Veterans Home Of California - Yountville - Snf

F-F812).

Review of the facility document titled, Diet Spreadsheet, dated 3/5/25, showed lunch served on 3/5/25 included Orange Chicken and Asian Vegetable Blend for regular textured diets (no texture modifications), ground Asian Vegetable Blend for Mechanical Soft textured diets (a modified textured diet consisting of soft, easily chewed foods), and Pureed Orange Chicken and Whipped Potatoes for pureed textured diets (modified textured diet consisting of smooth, pudding like consistency foods).

An observation on 3/5/25 at 12:05 p.m., showed retherm cart labeled 1D was unplugged by staff from the docking station and was ready to be transported to the resident ward for lunch food service.

On 3/5/25 at 12:07 p.m., a test-tray observation was conducted. The temperature of food was measured with

a calibrated thermometer for three test trays. Test tray 1 included pureed foods and the temperatures showed pureed chicken was 116.6 degrees Fahrenheit (F), and mashed potatoes were 109.4 degrees F.

The pureed chicken and mashed potatoes were just barely warm when tasted. In addition, the regular textured vegetables and the mechanical textured vegetables tasted bland. Food Service Supervisor (FSS) 1 tasted the vegetables and stated they had no flavor. Also, the regular and mechanical vegetables had a fibrous, unappealing texture. FSS 1 stated the vegetables were a little crunchy for a regular person. When

the regular textured Orange Chicken was tasted, it felt dry and a bit tough. FSS 1 stated the chicken was a little dry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 0804 It is the position of the American Dietetic Association (ADA; currently known as the Academy of Nutrition and Dietetics) that the quality of life and nutritional status of older residents in long-term care facilities may be Level of Harm - Minimal harm or enhanced by a liberalized diet. A diet that is not palatable or acceptable to the individual can lead to poor potential for actual harm food and fluid intake, which results in weight loss and undernutrition, followed by a spiral of negative health effects. [NAME], B., [NAME] K. C., & [NAME] P.K. (2002). Position of the American Dietetic Association: Residents Affected - Many Liberalized Diets for Older Adults in Long-Term Care. Journal of the American Dietetic Association 102(9), 1316-1323. https://doi.org/10.1016/S0002-8223(02)90289-0

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 34975

Residents Affected - Many Based on observation, interview, and facility document review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when:

1. The facility did not have a system in place to ensure all hot food was reheated to a minimum of 165 degrees Fahrenheit (F) and all cold food was held at or below 41 degrees F;

2. Three air vents located in the dish room and food production area in the Main Kitchen (where food was prepared for the licensed care kitchen), were not clean;

3. Supervisory staff did not cover facial hair in the kitchen where food was stored and handled;

4. Trays used for food service were in poor condition; and

5. An industrial can opener was not clean and stored available for use.

These failures had the potential to contaminate food and/or utensils for resident use and/or consumption, leading to food borne illness and/or illness from cross-contamination for 144 residents who received food from the kitchen.

Findings:

1. During an observation and interview on 3/3/25 at 9:16 a.m., staff placed chilled food on trays and placed

the trays in food carts. Food Service Supervisor (FSS) 1 explained the facility used a cook chill rethermalization (retherm) process for resident meals. Food was prepared and chilled in the Main Kitchen, then transferred to the licensed care facility kitchen where the chilled food was plated, placed on trays, placed in a cart, then stored in a cooler. The carts were plugged into docking stations for retherm about 45 minutes prior to food service. These carts were designed to reheat hot food and maintain cold food on the same tray.

An observation and interview on 3/3/25 at 11:55 a.m., showed the retherm carts were labeled with ward numbers. The 1C cart was unplugged and staff began to transport the cart out of the kitchen to the resident ward for lunch food service. The surveyor measured food temperatures on two random trays with a calibrated thermometer before the cart was taken out of the kitchen. The hot food temperatures on the first tray were above 165 degrees F. The temperatures on second tray were as follows: milk 46.6 degrees F, ground green bean medley 126 degrees F, chopped beer battered cod 147.7 degrees F, and rice 138.2 degrees F. FSS 1 stated the hot food needed to be at least 165 degrees F and the tray observed with food less than 165 degrees F had to be reheated.

In a consecutive interview on 3/3/25 at 12:05 p.m., when asked how the staff monitored temperatures of the food before it was served, Food Service Technician (FST) 1 stated temperatures were measured on one test tray on one of the five retherm carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 0812 An observation on 3/3/25 at 12:10 p.m., showed cart 1D was unplugged and pushed by a staff toward the door out of the kitchen. The surveyor measured the temperature of food on three random trays, with FSS 1, Level of Harm - Minimal harm or before it was transported out of the kitchen and the temperatures were as follows: potential for actual harm Tray 1: pureed fish filet patty 138.2 degrees F; pureed green beans 148.5 degrees F; pureed corn 155.7 Residents Affected - Many degrees F.

Tray 2: chopped beer battered Cod: 147.4 degrees F, mashed potatoes 140.9 degrees F, ground green bean medley 134.8 degrees F.

Tray 3: hot food temperatures were above 165 degrees F.

The cart was transported out of the kitchen by kitchen staff without reheating any food on the cart.

Review of the test tray documentation log titled Food and Nutrition Services HACCP [Hazard Analysis Critical Control Point] Data Collection .], dated 3/3/25, showed FST 1 documented food temperatures were as follows: Beer Battered Cod: 167 degrees F, Crinkle Fry: 169 degrees F, [NAME] Bean Medley: 168 degrees F, Chicken Noodle Soup: 178 degrees F, Milk: 37 degrees F. Although, the temperatures on the facility's test tray were appropriate, it was identified the test tray temperatures did not reflect the temperature of the food on all the trays in the carts.

On 3/5/25 beginning at 11:30 a.m., surveyors measured the temperatures of food on requested test trays on three retherm carts with a calibrated thermometer. The test tray food temperatures on carts 2C and 2D were above 165 degrees F.

On 3/5/25 at 12:07 p.m., food temperatures were measured with a calibrated thermometer on the third requested test tray for ward 1D. These temperatures were measured immediately when the cart was unplugged from the docking station and before the cart was transported to the ward. The temperatures were as follows:

Tray 1: pureed orange chicken 116.6 degrees F, whipped potatoes 109.4 degrees F, pureed pees 122.2 degrees F.

Tray 2: jasmine rice with ground orange chicken 127.8 degrees F, ground Asian vegetable blend 136.6 degrees F.

Tray 3: orange chicken 161.6 degrees F, Asian vegetable blend 154.2 degrees F.

During an interview on 3/5/25 at 3:08 p.m., the Director of Dietetics (DD) stated hot food was required to be reheated to 165 degrees F and cold food had to be held at 41 degrees or below. DD stated the HACCP temperature log for the retherm carts was the policy and procedure used for retherm of food. DD confirmed

in the licensed kitchen only one test tray was conducted on one retherm cart per meal. DD stated the test tray was rotated on different retherm carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 0812 Review of the test tray documentation log titled, Food and Nutrition Services HACCP [Hazard Analysis Critical Control Point] Data Collection .] showed the minimum temperature for hot food including entree, Level of Harm - Minimal harm or starch/cereal, vegetables, and soup, after retherm was 165 degrees F. The maximum temperature for cold potential for actual harm food including salad and milk was 41 degrees.

Residents Affected - Many 2. An observation in the Main Kitchen on 3/4/25 at 10:47 a.m., showed two ceiling air vents in the ware wash area had a black, fuzzy substance resembling dust on the vent cover and the ceiling surrounding the vent. One vent was located above a tall storage rack used to store clean pots and pans. The black substance observed around this vent extended to and down the wall to the top of the storage rack.

An observation in the Main kitchen on 3/4/25 at 10:49 a.m., showed a black, fuzzy substance resembling dust spread out from a wall air vent located in the hallway/food preparation area adjacent to the warewashing room.

In a consecutive interview with Food Manager (FM) 1 on 3/4/25 at 10:50 a.m., FM1 confirmed the air vents needed to be cleaned. When FM 1 was asked what the process was for having the air vents cleaned, FM 1 stated maybe kitchen staff needed to put in a work order for cleaning.

In an interview with the Housekeeping Custodian (HC) on 3/4/25 at 2:35 p.m., HC stated he was responsible for cleaning the outside of the vents in the Main Kitchen. HC stated Plant Operations was responsible for cleaning the inside of the vents because tools were needed to remove the vent covers. HC stated cleaning of

the outside of the air vents was not on a schedule and he did not receive work orders for cleaning the vents, however HC stated he usually went into the Main Kitchen monthly and cleaned the outside of the vents. HC stated the air vents were always dirty when he went into the Main Kitchen to clean them.

In an interview with the Direct Construction Supervisor (DCS) on 3/4/25 at 3:10 p.m., DCS stated he was temporarily doing the duties of the Chief Direct Operation Supervisor because the position was vacant. DCS stated the inside of vents were cleaned one time per year. DCS stated the janitor placed a work order when

the vents needed cleaning. DCS stated he thought a work order was received a couple of weeks ago, but the vents had not been cleaned yet because of a staffing shortage. DCS stated air filters in the air handlers (a part of a heating, ventilation, and air conditioning [HVAC] system that circulated conditioned air throughout a building) were replaced twice a year.

On 3/4/25 at 3:32 p.m., documentation of the most current work order for cleaning of the vents, the last cleaning of the air vents, and changing air filters for the air handling units was requested from DCS.

In an interview with the Infection Control Preventionist (IP) on 3/5/25 at 9:51 p.m., IP stated he inspected all areas, mostly nursing areas, for infection control prevention. IP stated sometimes he inspected other areas such as the kitchen but stated he never went into the Main Kitchen. IP stated he only inspected licensed areas.

Review of documentation titled, Annual Air Handler Maintenance Log showed air filters were changed throughout the kitchen from 12/23/24 to 12/29/24. No work orders or documentation to show the last cleaning of the air vents was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 0812 Review of the Policy and Procedure (P&P) titled, Food & [and] Nutrition Services - Equipment (All Homes), dated 8/7/24, showed all kitchen areas shall be kept clean. Level of Harm - Minimal harm or potential for actual harm According to the 2022 Federal Food Code, physical facilities, including air conditioning systems, shall be cleaned as often as necessary to keep them clean. Residents Affected - Many 3. An observation on 3/5/25 at 11:30 a.m., showed FSS 3 was working in the kitchen, monitoring food carts

in the trayline area. FSS 3 did not have his beard covered with a hair restraint.

In an interview with DD on 3/6/25 at 9:25 a.m., DD stated everyone in the kitchen needs to have hair and beards covered.

Review of the P&P titled Food & [and] Nutrition Services - Staff Operations and Training (All Homes) last revised 1/23/24, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair . beards and mustaches must be covered.

4. An observation on 3/3/25 at 10 a.m., showed a stack of trays, in multiple colors, on a storage rack for clean equipment. The trays were cracked and chipped. In addition, the trays had a build-up of worn and frayed tape on the tray surfaces.

During a concurrent interview on 3/3/25 at 10 a.m., FSS 1 stated the trays were used to hold desserts on trayline food service. FSS 1 confirmed the trays were cracked and had tape build-up.

According to the 2022 Federal Food Code, multi-use food-contact surfaces are to be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Equipment and utensil food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces are to be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and debris.

5. An observation on 3/3/25 at 9:53 a.m., showed an industrial can opener stored in a holder attached to a food preparation table. There was orange and black, sticky residue on the surface of the blade. The residue transferred to a paper towel when the blade was wiped.

During a concurrent interview on 3/3/25 at 9:53 a.m., FSS 1 stated the can opener was supposed to be cleaned after each use. FSS 1 confirmed the can opener was not clean.

According to the 2022 Federal Food Code, equipment and utensil food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and debris.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 39795

Residents Affected - Few Based on interview and record review, the facility failed to ensure Resident 57's medication was documented when Registered Nurse (RN) 6 did not document medications were given. This failure had the potential to cause negative health-related outcomes to Resident 57.

Findings:

During a review of Resident 57's Minimum Data Set (MDS- a tool for implementing standardized assessment and for facilitating care management in nursing homes) Section I- Active Diagnoses dated 2/6/25, the MDS indicated Resident 57 had the following diagnoses: Anemia (body does not produce enough healthy red blood cells to carry oxygen), Hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), and Hyperlipidemia (too much fat in the blood).

During a review of Resident 57's Current Medication Orders, the orders indicated, . Isosorb Mono (isosorbide mononitrate) Tab (tablet) 30 milligram (mg- unit of measure) ER (extended release) Take one (1) tablet by mouth every evening for heartbeat abnl (abnormal) . Atorvastatin Tab 80 mg . Take one (1) tablet by mouth every evening for Hyperlipidemia .

During a concurrent interview and record review on 3/5/25 at 11:55 a.m., with Registered Nurse Supervisor (RNS) 1 and RN 3, Resident 57's Medication Administration Record [MAR- a report detailing drugs administered] dated 3/1/25 to 3/31/25 was reviewed. Signature boxes on lines designated for Atorvastatin 80 mg and Isosorb Mono 30 mg medications and scheduled at 6 p.m. were left blank on 3/3/25. RN 3 stated she could not confirm the medications were refused by Resident 57 or administered because the signature boxes were left blank. RN 3 stated night shift RNs were responsible for auditing the MARs every 24 hours. RN 3 stated Resident 57's MAR did not indicate it was audited.

During an interview on 3/5/25 at 3:15 p.m., with RN 6, RN 6 stated he reviewed Resident 57's MAR prior to

the interview. RN 6 confirmed he worked the PM shift (2:30 p.m. to 11 p.m.) on 3/3/25 and stated he administered to Resident 57 Atorvastatin 80 mg and Isosorbide Mono 30 mg around 6 p.m. that evening. RN 6 stated he forgot to initial the MAR when he administered the medications. RN 6 stated facility policy required nurses to initial signature boxes at the time the medication was administered to residents or circle

the boxes if residents refused. RN 6 stated, on 3/3/25, he did not follow facility policy and procedure for medication administration. RN 6 stated it was an omission that placed Resident 57 at risk for a medication dosing error if not identified by night shift.

During a review of the facility's policy and procedure (P&P) titled, Medication, Administration Standards, last reviewed 11/21/24, the P&P indicated, . The licensed nurse is responsible to ensure the Six rights of medication administration are followed at all times . Right Documentation [the sixth right] . Medication name, administration time, route and dose of the drug or treatment administered to the Resident will be recorded in

the MAR/ TAR by the licensed nurse who administers the drug or treatment .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35030 potential for actual harm 39795 Residents Affected - Some Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment when:

1. Three of five staff (Contract Staff [CS] 1, Certified Nursing Assistant [CNA] 6, and Custodian Worker [HSK] 1) did not perform hand hygiene or utilize personal protective equipment (PPE- equipment worn to minimize exposure to infectious or hazardous materials, e.g. gown, gloves, mask, eye protection) in accordance with policy and procedure and nationally recognized infection prevention and control guidelines.

2. One of one custodian worker (HSK 1) did not follow facility procedure for the cleaning and disinfection of

an occupied room.

3. Five of five staff (Laundry Supervisor [LS] 1, LW 1, LW 2, LW 3, and HSK 1) did not know the dwell time (the amount of time a disinfectant must remain visibly wet on a surface to effectively kill specific germs) of facility products used for disinfection.

4. Enhanced Barrier Precautions was not identified and effectively implemented for one of three sampled residents (Resident 16) who had an indwelling urinary catheter (thin flexible tube inserted into the bladder through the urethra to drain urine continuously) in place.

5. Enhanced Barrier Precautions was not effectively implemented for two of two sampled residents (Resident 35 and Resident 64) having a Gastrostomy Tube (G-tube, a small, flexible tube inserted through the abdominal wall and into the stomach used to provide nutrition and medication to individuals who cannot eat or drink adequately on their own) during nutritional tube feeding administration.

6. Sterile technique (the practice of eliminating microorganisms from an environment or object to prevent infection) was not implemented for one of one sampled residents with a nephrostomy tube (a long, thin, plastic tube inserted through the skin directly into the kidney which drains fluid), when sodium chloride was injected into Resident 71's nephrostomy tube using non-sterile supplies.

These failures placed residents at risk for cross contamination and infection and could result in health-related disease.

Findings:

1. During an observation on 3/3/25 at 11:06 a.m., in [NAME] 2's hallway, CS 1 exited a resident's room holding a laundry bag with ungloved hands and used a paper tissue as a barrier between his hand and laundry bag. CS 1 emptied the contents of the laundry bag in the biohazard room (room designated to dispose or store infectious or potentially infectious materials and waste) and returned into Resident 109's room. CS 1 did not perform hand hygiene after handling the linen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During an interview on 3/3/25 at 11:13 a.m., with CS 1, CS 1 stated he bathed Resident 109 and changed

the linen on Resident 109's bed before transporting the soiled linen to the biohazard room. CS 1 Level of Harm - Minimal harm or acknowledged he did not wear gloves to carry the soiled linen bag and did not perform hand hygiene when potential for actual harm he exited Resident 109 and biohazard rooms. CS 1 stated his failure to wear gloves and preform hand hygiene was an oversight and hand hygiene should have occurred upon exit of both rooms to reduce the risk Residents Affected - Some of cross contamination.

During an interview on 3/4/25 at 2:03 p.m., with the Infection Preventionist (IP), the IP stated all staff were expected to follow facility infection prevention and control policies and procedures, contracted staff included.

The IP stated hand hygiene should occur anytime staff entered or left a resident's room or area that stored potentially soiled items. The IP stated although CS 1 used paper tissue as a barrier between the soiled linen bag and hands, staff were expected to wear gloves and perform hand hygiene when handling soiled linen to prevent the spread of disease and illness.

During an observation on 3/4/25 at 3:13 p.m., in Resident 57's room, CNA 6 obtained the blood pressure and body temperature of Resident 57. Signage posted on Resident 57's door indicated Enhanced Barrier Precautions (EBP- an infection control intervention to reduce the spread of germs) must be implemented prior to entrance into Resident 57's room. The sign also indicated staff must perform hand hygiene and wear at minimum a gown and gloves for high-contact activities. CNA 6 did not wear a gown or gloves and did not perform hand hygiene before handling another resident's privacy curtain.

During an interview on 3/4/25 at 3:20 p.m., with CNA 6, CNA 6 acknowledged she provided care to resident 57 without wearing gown and gloves. CNA 6 stated she was aware of Resident 57's EBP status due to a wound infection on Resident 57's leg. CNA 6 stated she should have worn gloves but forgot. CNA 6 stated EBP required staff wear mask and gloves and perform hand hygiene when providing resident care to prevent cross contamination to other residents, staff, and self.

During an observation on 3/6/25 at 8:49 a.m., in [NAME] 2's hallway, HSK 1 performed the cleaning of an occupied resident room (RM 1). HSK 1 wore gloves and face mask to perform the task. After cleaning RM 1, HSK 1 returned the mop used in RM 1 to the housekeeping cart and crossed the hallway to a second occupied resident room (RM 2). HSK 1 entered RM 2 and proceeded to clean RM 2. HSK 1 did not change his gloves during the cleaning process nor was hand hygiene performed in between tasks and the two rooms. HSK 1 touched his clothing, face mask, cleaning equipment, and cart with his contaminated gloves.

During an interview on 3/6/25 at 8:53 a.m., with HSK 1, HSK 1 stated he cleaned rooms on [NAME] 2 daily and the procedure observed was his process for cleaning occupied rooms. HSK 1 stated gloves were changed when visibly soiled, however he could not provide additional times hand hygiene should occur.

During an interview on 3/6/25 at 9:31 a.m., with the IP, the IP stated all staff were expected to implement standard precautions with resident care tasks, including housekeeping. The IP stated gown use was no longer required for daily cleaning of rooms and bathrooms, unless the room was an isolation room (separate room for residents with a contagious disease) or the risk for self-contamination existed. The IP reinforced the expectation for hand hygiene when entering and exiting resident rooms and in between tasks and glove changes. The IP also stated staff were required to use additional PPE (e.g. gown) for care provided to residents on EBP. The IP stated HSK 1 and CNA 6 did not follow facility policy and procedure for hand hygiene and PPE use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During a review of the facility's policy and procedure (P&P) Hand Hygiene Procedure . dated 12/24/18, the P&P indicated, . Per the Centers for Disease Control (CDC- a national health protection agency and Level of Harm - Minimal harm or regulating bodies of infection control, prevention, and awareness) keeping hands clean through improved potential for actual harm hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs . Preform Hand Hygiene . Before and after caring for someone who is sick . Before and after removing gloves Residents Affected - Some when caring for a resident . After coming into contact with blood or body fluids or open skin .

During review of the CDC document Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24,

the document indicated, .Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with . Handwashing with water and soap (e.g., plain soap or with an antiseptic) . Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) . Cleaning your hands reduces . The potential spread of deadly germs to patients . including those resistant to antibiotics .clean your hands . Immediately

before touching a patient . After touching a patient or patient's surroundings . After contact with blood, body fluids, or contaminated surfaces . Immediately after glove removal .wear gloves . When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment) . change gloves and clean hands . If gloves become soiled with blood or body fluids after a task . Before exiting a patient room .

During a review of the facility's Infection Control Guidelines 2.0- Isolation Precautions approved 4/15/08, the guidelines indicated, . Standard precautions constitute the primary strategy for the prevention of healthcare associated transmit function of infectious agents among patients and health care personnel. Standard precaution assumes that every person is potentially infected or colonized with an Organism that could be transmitted in the healthcare setting and applies the following infection control practices during the delivery of healthcare . wear gloves when it can be reasonable to anticipate contact with blood or other potentially infectious materials .

During concurrent observation and interview on 3/6/25 at 7:45 a.m., with Laundry Supervisor (LS), LW 1, and LW 2, in the Laundry Service Building, LW 1 and LW 2 demonstrated their process for doffing (remove) contaminated PPE. LW 1 discarded her gloves, unsnapped the overcoat (in place of gown) and placed the overcoat in the staff soiled linen bin, then grasped the front of her face mask and hair net for removal. LW 2 confirmed the sequence of LW 1's PPE removal procedure and stated she followed the same doffing procedure. LS stated LW 1 did not demonstrate proper technique for removal of contaminated PPE and the sequence demonstrated increased the risk for self-contamination and possible transmission of disease. LS stated the overcoat buttoned in the front which required extra handling and LW 1 should have performed hand hygiene prior to removing her mask to prevent self-contamination.

During a review of the CDC document How to Safely Remove Personal Protective Equipment (PPE) Example 2, undated, the document indicated, . Gown front and sleeves and the outside of gloves are contaminated . If your hands get contaminated during gown or glove removal, immediately wash your hands or use an alcohol-based hand sanitizer . Front of mask/respirator is contaminated- Do Not Touch . Perform Hand Hygiene Between Steps If Hands Become Contaminated and Immediately After Removing All PPE .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 2. During an observation on 3/6/25 at 8:49 a.m., in [NAME] 2's hallway, HSK 1 performed the cleaning of an occupied resident room (RM 1). The housekeeping cart, stationed outside the room, had four buckets (B1, Level of Harm - Minimal harm or B2, B3, and B4); three of the buckets (B1, B2, and B3) were half filled with a liquid solution. B4 was empty. potential for actual harm The bucket used for mopping floors (B3) had cloudy water with a gray grainy sediment at the bottom of the bucket. The two remaining buckets (B1 and B2) were unlabeled and had a johnny mop (a type of toilet bowl Residents Affected - Some cleaning tool with a fuzzy or soft, absorbent head) placed in the liquid solution. Small brown/ gray particles floated in B1 and B2's liquid. HSK 1 used a string mop to clean RM 1's bathroom and floor. HSK 1 swept the mop in and out of the bathroom onto the RM 1's floor in a series of repeated actions. After completion of the task, HSK 1 returned the mop to B3 and crossed the hallway to a second resident occupied room (RM 2). HSK 1 retrieved a johnny mop from B1 and wiped down the inside of RM 2's toilet bowel, toilet riser, and toilet seat, then returned the johnny mop to B1. Next, HSK 1 retrieved the mop from B3 and mopped RM 2's floor and bathroom, using the same procedure as in RM 1 (repeatedly mopping in and out of the room and bathroom). HSK 1 did not wipe any high touch surfaces nor furniture in RM 2.

During concurrent observation and interview on 3/6/25 at 8:53 a.m., with HSK 1, in [NAME] 2's hallway and janitorial room, HSK 1 stated the cleaning procedure demonstrated was the method he used for cleaning resident rooms on [NAME] 2. HSK 1 stated the liquid solution in B1, B2, and B3 were the same, two ounces of floor mop cleaner mixed with three quarters of a bucket of water. HSK 1 stated he used the same liquid until all rooms on [NAME] 2 were cleaned. HSK 1 showed the floor cleaner product used for cleaning resident rooms. One gallon bottle of [Name of Product] Floor Cleaner Concentrate solution sat on the floor of

the janitorial room. HSK 1 stated it was the only product available for him to use. HSK 1 stated he did not know if the solution had disinfecting properties.

During an interview on 3/6/25 at 9:31 a.m., with the IP, the IP stated the facility's floor cleaner was not a disinfectant (chemical product that destroys germs) and not acceptable for cleaning and disinfecting resident room surfaces and bathrooms. The IP stated HSK 1's practice of using a neutral floor cleaner to clean resident bathrooms placed residents at risk for gastrointestinal (relating to stomach and intestines) diseases and illnesses. The IP stated a diluted bleach solution should be used to clean and disinfect environmental surfaces in resident rooms and bathrooms. The IP also stated reuse of cleaning solutions had limitations; that cleaning and disinfecting solutions became less effective each time used equipment was placed into the solutions becoming a potential source and reservoir for germs. The IP stated dirty bucket water should be changed at regular intervals to ensure cleaning solution products remained clean and effective.

During an interview on 3/6/25 at 2 p.m., with the Housekeeping Supervisor (HSKS) and HSK 2, HSKS stated

the facility followed CDC's guidelines for environmental cleaning and described the procedure for cleaning resident rooms in the facility. HSKS stated housekeepers were expected to sweep dusty air vents, clean and disinfect doorknobs, high touch surface areas, and mop daily. HSKS stated housekeepers were expected to use two johnny mops and two string mops for the various cleaning tasks in each room. The HSKS stated one string mop should be used for a resident's bathroom floor and another for the room's floor. It was not acceptable to use one string mop for both resident bathroom and room floors. The HSKS stated the facility used bleach and [Name of Product] disinfectant solutions to clean and disinfect resident rooms and bathrooms, and floor cleaner was not an acceptable product to use for disinfection. The HSKS stated bucket water should be changed every third room to avoid neutralizing solutions and spreading germs throughout

the facility. HSKS stated HSK 1 did not follow facility policy and procedure for the cleaning of occupied resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During review of [Name of Product] Floor Cleaner Concentrate Solution Material Safety Data Sheet, indicated, . Product Use: Floor Cleaner . Level of Harm - Minimal harm or potential for actual harm During a review of the facility P&P Cleaning, Occupied Resident Room, approved 8/22/24, the P&P indicated, . dust all surfaces with disinfectant solution . Wipe bedside tables with disinfecting solution . Clean Residents Affected - Some mirrors and interior surfaces of glass . Empty and reline trash cans . vacuum or dust mop depending on area . remove cobwebs . clean and disinfect toilet and sink. Scrub with cleanser as needed . Wash doors and handles with disinfectant . completely mop floor and baseboards with disinfectant .

During a review of CDC's document Best Practices for Environmental Cleaning in Healthcare Facilities Version 2, the document indicated, . Environmental cleaning is part of Standard Precautions, which should be applied to all patients in all healthcare facilities . The cart should have enough cleaning cloths to complete

the required cleaning session, with a clean cloth for each patient zone to prevent cross-contamination . It is best practice to use a two- or three-bucket system for mopping . Two-bucket system (routine cleaning): one bucket contains a detergent or cleaning solution and the other contains rinse water . The rinse water bucket allows the mop to be rinsed and wrung out before it is re-dipped into the prepared solution . Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms [germs] . clean low-touch surfaces before high-touch surfaces . Clean patient areas (e.g., patient zones) before patient toilets . Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas . Never double-dip cleaning cloths into portable containers (e.g., bottles, small buckets) used for storing environmental cleaning products (or solutions) . Never leave soiled mop heads and cleaning cloths soaking

in buckets . Common high-touch surfaces include . bedrails . sink handles . bedside tables . edges of privacy curtains . transport equipment (e.g., wheelchair handles) . call bells . doorknobs . light switches . Toilets in patient care areas . have high patient exposure (i.e., high-touch surfaces) and are frequently contaminated. Therefore, they pose a higher risk of pathogen transmission than in general patient areas . Mop from cleaner to dirtier areas . Mop in a systematic manner, proceeding from area farthest from the exit and working towards the exit . Change mop heads/floor cloths and buckets of cleaning and disinfectant solutions as often as needed (e.g., when visibly soiled, after every isolation room, every 1-2 hours) and at the end of each cleaning session .

3. During concurrent interviews on 3/6/25 at 7:39 a.m., LS, LW 1, and LW 2 stated they used germicidal bleach wipes to clean and disinfect the sorting table to prevent transmission of disease and cross contamination during the sorting of soiled laundry. The LS stated the disinfectant was effective against communicable diseases as long as it was allowed to airdry after being applied. The LS, LW 1 and LW 2 stated they did not measure how much time the surface of the table took to airdry and/ or remained wet to effectively kill germs. The LS acknowledged dry times and time the surface remained wet varied based on weather conditions which could potentially affect the effectiveness of the disinfectant.

During an interview on 3/6/25 at 7:54 a.m., with LW 3, LW 3 stated his department used [Name of Product- hydrogen peroxide) disinfectant to clean high touch surface areas and equipment at the end of his shift. LW 3 stated he was not aware how long the product had to remain on the surfaces to be effective. LW 3 stated, it [disinfectant] just airdries. LW 3 stated he did not know how long the product took to airdry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During and interview on 3/6/25 at 8:53 a.m., with HSK 1, HSK 1 stated he used various cleaners and disinfectants throughout the day. HSK 1 stated he applied the disinfectant products and allowed them to Level of Harm - Minimal harm or airdry. HSK 1 stated he was not familiar with dwell times. potential for actual harm

During an interview on 3/6/25 at 2 p.m., with the HSKS and HSK 2, HSKS stated disinfectants utilized in the Residents Affected - Some facility were under the supervision of the facility IP. The HSKS stated housekeeping used a diluted bleach solution as the primary disinfectant for the facility. The HSKS stated the bleach solution had a dwell time of 10 minutes. The HSKS stated he did not evaluate the total contact time the disinfectant remained wet on surfaces. HSKS stated the disinfectant was effective if allowed to airdry.

During review of the information for use (IFU) [Name of Product] bleach germicidal wipes, undated, the IFU indicated, . Directions . Remove gross soil if present or if disinfecting for C. difficile [Clostridioides difficile- a bacteria that c spores . Wipe the surface until completely wet . Wait for the contact time (3 minutes for C. diff, fungi, TB and select viruses; 30 second for bacteria; 1 minute for most viruses) . Discard the wipe .

During a review of the IFU [Name of product] hydrogen peroxide disinfectant, dated 9/22/21, the IFU indicated, . When used as directed, this product is effective against (a broad spectrum of) pathogenic microorganisms . viruses, and fungi . To Use as a One- Step Cleaner/ Disinfectant . Pre- clean heavy soiled areas . Allow surface to remain wet for 1 minute. (For certain listed viruses, Allow treated surfaces to remain visibly wet for one-minute, additional towelettes if needed to ensure the correct visibly wet surface contact time .

During a review of the CDC's document TOPIC 12: Environmental Cleaning & Disinfection: What is Contact Time?, undated, the document indicated, . Sometimes called dwell time, this is the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, to effectively kill germs . Wait until contact time is complete before using objects or surfaces or before a new patient comes into a room . Follow the instructions on the disinfectant label - especially instructions for contact time .

41816

50674

4. During a concurrent observation and interview on 3/3/25 at 3 p.m. with Resident 16 in Resident's room, Resident 16 was lying awake in bed and had an indwelling urinary catheter bag attached to the lower rail of

the bed frame. Resident 16 stated she was currently using an indwelling urinary catheter, and staff was assisting with care by changing and emptying the bag as needed. There was no Enhanced Barrier Precautions (EBP) sign to indicate appropriate use of Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was posted outside the Resident's room door. There was no isolation cart for PPE storage noted outside of Resident 16's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During a concurrent observation and interview on 3/5/25 at 9:24 a.m. with Certified Nursing Aide (CNA) 3 outside of Resident 16's room, CNA 3 stated Resident 16 was dependent on staff and required help with Level of Harm - Minimal harm or bathing and toileting. CNA 3 stated that only gloves and masks were worn when giving direct care because potential for actual harm the Resident was not on any isolation precautions. CNA 3 stated Resident 16 had no isolation sign posted or cart outside of the Resident's room, so the Resident was not on isolation. Residents Affected - Some

During a concurrent observation and interview on 3/5/25 at 9:30 a.m. with Licensed Vocational Nurse (LVN) 1 outside of Resident 16's room, LVN 1 stated there was no isolation cart or isolation precautions sign posted on the door to indicate Resident 16 was on isolation precautions. LVN 1 further stated if there was an isolation cart and sign posted outside the door, then the staff would wear what was posted every time the staff would go in the room to give care to Resident 16.

During a concurrent interview and record review on 3/6/25 at 11:20 a.m. with Infection Control Preventionist (IP), the facility provided list of Residents with isolation precautions was reviewed. The list indicated Resident 16 was on Enhanced Barrier Precautions and the reason for precautions indicated, Indwelling Device-Catheter. The record also indicated, Potential Clearance Date for Resident 16 was Indefinite. IP stated the Residents who are on EBP have signs posted to their doors to notify staff and people of what to wear when they enter the room to prevent transmission of infection.

During a record review of Resident 16's Minimum Data Set (MDS- A resident assessment tool), dated 1/24/25, the MDS indicated the Resident had an indwelling catheter and was dependent on staff for toileting hygiene and personal hygiene.

During a record review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions (EBP), dated 6/25/24, the P&P indicated, EBP are essential infection control measures designed to minimize

the transmission of multidrug-resistant organisms (MDROs) and protect both residents and staff in heathcare settings. The P&P indicated, Use EBP for residents with chronic wounds or indwelling medical devices, regardless of MDRO status. The P&P further indicated, Staff will . Display clear signs outside the resident's room indicating EBP and required PPE (gown and gloves).

5. During a concurrent observation and interview on 3/5/25 at 5 p.m. with RN 9 on [NAME] 2D while observing the start of Resident 64's tube feeding process. There was signage noted on the wall in front of Resident 64's room indicating EBP precautions were required during tube feedings. RN 9 stated she did not need to wear a gown for administration of the fluids. RN 9 stated, I use them when I do a dressing change and while suctioning, not with feeding. No cart was located near the resident room. RN 9 read the signage and confirmed it was required and donned the required protection. She stated staff have not been wearing gowns for this process. RN 9 stated, I was not aware it was required.

During an interview on 3/5/25 at 5:10 p.m. with Resident 64, Resident 64 stated, The nursing staff have not been wearing gowns for this [delivering of formula through the tube]. Resident 64 stated, I know it is for my safety that they do.

During a review of the facility Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 6/25/24, the policy indicated the use of EBP was mandated for residents identified as high risk for multidrug resistant organisms ([NAME]), including residents with indwelling devices [G-tube], during high contact resident activities. The policy indicated indwelling devices such as feeding tubes provide a direct pathway for pathogens to enter the body and cause infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During a review of the signage in front of Resident 64's room titled, Enhanced Barrier Precautions, undated,

the signage indicated, All providers and staff must wear at least a gown and gloves for these High Contact Level of Harm - Minimal harm or Resident Care Activities: [including] Indwelling Device Care or Use: [including] Feeding tube. potential for actual harm 52357 Residents Affected - Some 5. During a review of Resident 35's Face Sheet (demographics), dated 12/18/24, the Face Sheet indicated Resident 35 was admitted on [DATE REDACTED] with diagnoses which include tongue carcinoma (a type of cancer of

the tongue), dysphagia (difficulty swallowing foods and liquids), and gastrostomy tube (G-tube - a small flexible tube that is inserted through the skin into the stomach to provide nutrition and fluids).

During an observation on 3/3/25 at 9:34 a.m., in Resident 35's room, a sign was observed outside of the room alerting staff that Resident 35 required Enhanced Barrier Precautions (EBP - infection control practice that uses PPE-personal protective equipment including gloves and gowns to reduce the spread of infection).

The EBP sign indicated that staff are required to wear a gown and gloves when performing High-Contact Activities including providing care for indwelling medical devices such as G-tubes.

During a concurrent observation and interview on 3/6/25 at 12:02 p.m. with LVN (Licensed Vocational Nurse (LVN) 2 in Resident 35's room, LVN 2 was observed administering medications through Resident 35's G-tube; LVN 2 was not wearing a gown. LVN 2 confirmed she did not wear a gown while administering G-tube medications to Resident 35 and stated she was unaware a gown was required.

During an interview on 3/6/25 at 2:02 p.m. with Nursing Supervisor (NS) 3, NS 3 stated staff must wear gloves and a gown when providing care for residents with a G-tube or other indwelling medical device. NS 3 stated it was important to use EBP to protect the resident from infection.

During a review of the facility's Enhanced Barrier Precautions (EBP) Policy, approved on 6/25/24, the policy indicated, This policy mandates the use of EBP, including the donning of gowns and gloves during high-contact resident care activities, for residents identified as high-risk due to .indwelling medical devices. Examples provided of indwelling medical devices included G-tubes.

6. A review of Resident 71's Face Sheet (demographics), dated 01/21/25, indicated Resident 71 was admitted on [DATE REDACTED] with diagnoses that included urinary tract infection (UTI - an infection of the bladder and or kidneys) and severe sepsis with septic shock (life threatening condition resulting from an infection).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 During a concurrent observation and interview on 3/6/25 at 11:00 a.m. with Registered Nurse (RN) 10 in Resident 71's room. RN 10 was observed preparing to flush Resident 71's nephrostomy tube (a long, thin, Level of Harm - Minimal harm or plastic tube inserted through the skin directly into the kidney which drains fluid). RN 10 donned clean gloves, potential for actual harm opened a small sterile drape, (a sterile sheet used to create a sterile field during procedures with the purpose of preventing the spread of infection from non-sterile areas and protecting the resident from contamination) Residents Affected - Some and placed the sterile drape under Resident 71's nephrostomy tubing. RN 10 removed a green cap from the port attached to the nephrostomy tubing and placed the green cap on the bedside table. RN 10 donned sterile gloves (gloves which have been sterilized to eliminate any bacteria to protect residents from infection

during procedures. Once sterile gloves are donned, staff should not touch anything except other sterile supplies) and opened an alcohol wipe (non-sterile) and used it to clean the port of the nephrostomy tube. RN 10 then picked up a syringe filled with sodium chloride (solution to flush the nephrostomy tube) which was wrapped in plastic (non-sterile). RN 10 unwrapped the syringe with her sterile gloves and proceeded to use

the port to inject sodium chloride into Resident 71's nephrostomy tube. RN 10 then placed the green cap (non-sterile) back on the port of the resident's nephrostomy tube.

During an interview on 3/6/25 at 11:15 a.m. with RN 10, RN 10 confirmed she used sterile gloves to open the alcohol swab wrapper and to remove the plastic overlay from the sodium chloride syringe. RN 10 confirmed

these supplies were not sterile and her sterile gloves were contaminated by handling the non-sterile supplies. RN 10 further stated the green cap she removed from the bedside table and placed back on Resident 71's nephrostomy tube port was not sterile.

During an interview on 03/06/2025 at 2:02 p.m. with Nursing Supervisor (NS) 3, NS 3 stated it was important to use sterile technique when flushing Resident 71's nephrostomy tube because the nephrostomy tube was inserted through the skin directly into the resident's kidney. NS 3 stated failure to use sterile technique when flushing the nephrostomy tube could result in Resident 71 developing a serious infection.

During a review of the facility's policy and procedure (P&P) titled Nephrostomy Tube, Management, dated 04/09/2024, the P&P indicated, Flushing of Nephrostomy . flushing of the nephrostomy tube is a sterile procedure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 555095 Department of Health & Human Services Printed: 09/04/2025 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 555095 B. Wing 03/07/2025

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

Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599

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 34975 potential for actual harm Based on observation, interview, and facility document review, the facility failed to maintain a walk-in freezer Residents Affected - Few when there was a large amount of ice build-up on the ceiling as well as ice build-up on boxes of food. The failure to maintain one freezer in one out of two kitchens had the potential to result in decreased quality and contamination of food.

Findings:

An observation in a walk-in freezer (referred to as the warehouse freezer) located in the Main Kitchen (where food was stored and prepared for the licensed care kitchen) on 3/4/25 at 10:25 a.m., showed ice build-up on

the ceiling between wall mounted fans. The ice measured more than 24 inches long, 18 inches wide, and 2 inches thick. In addition, boxes of food stored below the fan had a layer of ice build-up on the top surface of

the boxes.

During a concurrent interview on 3/4/25 at 10:25 a.m., Food Manager (FM) 1 stated he did not know what the ice build-up was from. FM 1 confirmed there was ice build-up on boxes of food and stated he was unaware of the ice build-up.

During an interview on 3/6/25 at 3:08 p.m., the Dietary Director (DD) stated freezers need to be free of ice-build-up.

During an interview with the Direct Construction Supervisor (DCS) on 3/4/25 at 3:10 p.m., DCS stated his staff usually went into the warehouse freezer every other week but right now about every month because of

a staff shortage. DCS stated he was not aware of ice build-up.

During a review of the policy and procedure titled, Food & [and] Nutrition Services - Equipment (All Homes), dated 9/18/24, showed equipment will be maintained in good working order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 555095