as contingent upon compliance with federal regulations at Resident Rights (481.10) and Physical Environment (483.90).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 055039 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055039 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 50598 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the environment was free of Residents Affected - Many pests for a census of 81 residents when roaches were found in front and beneath the microwave that was used to reheat foods for the residents.

This failure had the potential for the cross-contamination of foods stored in the resident's refrigerator, and foods being reheated in the resident's microwave, resulting in food-borne illnesses.

Findings:

During a concurrent interview and observation with the Certified Dietary Manager (CDM) on 2/18/25 at 4:41 PM, The resident's microwave that was used to reheat the residents outside food, was found with layers of old food splatters. The CDM stated the house keeping were the ones cleaning the microwave.

During a follow up observation on the microwave to reheat the residents' food on 2/21/25 at 9:13 AM, prior to opening the microwave, a roach was found walking in front of the microwave.

During a concurrent interview and observation with the House Keeping Supervisor (HS) on 2/21/25 at 9:20 AM, the HS confirmed the splatters that were there three days ago remained with additional layers of food and stated the microwave was supposed to be cleaned twice a day. While observing the microwave, the microwave was moved, and multiple roaches began to run in various directions. The HS grabbed a paper towel and began to smash the roaches. The HS confirmed the bugs running away were roaches.

During an interview with the Maintenance Supervisor (MS) on 2/21/25 at 1:40 PM, the MS stated the facility had regular pest control monthly. The MS confirmed the presence of roaches and stated, the roaches are bad and pose an infection control issue.

During a concurrent interview and record review with the MS and the Physical Plant Supervisor (PPS) on 2/21/25 at 2:07 PM, the PPS stated, when there were reports of pests, they would inspect the issue and contact the contractor. The MS stated he had not seen roaches in the building ever. A record review of the pest control document titled, Work Order/ Invoice, service date 11/5/24, indicated, one resident reported sightings of roaches in their room and treatment was provided. The PPS stated the risk for having roaches in

the facility were that they bring diseases, can make the residents sick, and they may swallow it. The PPS stated, it's important to have a pest control program because these roaches multiply fast. The PPS stated his expectation was the facility needs to be cleaned every day and [including] the counter tops.

According to the 2022 Federal Food Code, section 6-501.111 stated . Controlling Pests .The premises shall be maintained free of insects, rodents, and other pests .by .routinely inspecting the premises for evidence of pests .Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. (https://www.fda.gov/media/164194/download)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 055039