Health inspection·October 14, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a physician of a change of condition for one of 12 residents (Resident 99) when she had severe pain caused by decreased blood circulation in her right leg. This resulted in Resident 99 having continued severe pain due to a blood clot that required surgical intervention of removing her right leg above the knee. Findings: A review of a facility policy titled, Change in Resident's Condition or Status, revised December 2016, indicated the facility staff should promptly notify the resident, attending physician in changes in a residents medical/mental condition. The Licensed Nurse (LN) will notify physician when a significant change in the resident's physical/emotional/mental condition and the need to alter the resident's medical treatment. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff. The nurse will make detailed observations and gather relevant pertinent information for the physician. The nurse will record in the medical record the information relative to the changes in medical/mental status. A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (reduced blood flow), chronic venous hypertension with stasis ulcers (high blood pressure in legs causing wounds) and dementia. Resident 99 was unable to make her own healthcare decisions. A review of a quarterly social services note dated 8/26/2021, indicated Resident 99 was only alert to self with intermittent confusion and lack of orientation. Resident 99 was unable to complete the brief interview for mental status or mood interview. A review of the Resident 99's nursing progress notes indicated: On 9/5/2021 at 6:49 am, Registered Nurse (RN) M documented on night shift Resident 99 continually and loudly yelled for the first five hours of the shift (night shift started at 10:15 pm. Resident 99 was unable or unwilling to verbalize what might be causing distress. Resident declined to ingest Tylenol (mild pain) after previously nodding her head in agreement that she was in pain and said she would accept the Tylenol. Resident unable to pin point locate or describe the pain. Since this was the first time in five months this RN M has observed any such behavior from this resident, she is being put on alert charting (72 hours) for an appropriate temporary monitoring. Three days later, on 9/08/2021 at 10:04 pm, RN D documented Resident 99 had a purple discoloration on the right foot. Medical Director A was notified and received order to send resident to the emergency room (ER) for evaluation. There was no physician notification, alert charting, nursing progress note, or Interdisciplinary Team (IDT- a group of health care disciplines that discuss resident care needs) documentation found in the record from 9/5/2021 to 9/8/2021 about the change in condition for Resident 99. A review of the event (notes about changes in resident condition) summary list from 1/1/2021 to 9/30/2021, indicated there were no changes in condition documented for Resident 99's change in pain and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 2 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0580 right leg circulation (purple to black color). Level of Harm - Minimal harm or potential for actual harm During an interview on 10/14/2021 at 12:30 pm, RN M stated he did not know Resident 99 very well. RN M confirmed on 9/5/2021, Resident 99 seemed different so he asked the Certified Nursing Assistants (CNAs) who care for resident, if the hours of yelling were normal for her. RN M stated the CNAs stated it was not normal for Resident 99 to loudly yell for that long. RN M confirmed he did not notify the physician of the change, did not assess Resident 99 for skin issues. RN M stated she could not verbally communicate and did not know where her pain could be coming from. RN M confirmed the details of his nursing progress notes, that Resident 99 was able to nod that she was in pain just did not know where. RN M stated she refused the Tylenol when offered. RN M stated I do not know where to document a change of condition, whether in an event note or a tablet at the nursing station, he just verbally told the day shift nurse about the events that night. Residents Affected - Few During an interview on 10/14/2021 at 10:30 am, the Director of Nursing (DON) recalled observing Resident 99 on 9/8/2021 (day sent to the ER) sitting in her wheelchair in the hallway making humming and moaning noises. DON asked nursing staff if this was unusual for this resident and they responded she does this. DON confirmed her expectation for a change of condition of any resident was for the LNs to assess the resident from head to toe, notify the physician, initiate an event in the electronic medical record and make a progress note about the assessment findings. DON was not made aware of the change of condition that started for Resident 99 on 9/5/2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 3 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff completed timely a comprehensive quarterly assessment for one of 12 residents (Resident 99). This failure resulted in no plan of care for Resident 99's non-verbal pain to go unrecognized and untreated. Findings: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated a comprehensive, person centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS, resident assessment). At least quarterly the Interdisciplinary Team (IDT- group of health care disciplines that discuss resident care needs) in conjunction with the quarterly MDS will meet to review and update the care plan. Assessments of residents are ongoing and care plans are revised as information about the resident's conditions change. A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (reduced blood flow), chronic venous hypertension with stasis ulcers (high blood pressure in legs causing wounds) and dementia. Resident 99 was unable to make her own healthcare decisions. During a concurrent interview and record review of Resident 99's quarterly comprehensive assessment dated [DATE], the MDS nurse confirmed it was not done due to not having an MDS nurse since 9/1/2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 4 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and/or revise the care plans for three of three sampled residents (Resident 346, 29, and 99) when: 1. Resident 346 had no care plan developed for a pressure injury (bed sore) and for psychotropic drug use (drugs that alter mood and behavior). This resulted in Resident 346 having no plan for the treatment of her pressure injury and no goals for using psychotropic drugs. 2. Resident 29's care plan was not revised with specific interventions for irrigating a suprapubic catheter (a tube that goes directly into the bladder from the abdomen to drain urine when the kidneys no longer work). This resulted in Resident 29 receiving unsterile catheter care when it should have been sterile. 3. Resident 99 did not have a care plan developed for non verbal pain and for her peripheral vascular disease (decreased blood flow). This resulted in Resident 99's non verbal signs of pain and decreased blood flow in her right leg to go unrecognized and untreated. 4. Resident 20 did not have a care plan developed for a Peripheraly Inserted Centeral Catheter (PICC)(A soft, long catheter that is inserted into a vein in the arm and the tip is positioned in a large vein near the heart), that was used for the infusion of Antibiotic therapy. This resulted in Resident 20's PICC line to be replaced two times, missed nursing assessments, missed antibiotic treatments and an increase chance of infections. Findings: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised December 2016, directed that: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; d. Include the resident's stated goals upon admission and desired outcomes; f. Incorporate identified problem areas; g. Incorporate risk factors associated with identified problems; 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 5 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0656 b. When the desired outcome is not met; Level of Harm - Minimal harm or potential for actual harm c. When the resident has been readmitted to the facility from a hosptial stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. Residents Affected - Some 1. Resident 346 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, hypothyroidism (the thyroid gland is underactive), depression, constipation, weakness, and memory loss and an unstageable (not open yet) pressure injury to her right posterior (toward the back) heel. On 10/12/2021 at 10:20 AM, an observation was conducted with LN (Licensed Nurse) B. Resident 346 had a small, 0.4 centimeter (cm less than a quarter inch) long x 0.3cm wide and 0.1cm deep, dry pressure injury to her right posterior heel. On 10/13/21 at 11:02 AM, an interview and concurrent care plan review was conducted with LN B. There was no care plan developed for Resident 346's pressure injury to her right heel. LN B confirmed that no individualized care plan had been developed which described the treatment plan and goals that were needed to heal Resident 346's pressure injury. Record review showed that on 9/30/21, Resident 346 had Physician Order's for Zyprexa (an antipsychotic drug) 10 milligrams (mg) at bedtime for crying. No care plan had been developed which specified the risks or expectations of using this medication to treat Resident 346's crying episodes. There was no description of what interventions the facility was going to take for her crying episodes, and no goal or expected outcome had been established. On 9/30/21, Depakote (an antiseizure drug used to stabilize mood) 125 mg three times a day was ordered for crying. No care plan had been developed which specified the risks and expectations of using this medication to treat Resident 346's crying. No goals or person centered interventions had been identified. On 10/13/21 at 9:25 AM, the Director of Staff Development (DSD) confirmed that Resident 346 did not have care plans developed for a pressure injury to her right foot or for the use of Zyprexa and Depakote and stated, the care plans should have been developed. 2. Resident 29 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a disease where the immune system eats away at the protective covering of the nerves and disrupts the communication from the brain to the body), pressure ulcers, Schizoaffective disorder (a combination of depression, delusions, hallucinations, and mania- high energy periods), mood disorder, seizures, anxiety, chronic pain syndrome, and a neurogenic bladder (neurological damage to a bladder which causes it not to empty and requires a tube to drain the urine). On 10/11/21 at 3:16PM, during an observation and interview with Resident 29, a 60 milliliter (ml) syringe in a plastic bag was taped to the foot of her bed. Resident 29 had no knowledge of why the syringe was there. A review of Resident 29's Treatment Administration Record (TAR) reflected that a physician's order was obtained on 7/15/2020 and revised on 10/6/21, to irrigate Resident 29's suprapubic catheter with 30ml of Acetic Acid (a vinegar solution commonly used to keep bladder catheters from getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 6 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0656 plugged up with matter) 0.25 percent (%) twice a day. Level of Harm - Minimal harm or potential for actual harm Resident 29 had a care plan titled, Suprapubic Urinary Cath Care Plan, that was created on 6/13/2017. The interventions for the care plan were not revised or updated when the physician's order to irrigate the suprapubic catheter were obtained on 7/15/2020 or updated on 10/6/21. There were no interventions which described how or when Resident 29's suprapubic catheter was to be irrigated, what risks were involved or that this procedure required using a sterile technique with sterile supplies. Residents Affected - Some On 10/13/21 at 9:50 AM, during a care plan review and interview, LN B confirmed that Resident 29's care plan was not updated when they began irrigating the suprapubic catheter back in July 2020, and it should have been. 3. A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (reduced blood flow), chronic venous hypertension with stasis ulcers (high blood pressure in legs causing wounds) and dementia. Resident 99 was unable to make her own healthcare decisions. A review of a quarterly social services note dated 8/26/2021, indicated Resident 99 was only alert to self with intermittent confusion and lack of orientation. Resident 99 was unable to complete the brief interview for mental status or mood interview. A review of Resident 99's care plan history from 2/01-9/30/2021, indicated no resident specific interventions for peripheral vascular disease and pain. There were new care plan interventions for pain upon her readmission on [DATE]. During an interview on 10/12/2021 at 2:25 PM, Certified Nursing Assistant (CNA) N stated Resident 99 was hard to understand and never heard her talk, she made noises or groaned when moved or repositioned. CNA N stated Resident 99 often refused showers. CNA N stated Resident 99's legs would get very purple when she sat up in her wheelchair too long. CNA N stated her wheelchair did not have any leg lifts or special fitting to allow legs to be elevated. CNA N stated she had not told anyone about her purple legs. CNA N worked the day shift on 9/08/2021, when Resident 9 went to the hospital. CNA N stated Resident 99 was yelling and bottom of her right foot was black and her leg was dark purple. CNA N stated yelling, moaning and refusing care could be a sign of pain. CNA N stated she changed her process of looking at skin since this happened, she always removes socks now. CNA N stated the facility had not had an inservice about the incident, she did not want this to happen again so she made changes on how she monitors residents skin. During an interview on 10/12/2021 at 2:40 PM, CNA O stated Resident 99 was quiet although would moan at time while in bed or in wheelchair. During an interview on 10/12/2021 at 2:50 PM, LN A stated Resident 99 often refused showers and medications. LN A stated nursing depends on CNAs for skin check reports on shower days. LN A stated she does not always receive the completed shower sheets from the CNAs. LN A stated their treatment nurse was also checking the skin weekly although they have been without one for awhile. LN A stated Resident 99 does moan and has Tylenol for pain. LN A stated the pain assessment in the record should include location, and a description for non verbal signs such as grimacing. During a concurrent interview and record review on 10/14/2021 at 1:30 PM, MDS nurse confirmed Resident 99's quarterly comprehensive assessment dated [DATE], was not done due to not having an MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 7 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0656 nurse since 9/1/2021. Level of Harm - Minimal harm or potential for actual harm During a interview on 10/19/2021 at 11:40 AM, a family member (FM) stated they were present when the emergency services arrived. FM stated Resident 99's right leg dark purple and her right ankle turning black. FM stated when Resident 99 was touched she would scream out in pain. FM stated Resident 99 had been non verbal since earlier this year, January 2021, when she had COVID19. Residents Affected - Some During an interview on 10/14/2021 at 10:30 AM, the Director of Nursing (DON) recalled observing Resident 99 on 9/8/2021 (day sent to the hospital) sitting in her wheelchair in the hallway making humming and moaning noises. DON asked nursing staff if this was unusual for this resident and they responded she does this. DON confirmed the pain assessments for Resident 99 did not include non verbal signs of severe pain. DON confirmed the were no care plans that addressed Resident 99's risk factors and interventions related to her peripheral vascular disease and pain. 4. A review of Resident 20's medical record indicated Resident 20 was re-admitted to this facility on 8/10/2021 after a hospital stay. Her diagnosis included septic (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) arthritis of the left knee. Resident 20's brief interview for mental status (BIMs) score was 15, indicating Resident 20 was cognitively intact. During a review of Resident 20's nursing progress notes dated 8/10/2021, at 2:14 PM, by Licensed Vocational Nurse (LN) E, LN E noted that Resident 20 had a PICC line in the right upper arm. During a review of Resident 20's nursing progress notes dated 8/10/2021, at 4:13 PM, by LN M, LN M noted that Resident 20 had an order for Vancomycin (An antibiotic medication used to treat complicated bacterial infections) intravenously (IV) every 12 hours thru the PICC line. During a review of Resident 20's comprehensive care plan last edited on 10/12/2021 there was no plan of care identified for the care of Resident 20's PICC line, which would include dressing changes, flushing the line, monitoring for signs or symptoms of infection or displacement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 8 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement it's care plan for one of 37 residents (Resident 10) according to policy on falls. This resulted in the resident experiencing a fall, and created the potential for further falls, injury, illness and death. Residents Affected - Some Findings: Resident 10 was admitted to the facility on [DATE] with acute respiratory disease (rapid onset of a breathing problem), multiple sclerosis (a disease that attacks muscle coordination), Alzheimer's, dementia, and a history of falling. A review of the facility's record titled Falls: Policy and Implementation (Revised March, 2018) indicated: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Further, In conjunction with the attending physician, staff will identify and implement relevant interventions. A review of Resident 10's medical record included a Fall Care Plan dated 9/12/2020, which indicated At risk for falls [related to] unsteady gait, altered balance while standing and/or walking, muscle spasms, MS [multiple sclerosis], antidepressants, history of falls. The record indicated that the approach to eliminating that fall risk would include floor mats on both sides of the bed, and Keep bed in lowest position with brakes locked. The timing of interventions was as follows: 1. Ask for assistance as needed (9/12/2020) 2. Orient to New Environment (9/12/2020) 3. Medication Review (9/12/2020) 4. Provide verbal Reminders (9/12/2020) 5. Provide proper well maintained foot wear as indicated (9/12/2020) 6. Keep bed in lowest position with breaks locked (9/12/2020) 7. Floor Mats (11/30/2020) The record contained no apparent interventions that addressed the resident's subsequent fall on 9/21/2021. A review of Resident 10's medical record included a Behavior Care Plan with a start date of 1/8/2021. That care plan indicated, Resident intentionally trying to get out from bed, but she is not able to get out of bed by self due to impaired mobility [related to diagnosis of] multiple sclerosis, and Long term Goal Target Date: 12/16/2021: will keep bed in low position The record indicated that the start date of this intervention was 1/8/2021. A review of Resident 10's MDS (Minimum Data Set, a resident assessment tool used for the Centers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 9 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0658 Level of Harm - Minimal harm or potential for actual harm for Medicare/Medicaid Services) dated 6/18/2021, indicated in the section Cognitive Patterns that Resident 10's response when asked what year it was missed by greater than five years, and that she was unable to report the correct day or month. She required prompting when asked to recall the words sock, blue and bed, and her resulting Brief Interview of Mental Status (BIMS) score was six of 15 possible points, or very severe impairment. Residents Affected - Some A review of the facility's record titled, IDT (interdisciplinary team) New admission Review, dated 7/21/2021, indicated that Resident 10 left the facility to go to a nearby hospital for altered mental status (confusion/unresponsiveness). The record indicated that the resident had fall risks: Risk factors: At risk for falls due to cognitive impairment, poor tolerance, decreased strength, impaired endurance and weakness. Other fall risk factors include diagnoses of Alzheimer's, dementia and depression, anxiety . A review of the record titled Resident Progress Notes dated 9/22/2021, indicated that on 9/21/2021, Resident had an unwitnessed fall around 2030 [8:30 PM]. Resident found laying down on the floor near the bed. Upon asking resident, stated she was trying to sit on the wheelchair, and No injuries, no complaints of pain . The record indicated, when resident is out of bed place bed in high position to deter resident from attempting to transfer self back in bed . On 10/11/21 at 12:05 PM, Resident 10's bed was observed to be in a high position and no floor mats were noted on either side of her bed. In a concurrent interview and observation with Resident 10 on 10/13/2021 at 3:20 PM, the resident was observed in bed in high position with no fall mats in the room. Resident was wearing fuzzy colorful streetwear socks with no apparent non-slip bottoms. The socks appeared and felt slippery. Resident 10 stated, No my bed is not in the low position. I can barely get in and out of it. Did it contribute to my fall [on 9/22/2021]? Yes! The floor is slippery and I slide underneath the bed! In an interview and concurrent observation of Resident 10's bed on 10/13/2021 3:25 PM, RN (Registered Nurse) 1 stated, Resident 10 is supposed to have her bed in the low position. It is not in the low position. I don't know why the bed would need to be in the high position. The bed should be flat. RN1 could not explain why Resident 10's care plan would ever contain an intervention to keep the bed in high position when she was not in bed. RN1 further stated, [Resident 10] was not supposed to have a fall mat although the care plan indicated that there should be two of them. In an interview on 10/13/2021 at 3:50PM, CNA1 (Certified Nursing Assistant) stated, Yes, [Resident 10] is supposed to have her bed in low position. She is supposed to have mats on the floor. I think we have them. The bed could be lower. In an interview on 10/13/21 at 3:24 PM, DSD (Director of Staff Development) was shown the care plan indicating the need to keep the bed in the lowest position. I see that in the care plan. It's a mistake. It probably carried over from an old order that was discontinued DSD concurred that the last date the care plan had been updated was 9/12/2020, which was prior to her most recent fall, and had not been updated subsequently. Resident 10's bed was observed to be in the highest position on 10/14/2021 at 8:30 AM. In an interview on 10/14/2021 at 10:30 AM, DSD stated that changes to care plans are communicated to staff verbally, and that the bed being in low position and the fall mats were not communicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 10 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide services to maintain good grooming and hygiene for one of twelve sampled residents (Resident 9) when the resident's fingernails were long and dirty. This failure had the potential to cause breaks in Resident 9's skin and to spread germs which could have caused infections. Residents Affected - Few Findings: Review of the facility document, titled, C.N.A. Clinical Performance Evaluation, dated 9/1/2019, showed a checklist of skills that Certified Nursing Assistants (CNAs) were to have demonstrated. Under the Performance Area category of Personal Care Skills, one of the items listed was, Fingernails clean. Review of the facility policy, titled, Care of Fingernails/Toenails, revised 10/1/2010, indicated its purpose was to clean the nail bed, to keep nails trimmed, and to prevent infections. Under the general guidelines listed, the policy indicated that trimmed and smooth nails prevented the resident from accidentally scratching and injuring their skin. Staff were instructed not to trim the nails of diabetic residents or residents with circulation problems, unless otherwise permitted. Staff were instructed to soak the resident's hands in warm soapy water, to clean the dirt from under the nails with an orange stick, and to file the nails with a nail file or emery board. Review of Resident 9's clinical record showed admission to the facility on 3/20/2021 with diagnoses that included diabetes (a disease of blood sugar regulation), end-stage renal disease (the final, permanent stage of chronic kidney disease when the kidneys can not function on their own), and Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought and mood). Resident 9's health conditions of diabetes and renal disease could have made them more vulnerable to complications resulting from infections. During a concurrent interview and observation, 10/11/2021, at 2:44 PM, Resident 9 rested on their back in bed. Resident 9 picked at the inside of one nostril, and smeared blood from their nose onto the bedsheet. Resident 9 had long, dirty, jagged fingernails on all ten fingers. The nail length was at least one-quarter inch, with dark material underneath them. During a concurrent interview and observation, on 10/11/2021, at 2:46 PM, the Activities Assistant confirmed Resident 9's fingernails were long and dirty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 11 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure nursing staff developed and implemented a resident plan of care for two of four residents (Resident 99 and ) when: Residents Affected - Few 1. Resident 99's change of condition for skin and pain were not identifed through the nursing assessments. This failure resulted in Resident 99 to have severe pain and required surgical intervention for a right above knee amputation. 2. The nursing staff failed to provide appropriate care and services according to facility's policy and professional standards of care to assess and maintain Resident 20's Peripherally Inserted Central Catheter (PICC) (A soft, long catheter that is inserted into a vein in the arm and the tip is positioned in a large vein near the heart). This failure caused the PICC line to be replaced two times, two doses of antibiotic therapy to be missed, and an increased risk of infection for Resident 20. Findings: A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (reduced blood flow), chronic venous hypertension with stasis ulcers (high blood pressure in legs causing wounds) and dementia. Resident 99 was unable to make her own healthcare decisions. A review of a quarterly social services note dated 8/26/2021, indicated Resident 99 was only alert to self with intermittent confusion and lack of orientation. Resident 99 was unable to complete the brief interview for mental status or mood interview. A review of the Resident 99's nursing progress notes indicated: On 9/1/2021 at 1:34 pm, Licensed Nurse (LN) A notified the nurse practitioner of Resident 99's refusal of medications for three days. On 9/5/2021 at 6:49 am, Registered Nurse (RN) M documented on night shift Resident 99 continually and loudly yelled for the first five hours of the shift (night shift started at 10:15 pm). Resident 99 was unable or unwilling to verbalize what might be causing distress. Resident declined to ingest Tylenol (mild pain) after previously nodding her head in agreement that she was in pain and said she would accept the Tylenol. Resident unable to pin point locate or describe the pain. Since this was the first time in five months this RN M has observed any such behavior from this resident, she is being put on alert charting (72 hours) for an appropriate temporary monitoring. There was no physician notification, alert charting, nursing progress note, or Interdisciplinary Team (IDTgroup of health care disciplines that discuss resident care needs) documentation found in the record from 9/5/2021 to 9/8/2021 about the change in condition for Resident 99. A review of an event (notes about changes in resident condition) summary list from 1/1/2021 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 12 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/30/2021, indicated there were no changes in condition documented for Resident 99's change in pain and right leg circulation (purple to black color). Three days later, on 9/08/2021 at 10:04 pm, RN D documented Resident 99 had a purple discoloration on the right foot. Medical Director A was notified and received order to send resident to the emergency room (ER) for evaluation. A request was made for shower sheets (used by CNA [Certified Nursing Assistants] staff to document skin issues) or stop and watch early warning tool (CNAs use to identify any changes in residents) both forms are given to licensed nursing for evaluation. There were no documents received for July-September 2021. A review of the Medication Administration Record (MAR) for September 2021, indicated Resident 99 had pain on 9/4/2021, of a three (mild) of 10 on a pain scale (0 no pain, 1-2 least pain, 3-4 mild pain, 5-6 moderate pain, and 7-10 severe to very severe) on night shift (NOC), had a pain level of 5 (moderate) on 9/5/2021 on evening shift, and a pain level of 2 (mild) on 9/5/2021 NOC shift. Tylenol was given on 9/5/2021 at 3:49 am. Tylenol was given only one time in September 2021 for pain. A review of Resident 99's physician order dated 6/29/2018, indicated Tylenol 650 milligrams as needed for generalized body pain mild to moderate every eight hours. There were no other pain medication orders found in the record for severe pain until Resident 99's return to the facility on 9/15/2021. A review of Resident 99's care plan history from 2/01-9/30/2021, indicated no resident specific interventions for peripheral vascular disease and pain. There were new care plan interventions for pain upon her readmission on [DATE]. A review of a resident progress notes for hospital stay from 9/8/2021 to discharge on [DATE] indicated: 9/8/2021- Hospital course patient presented with a chief complaint of right foot discoloration that began an unknown time ago. Patient was non verbal. Emergency medical services reported the facility noted her right foot to appear discolored with perceived pain. 9/9/2021-facility was called and spoke with a nurse who stated Resident 99 non verbal and mostly sleeps, the discoloration was noted yesterday afternoon, the resident has progressively declined often refusing food and medications for the past several months. 9/10/2021- Resident 99 remains non verbal her right foot is blue/purple up the shin. 9/11/2021- Resident 99 had amputation above knee on right side due to severe vascular disease and a deep vein thrombosis (blood clot). Resident 99 was discharged back to the facility on 9/15/2021, with physician orders including Morphine (strong pain medication) for severe pain and hospice (end of life care). A review of a progress note dated 9/27/201 at 6:30 am, Resident 99 had no vital signs, hospice and responsible party were notified. A review of the point of care history for Resident 99's bathing activity from 6/1 to 9/8/2021, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 13 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 99 had bathed four times a month. Facility did not evaluate the reason for shower refusals and reduced the opportunities for skin checks. During an interview on 10/12/2021 at 2:25 pm, CNA N stated Resident 99 was hard to understand and never heard her talk, she made noises or groaned when moved or repositioned. CNA N stated Resident 99 often refused showers. CNA N stated Resident 99's legs would get very purple when she sat up in her wheelchair too long. CNA N stated her wheelchair did not have any leg lifts or special fitting to allow legs to be elevated. CNA N stated she had not told anyone about her purple legs. CNA N worked the day shift on 9/08/2021, when Resident 9 went to the hospital. CNA N stated Resident 99 was yelling and bottom of her right foot was black and her leg was dark purple. CNA N stated yelling, moaning and refusing care could be a sign of pain. CNA N stated she changed her process of looking at skin since this happened, she always removes socks now. CNA N stated the facility had not had an inservice about the incident, she did not want this to happen again so she made changes on how she monitors residents skin. During an interview on 10/12/2021 at 2:40 pm, CNA O stated Resident 99 was quiet although would moan at time while in bed or in wheelchair. During an interview on 10/12/2021 at 2:50 pm, Licensed Nurse (LN) A stated Resident 99 often refused showers and medications. LN A stated nursing depends on CNAs for skin check reports on shower days. LN A stated she does not always receive the completed shower sheets from the CNAs. LN A stated their treatment nurse was also checking the skin weekly although they have been without one for awhile. LN A stated Resident 99 does moan and has Tylenol for pain. LN A stated the pain assessment in the record should include location, and a description for non verbal signs such as grimacing. During an interview on 10/14/2021 at 12:30 pm, RN M stated he did not know Resident 99 very well. RN M confirmed on 9/5/2021, Resident 99 seemed different so he asked the Certified Nursing Assistants (CNAs) who care for resident, if the hours of yelling were normal for her. RN M stated the CNAs stated it was not normal for Resident 99 to loudly yell for that long. RN M confirmed he did not notify the physician of the change, did not assess Resident 99 for skin issues. RN M stated she could not verbally communicate and did not know where her pain could be coming from. RN M confirmed the details of his nursing progress notes, that Resident 99 was able to nod that she was in pain just did not know where. RN M stated she refused the Tylenol when offered. RN M stated I do not know where to document a change of condition, whether in an event note or a tablet at the nursing station, he just verbally told the day shift nurse about the events that night. During an interview on 10/14/2021 at 2 pm, the Director of Staff Development (DSD) confirmed that Resident 99's right foot was purple on the bottom and top of her foot and cool to the touch on 9/8/2021, the day she was transferred to the hospital. DSD confirmed she did not make an assessment note in the record. During an interview on 10/19/2021 at 11 am, Paramedic (PM) explained they were called to the facility for an emergency. PM stated they found Resident 99 in bed, non verbal, with a couple of employees. PM stated Resident 99's right leg was exposed, looked atrophied (wasted) from the mid calf down her was dark purple to her foot. PM could not find a pulse in her right foot. PM interview the nursing staff, nurses and nursing assistants and no one could state how long this had been going on, if this was a new or old injury. PM stated Resident 99 would scream out in pain and was guarded if the right leg was approached. PM stated this type of issue does not happen overnight, takes time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 14 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm During a interview on 10/19/2021 at 11:40 am, a family member (FM) stated they were present when the emergency services arrived. FM stated Resident 99's right leg dark purple and her right ankle turning black. FM stated when Resident 99 was touched she would scream out in pain. FM stated Resident 99 had been non verbal since earlier this year, January 2021, when she had COVID19. FM stated Resident 99 had stopped participating in her favorite activity Bingo around the same time. Residents Affected - Few During an interview on 10/14/2021 at 10:30 am, the Director of Nursing (DON) recalled observing Resident 99 on 9/8/2021 (day sent to the ER) sitting in her wheelchair in the hallway making humming and moaning noises. DON asked nursing staff if this was unusual for this resident and they responded she does this. DON confirmed her expectation for a change of condition of any resident was for the LNs to assess the resident from head to toe, notify the physician, initiate an event in the electronic medical record and make a progress note about the assessment findings. DON stated the expectation of the LN was to document a weekly progress note about skin checks. DON stated no LN chart audits for pain, skin, or activities of daily living (showers, skin issues) were happening due to having no medical record staff for a few months. DON confirmed they did not have a desk or charge nurse and a treatment nurse (wound care and skin checks) for a few months as well. DON confirmed there was no alert or event documentation done for Resident 99 found in the record. DON confirmed the screaming, moaning and refusals of medications, and showers could be a sign of pain. DON confirmed the pain assessments for Resident 99 did not include non verbal signs of severe pain. DON confirmed the were no care plans that addressed Resident 99's risk factors and interventions related to her peripheral vascular disease and pain. DON was not made aware of the change of condition that started for Resident 99 on 9/5/2021. A review of a facility policy titled Prevention of Pressure Ulcers/Injuries/Skin breakdown Clinical protocol revised July 2017, indicated purpose is to provide information regarding identification of pressure ulcer/injury risk factors. Risk assessment conduct a comprehensive skin assessment of areas of impaired circulation due to pressure of positioning or medical devices. Inspect skin when performing activities of daily living. Inspect pressure points buttocks and heels. Evaluate, report and document potential changes in the skin. Review the intervention strategies for effectiveness on an ongoing basis. A review of a facility policy titled Administering Pain Medications revised October 2017, indicated pain management is the process of alleviating residents pain to a level that is acceptable to the resident. Be familiar with non verbal signs of pain for example: groaning, crying, screaming, facial expressions of grimacing and frowning, changes in skin color, behaviors such as resisting care, irritability, decreased participation in activities, guarding, and loss of appetite. Wong-Baker faces pain rating scale for non verbal cognitively impaired (dementia) residents. Conduct an interview or observation for resident pain status, for severity, location, verbal and nonverbal signs of pain, general condition of resident and if pain has worsened. Evaluate the effectiveness of the non pharmacological (medication) interventions. Report other information in accordance with facility policy and standards of practice. Document the medication, dose, route, severity, and results of the medication. A review of the facility's contracted pharmacy's ( the pharmacy that provided and supported the facility's IV therapy) policy, dated 2020, section 12, titled Intravenous Therapy Peripherally Inserted Central Catheter (PICC) procedures indicated: A. Care of peripherally inserted central catheter (PICC) purpose is to provide standard for the safe maintenance of the PICC catheter in order to reduce the risk of infection or dislodging. 5. Excess catheter (the length of the PICC catheter that is exposed outside of the arm) shall have been measured, coiled and secured to injection site near the antecubital fossa(inner aspect of the elbow). Remeasure catheter if slippage of catheter is suspected for any reason. 9. Attending facility IV staff shall be knowledgeable in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 15 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care of PICC lines. 11. Caution is needed to change dressing without disturbing excess catheter. 14. Use a 10 ml (cc) or larger syringe for flushing catheter to reduce pressure on the catheter and prevent rupture of catheter. 15. When catheter is not in use, flush daily with 10 ml (cc) sodium chloride 0.9%. A review of the facility's policy and procedure titled, Central Venous Catheter Dressing Changes, dated April 2016, indicated to observe insertion site and surrounding area for complication. Document location and objective description of insertion site and to report any signs and symptoms of complications to physician, supervisor, and oncoming shift. 2a. A review of Resident 20's medical record indicated Resident 20 was re-admitted to this facility on 8/10/2021 after a hospital stay. Her diagnosis included septic (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) arthritis of left knee. Resident 20's brief interview for mental status (BIMs) score was 15, indicating Resident 20 was cognitively intact. During a review of Resident 20's nursing progress notes dated 8/10/2021, at 2:14 PM, Licensed Vocational Nurse (LN) E noted that Resident 20 had a PICC line in the right upper arm. There was no mention of the measurments of the excess of the PICC line. During a review of Resident 20's nursing progress notes dated 8/10/2021, at 4:13 PM, LN M noted that Resident 20 had an order for Vancomycin (An antibiotic medication used to treat complicated bacterial infections) intravenously (IV) every 12 hours thru the PICC line. During a review of Resident 20's medication administration record (MAR) on 9/2/2021, on the pm shift, the record indicated, RN I changed the PICC line dressing. There were no nursing progress notes of the dressing change, condition of the site or measurements of the exposed PICC line. During a review of Resident 20's nursing progress notes dated 9/7/2021, (5 days after the dressing change) at 3:09 PM, RN N noted due to residents' IV occlusion (a blockage, unable to use) a new order received per [physician's name] for slow Activase (a de-clotting medication) 2 mg IV fuse(flush) via PICC line my(may) repeat X 1. The order and information were faxed to the facility's PICC consultants to perform the task of de-clotting the PICC line. There was no documentation of how much of the PICC line was exposed. During a review of Resident 20's nursing progress notes dated 9/7/21 at 4:45 PM, RN N stated [Name of IV company] staff informed this nurse that Activase 2 mg may not work due to tip of IV (PICC) displacement. Received verbal order from, [physician's name] to replace PICC line to continue vancomycin IV due to non-patency of PICC. During a review of Resident 20's IV consultant's comment notes dated 9/7/2021, RN O noted PT (patient) alert and oriented. RN O had initially arrived to de-clot PICC, but he noted that since the PICC line had gone from its original exposed length of 2 cm to 13 cm,(a difference of 11 cm that had been pulled out of the arm) , the PICC tip was not in a favorable position to leave in place. De-clot was canceled in lieu of PICC replacement. A new PICC was placed by the nurse consultant. During a concurrent interview and observation on 10/11/21, at 11:03 AM, Resident 20 was lying in bed with her right arm uncovered. There was an IV showing in her right antecubital (the surface of the arm in front of the elbow). Resident 20 verified that it was a PICC line and that they used it for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 16 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm some antibiotics. She stated, when the staff would change the dressing site, they would pull on the PICC line and pull some of the catheter out and it had to be replaced. During an interview on 10/12/2021, at 10:00 am, with the DON, the DON verified that there were no measurements, from her staff, of the exposed length of the PICC line during their assessments. Residents Affected - Few During an interview on 10/14/2021, at 3:10 pm, with the DON, the DON verified that she did not know the PICC line had been pulled out to 13 cm of exposed line and the that the tip of the PICC line was not in a favorable position for infusion. She stated, that never happened. During an interview on 10/18/2021 at 1:04 pm with RN P, director of the facility's IV consultant company, she verified the notes from her staff (RN O) from 9/7/2021 and stated that sometimes a PICC will get pulled out with dressing changes by the nurses. We have no way of knowing when a PICC is pulled out, so we rely on the nurses at the facility to let us know. When we put in a PICC we leave our documentation of the measurements and type of catheter with the facility and it becomes the facilities line and they have to let us know when there is a problem. We expect them to put our documentation in the chart to be referred to. If you were a prudent nurse, you would check the measurements with assessments. 2b. During a review of Resident 20's MAR dated 9/13/2021, at 9:00 AM, LN A noted that the Vancomycin 1000 mg was not administered due to a clogged IV (PICC) line. During a review of Resident 20's nursing progress notes dated 9/13/2021, at 10:11 AM, by LN A, she indicated, due to resident's IV line occlusion, new order received for Activase 2 mg, 1 dose in clogged lumen may repeat x 1. During a review of Resident 20's IV consultant's comment notes by RN Q, dated 9/13/21, at 1:20 PM, RN Q indicated arrived for de-clot, needless connector missing (the cap that maintans pressure in the PICC line) on arrival, visible blood in line, Curo (a disinfecting cap for needless connectors not the required cap that provides pressure) attached directly to catheter. PICC removed. Instructions given on PICC care and Nurse sup(supervisor) notified of situation During a review of Resident 20's nursing progress notes dated 9/13/2021, at 2:46 PM, RN R noted Replace PICC line due to compromised line, No cap present. During a review of Resident 20's nursing progress note dated 9/13/2021, at 7:04 PM, RN R noted Resident missed two doses (of vancomycin) due to clogged PICC line. During an interview on 10/14/2021, at 10:46 AM, Resident 20 indicated that the PICC had to be changed twice, close to together because they pulled it out and it clotted. I did miss some vancomycin treatments because of it. During an interview on 10/14/2021, at 3:10 pm, with the DON, the DON was unaware that the needless connector was missing on 9/13/21. She stated she was not informed of these issues. She verified that some IV therapy had been misssed. During an interview on 10/18/2021 at 1:04 pm with RN P, director of the facility's IV consultant company, she verified that on 9/13/2021 when the PICC nurse came to de-clot the line she found the needless injection cap missing and there was blood noted in the line. This cap holds the pressure on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 17 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the line and keeps things from getting in the line. If there is no pressure in the line, then anything can get up in there and there is a high chance of infection. The PICC nurse documented that she educated the nursing supervisor about this issue. Due to the cap missing the PICC needed to be changed. 2c. During a review of Resident 20's transcribed Physician orders dated, 8/11/2021, an order written indicated: IV-Flush 5cc (mL) of normal saline before and after medication administration. A review of a document in Resident 20's medical record titled [IV consultant company's name]Nursing Care for PICC Lines, dated 9/7/21, Flushing guidelines were to flush with 10 mL (cc) of normal saline (NS). During an interview on 10/12/2021, at 9:47 AM, with the DSD, she verified that Resident 20 had a PICC line and the orders for the PICC line were to Flush IV with 5 cc of normal saline before and after medication administration. DSD indicated that she was not aware what the standard care was for a PICC line or how much it should be flushed with. The DSD indicated that she did not do anything with PICC lines. The DSD indicated that she or the DON were responsible to verify Physician's orders. DSD indicated that she may have verified these orders. During an interview on 10/12/2021, at 10:00 am, with the DON, the DON verified that a PICC line should be flushed with 10 cc of normal saline. She verified the order was wrong. A review of the facilities policy titled Central Venous and Midline Catheter Flushing dated April 2016, the policy indicated the flushing technique was to use a syringe barrel size of 10 mL or greater when flushing an infusion catheter to avoid excessive pressure inside the catheter, to prevent potential rupture of the catheter, and to prevent dislodgement of clots. Flushing to maintain patency of catheter: 3. Connect 10 mL barrel size syringe containing saline (amount as ordered or per facility protocol) to catheter via needleless connection device 5. Slowly administer appropriate amount of saline flush (per pharmacy or facility protocol) . 2d. During a review of Resident 20's nursing progress notes dated, 9/30/2021 at 4:01 PM, RN D noted she received a written order from the doctor to stop vancomycin IV on 9/30/2021. During a review of Resident 20's MAR dated 9/30/2021, the MAR verified the last dose of Vancomycin was on 9/30/2021. During a review of Resident 20's Physician orders dated, 10/2/2021, there was an order to discontinue IV flush and the monitoring of the IV site every shift for signs and symptoms of infections. During a review of Resident 20's nursing progress notes from 9/30/2021 thru 10/11/2021, (11 days) there were no notes in the nurse's progress notes about the PICC that remained in her right upper arm. A review of Residents MAR, that was generated on 10/13/2021, at 7:14 AM, for the month of October 2021, verified that the PICC was flushed with 5cc and monitored for infection on days 10/1/2021 and 10/2/2021 and there was a dressing change on 10/7/21. There were no flushes or monitoring documented on the MAR from the 3rd thru the 11th of October. (9 days). During an interview on 10/12/2021, at 9:47 AM, with the DSD, The DSD verified that Resident 20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 18 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few currently had a PICC line in and the flush and monitoring order had been discontinued on 10/2/202. (10 days before the PICC was removed). During a review of Resident 20's physician order dated 10/12/2021 an order was written after 2:30 PM to discontinue the PICC Line. The order was 9 days after the last documented flush or monitoring for signs and symptoms of infections of the PICC line. The PICC was documented as removed on 10/12/2021 during the pm shift as verified per the MAR. 2e. During a review of three RN's competency skills checklist, two of three RN's, (RN I and RN D) checklists were incomplete due to missing evaluation dates and associate signatures. Both RN's were hired on 7/15/2020 and their training was initiated a year later, 7/15/2021. RN I had no recorded date for the training of care and maintenance for central lines and PICC lines. During an interview on 10/14/2021, at 10:18 AM, with RN J, she indicated that she started working in August of 2021. She trained for about a month. She denied using any check off list for her training. She stated she was trained by a bunch of different nurses. Some were on call nurses. She stated there was no way of knowing if some training was missed because there was no paperwork involved and no check off list provided to her to keep track of what she had learned. I asked her what she knew about PICC lines and she stated that they go into the artery (the correct place was the vein) and it's a quick way to deliver medicine. She confirmed that at times she was assigned to take care of Resident 20's PICC line during her shift. She mentioned that she flushed the line with I believe it is 100 cc of saline. She denied ever measuring the exposed tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 19 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one of three residents (Resident 10) from accidental hazards when it did not follow its policy for resident safety. This resulted in a resident's fall and the potential for further falls, injury, illness and death. Refer to tag F658. Findings: Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE] with diagnoses which included acute respiratory disease (onset of a breathing problem), multiple sclerosis (a disease that attacks muscle coordination), Alzheimer's, dementia, and a history of falling. A review of the facility's record titled Safety and Supervision of Residents dated January 2011 indicated, Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A (Quality Assessment and Assurance) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. A review of that same document indicated, Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS (Minimum Data Set, a Center for Medicare/Medicaid services clinical assessment tool). The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. A review of the record titled Resident Progress Notes dated 9/22/2021 for Resident 10, indicated that on 9/21/2021, Resident had an unwitnessed fall around 2030 [8:30 PM]. Resident found laying down on the floor near the bed. Upon asking resident, stated she was trying to sit on the wheelchair, and No injuries, no complaints of pain . The record indicated, when resident is out of bed, place bed in high position to deter resident from attempting to transfer self back in bed . On 10/11/2021 at 12:05 PM, Resident 10's bed was observed to be in a high position and no floor mats were noted. While interviewing Resident 10 on 10/13/2021 at 3:20 PM, the resident was observed in bed in high position with no fall mats in the room. Resident 10 was wearing fuzzy colorful streetwear socks with no apparent non-slip bottoms. Resident 10 stated that the socks were brought into the facility by a family member. She stated, No my bed is not in the low position. I can barely get in and out of it. Did it contribute to my fall [on 9/22/2021]? Yes! The floor is slippery and I slide underneath the bed! In an interview and concurrent observation of Resident 10's bed on 10/13/2021 03:25 PM, RN I (Registered Nurse) stated, Resident 10 is supposed to have her bed in the low position. It is not in the low position. I don't know why the bed would need to be in the high position. The bed should be flat. RN I was unaware of the care plan's indication of the need for fall mats, stating, [Resident 10] was not supposed to have a fall mat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 20 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/13/2021 at 3:50PM, CNA K (Certified Nursing Assistant) stated, Yes, [Resident 10] is supposed to have her bed in low position. She is supposed to have mats on the floor. I think we have them. The bed could be lower. In an interview on 10/13/2021 at 3:24 PM, DSD (Director of Staff Development) was shown the care plan indicating the need to keep the bed in the lowest position. I see that in the care plan. It's a mistake. It probably carried over from an old order that was DC'd [discontinued] Resident 10's bed continued to be observed to be in the highest position on 10/14/2021 at 8:30 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 21 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete pain management assessment, develop and implemented a comprehensive person-centered plan for non verbal pain for one of four residents (Resident 99). As a result, Resident 99 suffered unnecessary severe pain from a blot clot that required surgical intervention for a right above knee amputation. Residents Affected - Some Findings: A review of a facility policy titled, Administering Pain Medications, revised October 2017, indicated pain management is the process of alleviating residents pain to a level that is acceptable to the resident. Be familiar with non verbal signs of pain for example: groaning, crying, screaming, facial expressions of grimacing and frowning, changes in skin color, behaviors such as resisting care, irritability, decreased participation in activities, guarding, and loss of appetite. Wong-Baker faces pain rating scale for non verbal cognitively impaired (dementia) residents. Conduct an interview or observation for resident pain status, for severity, location, verbal and nonverbal signs of pain, general condition of resident and if pain has worsened. Evaluate the effectiveness of the non pharmacological (medication) interventions. Report other information in accordance with facility policy and standards of practice. Document the medication, dose, route, severity, and results of the medication. A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (reduced blood flow), chronic venous hypertension with stasis ulcers (high blood pressure in legs causing wounds) and dementia. Resident 99 was unable to make her own healthcare decisions. A review of a quarterly social services note dated 8/26/2021, indicated Resident 99 was only alert to self with intermittent confusion and lack of orientation. Resident 99 was unable to complete the brief interview for mental status or mood interview. A review of the Resident 99's nursing progress notes indicated: On 9/1/2021 at 1:34 pm, Licensed Nurse (LN) A notified the nurse practitioner of Resident 99's refusal of medications for three days. On 9/5/2021 at 6:49 am, Registered Nurse (RN) M documented on night shift Resident 99 continually and loudly yelled for the first five hours of the shift (night shift started at 10:15 pm). Resident 99 was unable or unwilling to verbalize what might be causing distress. Resident declined to ingest Tylenol (mild pain) after previously nodding her head in agreement that she was in pain and said she would accept the Tylenol. Resident unable to pin point locate or describe the pain. Since this was the first time in five months this RN M has observed any such behavior from this resident, she is being put on alert charting (72 hours) for an appropriate temporary monitoring. There was no physician notification, alert charting, nursing progress note, or Interdisciplinary Team (IDTgroup of health care disciplines that discuss resident care needs) documentation found in the record from 9/5/2021 to 9/8/2021 about the change in condition for Resident 99. Three days later, on 9/08/2021 at 10:04 pm, RN D documented Resident 99 had a purple discoloration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 22 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the right foot. Medical Director A was notified and an order was received to send resident to the emergency room (ER) for evaluation. A review of Resident 99's physician order dated 6/29/2018, indicated Tylenol 650 milligrams as needed for generalized body pain mild to moderate every eight hours. There were no other pain medication orders found in the record for severe pain until Resident 99's return to the facility from the hospital on 9/15/2021. A review of Resident 99's care plan history from 2/01 to 9/30/2021, indicated no resident specific interventions for pain. There were new care plan interventions for pain upon her readmission on [DATE]. A review of a resident progress notes for hospital stay from 9/8/2021 to discharge on [DATE] indicated: 9/8/2021- Hospital course patient presented with a chief complaint of right foot discoloration that began an unknown time ago. Patient was non verbal. Emergency medical services reported the facility noted her right foot to appear discolored with perceived pain. 9/9/2021-facility was called and spoke with a nurse who stated Resident 99 non verbal and mostly sleeps, the discoloration was noted yesterday afternoon, the resident has progressively declined often refusing food and medications for the past several months. 9/10/2021- Resident 99 remains non verbal her right foot is blue/purple up the shin. 9/11/2021- Resident 99 had amputation above knee on right side due to severe vascular disease and a deep vein thrombosis (blood clot). Resident 99 was discharged back to the facility on 9/15/2021, with physician orders including Morphine (strong pain medication) for severe pain and hospice (end of life care). A review of the point of care history for Resident 99's bathing activity from 6/1 to 9/8/2021, Resident 99 had bathed four times a month. Facility did not evaluate the reason for shower refusals and reduced the opportunities for skin checks. During an interview on 10/12/2021 at 2:25 pm, Certified Nursing Assistant (CNA) N stated Resident 99 was hard to understand and never heard her talk, she made noises or groaned when moved or repositioned. CNA N stated Resident 99 often refused showers. CNA N stated Resident 99's legs would get very purple when she sat up in her wheelchair for too long. CNA N stated her wheelchair did not have any leg lifts or special fitting to allow legs to be elevated. CNA N stated she had not told anyone about Resident 99's purple legs. CNA N worked the day shift on 9/08/2021, when Resident 9 went to the hospital. CNA N stated Resident 99 was yelling and the bottom of her right foot was black and her leg was dark purple. CNA N stated yelling, moaning and refusing care could be a sign of pain. During an interview on 10/12/2021 at 2:40 pm, CNA O stated Resident 99 was quiet although would moan at time while in bed or in wheelchair. During an interview on 10/12/2021 at 2:50 pm, Licensed Nurse (LN) A stated Resident 99 often refused showers and medications. LN A stated nursing depends on CNAs for skin check reports on shower days. LN A stated she does not always receive the completed shower sheets from the CNAs. LN A stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 23 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some their treatment nurse was also checking the skin weekly although they have been without one for awhile. LN A stated Resident 99 does moan and has Tylenol for pain. LN A stated the pain assessment in the record should include location, and a description for non verbal signs such as grimacing. During an interview on 10/14/2021 at 12:30 pm, RN M stated he did not know Resident 99 very well. RN M confirmed on 9/5/2021, Resident 99 seemed different so he asked the Certified Nursing Assistants (CNAs) who care for resident, if the hours of yelling were normal for her. RN M stated the CNAs stated it was not normal for Resident 99 to loudly yell for that long. RN M confirmed he did not notify the physician of the change, and did not assess Resident 99 for skin issues. RN M stated Resident 99 could not verbally communicate and did not know where her pain could be coming from. RN M confirmed the details of his nursing progress notes, that Resident 99 was able to nod that she was in pain just did not know where. RN M stated she refused the Tylenol when offered. RN M stated I do not know where to document a change of condition, whether in an event note or a tablet at the nursing station, he just verbally told the day shift nurse about the events that night. A review of the Medication Administration Record (MAR) for September 2021, indicated Resident 99 had pain on 9/4/2021, of a three (mild) of 10 on a pain scale (0 no pain, 1-2 least pain, 3-4 mild pain, 5-6 moderate pain, and 7-10 severe to very severe) on night shift (NOC), had a pain level of 5 (moderate) on 9/5/2021 on evening shift, and a pain level of 2 (mild) on 9/5/2021 NOC shift. Tylenol was given on 9/5/2021 at 3:49 am. Tylenol was given only one time in September 2021 for pain. During an interview on 10/19/2021 at 11 am, Paramedic (PM) explained they were called to the facility for an emergency. PM stated they found Resident 99 in bed, non verbal, with a couple of employees at the bedside. PM stated Resident 99's right leg was exposed, looked atrophied (muscle wasted) from the mid calf down and was dark purple to her foot. PM could not find a pulse in her right foot. PM interviewed the nursing staff, nurses and nursing assistants and no one could state how long this had been going on, or if this was a new or old injury. PM stated Resident 99 would scream out in pain and was guarded if the right leg was approached. PM stated this type of issue does not happen overnight, it takes time. During a interview on 10/19/2021 at 11:40 am, a family member (FM) stated they were present when the emergency services staff arrived. FM stated Resident 99's right leg was dark purple and her right ankle was turning black. FM stated when Resident 99 was touched she would scream out in pain. FM stated Resident 99 had been non verbal since earlier this year, January 2021, when she had COVID-19. FM stated she stopped going to her favorite activity bingo, around this time as well. During an interview on 10/14/2021 at 10:30 am, the Director of Nursing (DON) recalled observing Resident 99 on 9/8/2021 (the day Resident 99 was sent to the ER) sitting in her wheelchair in the hallway making humming and moaning noises. DON asked nursing staff if this was unusual for this resident and they responded she does this. DON confirmed the screaming, moaning and refusals of medications, and showers was a sign of pain. DON confirmed the pain assessments for Resident 99 did not include non verbal signs of severe pain. DON confirmed the were no care plans that addressed Resident 99's risk factors related to her peripheral vascular disease and pain. DON was not made aware of the change of condition that started for Resident 99 on 9/5/2021. DON confirmed her expectation for a change of condition of any resident was for the LNs to assess the resident from head to toe, notify the physician, initiate an event in the electronic medical record and make a progress note about the assessment findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 24 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 29 was admitted to the facility on [DATE] with diagnoses that included; Multiple Sclerosis (MS-a disease where the immune system eats away at the protective covering of the nerves and disrupts the communication from the brain to the body), pressure ulcers, Schizoaffective disorder (a combination of depression, delusions, hallucinations, and mania- high energy periods), Mood disorder, seizures, anxiety, chronic pain syndrome, neurogenic bladder (neurological damage to a bladder which causes it not to empty and requires a tube to drain the urine) and a suprapubic catheter (a soft tube that is inserted directly into the bladder through an opening in the lower abdomen to drain urine). On 10/11/21 at 3:16PM, during an observation and interview with Resident 29, a 60 milliliter (ml) syringe in a plastic bag was taped to the foot of her bed. Resident 29 had no knowledge of why the syringe was there. She was observed to have a urinary catheter drainage bag with clear yellow urine hanging from the bed frame. Resident 29 stated that she had MS which is why she had a suprapubic catheter. A review of Resident 29's Physician's Orders for 10/2021, showed that on 10/6/2021 an order was written for Acetic Acid (a vinegar solution commonly used to irrigate bladder catheters and prevent blockage from matter) 0.25 percent (%), Irrigate supra pubic catheter with 30ml (milliliters) BID (twice a day) due to excessive sediment. A review of Resident 29's Treatment Administration Record (TAR) reflected that the original physician's order was obtained on 7/15/2020 and then revised on 10/6/21, for the bladder irrigation. There were no additional directions or instructions on performing this procedure. Nothing in the Physician's Orders or TAR indicated that the nurse should be using sterile technique and sterile supplies. On 10/13/21 at 9:50AM, LN (Licensed Nurse) B was interviewed. LN B was asked to describe how she performed the bladder irrigation on Resident 29. LN B took the Acetic Acid 0.25% from her treatment cart. She was asked if the solution was sterile or non-sterile. She stated that she did not know and after reading the label determined that the solution was sterile. She then went to the supply room and showed the 60ml syringe that she used to draw up the Acetic Acid solution. When asked if the syringe was sterile, she did not know. The syringe was not sterile. LN B was asked how she created a sterile field for the procedure, she stated I don't. LN B then confirmed that the facility did not have sterile irrigation trays (a manufactured sterile tray of all supplies need to irrigate a catheter including the sterile drapes, syringe and sterile gloves) or sterile gloves available. LN B described that she disconnected the catheter tubing with gloved hands, cleaned the catheter tube with alcohol, drew up 30ml of Acetic Acid 0.25% that she had poured into a non-sterile cup and then irrigated the bladder with a non-sterile 60ml syringe. LN B stated that she was not aware that irrigating a bladder was a sterile procedure. LN B added, I only became the treatment nurse last week and I have not had any training, this is my first job. On 10/13/21 at 10:31AM, the Director of Nursing (DON) was interviewed. The DON stated that she was not aware that LN B had not been using sterile technique when irrigating Resident 29's suprapubic catheter. The DON stated, It should be done using sterile technique. A review of the facility's policy titled, Irrigation of Suprapubic Catheter undated, directed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 25 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 The purpose of a proper suprapubic catheter irrigation is to assist in ensuring that the resident's bladder is empty, reduce the chance of infection and keep the device functioning effectively. Level of Harm - Minimal harm or potential for actual harm Procedural Preparation Residents Affected - Some 4. Prepare the necessary equipment and supply; a. Disposable Irrigation set b. Gloves c. Sterile, normal saline solution or Acetic Acid 0.25% Solution d. Alcohol wipes Procedure 1. First, open the irrigation set, which includes a sterile irrigation tray and 60cc catheter tip syringe 2. Fill the tray with the saline or Acetic Acid 0.25% solution (Make sure that the sterility of the tray and solution is maintained, as this will prevent infection). 3 a. Resident 99's record was reviewed. On 9/5/2021 at 6:49 am, Registered Nurse (RN) M documented on night shift, Resident 99 continually and loudly yelled for the first five hours of the shift (night shift started at 10:15 pm). Resident 99 was unable or unwilling to verbalize what might be causing distress. Resident declined to ingest Tylenol (mild pain) after previously nodding her head in agreement that she was in pain and said she would accept the Tylenol. Resident unable to pin point locate or describe the pain. Since this was the first time in five months this RN M has observed any such behavior from this resident, she is being put on alert charting (72 hours) for an appropriate temporary monitoring. There was no physician notification, alert charting, nursing progress note, or Interdisciplinary Team (IDTgroup of health care disciplines that discuss resident care needs) documentation found in the record from 9/5/2021 to 9/8/2021 about the change in condition for Resident 99. A review of an event (notes about changes in resident condition) summary list from 1/1/2021 to 9/30/2021, indicated there were no changes in condition documented for Resident 99's change in pain and right leg circulation (purple to black color). Three days later, on 9/08/2021 at 10:04 pm, RN D documented Resident 99 had a purple discoloration on the right foot. Medical Director A was notified and an order was received to send Resident 99 to the emergency room (ER) for evaluation. A request was made for shower sheets (used by Certified Nursing Assistant (CNA) staff to document skin issues) or stop and watch early warning tool (CNAs use to identify any changes in residents) both forms are given to licensed nursing for evaluation. There were no documents received for July-September 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 26 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm A review of the Medication Administration Record (MAR) for September 2021, indicated Resident 99 had pain on 9/4/2021, of a three (mild) of 10 on a pain scale (0 no pain, 1-2 least pain, 3-4 mild pain, 5-6 moderate pain, and 7-10 severe to very severe) on night shift (NOC), had a pain level of 5 (moderate) on 9/5/2021 on evening shift, and a pain level of 2 (mild) on 9/5/2021 NOC shift. Tylenol was given on 9/5/2021 at 3:49 am. Tylenol was given only one time in September 2021 for pain. Residents Affected - Some A review of Resident 99's physician order dated 6/29/2018, indicated Tylenol 650 milligrams as needed for generalized body pain mild to moderate every eight hours. There were no other pain medication orders found in the record for severe pain until Resident 99's return to the facility on 9/15/2021. A review of Resident 99's care plan history from 2/01 to 9/30/2021, indicated no resident specific interventions for peripheral vascular disease and pain. There were new care plan interventions for pain upon her readmission on [DATE]. A review of a resident progress notes for hospital stay from 9/8/2021 to discharge on [DATE] indicated: 9/8/2021- Hospital course patient presented with a chief complaint of right foot discoloration that began an unknown time ago. Patient was non verbal. Emergency medical services reported the facility noted her right foot to appear discolored with perceived pain. 9/9/2021-facility was called and spoke with a nurse who stated Resident 99 non verbal and mostly sleeps, the discoloration was noted yesterday afternoon, the resident has progressively declined often refusing food and medications for the past several months. 9/10/2021- Resident 99 remains non verbal her right foot is blue/purple up the shin. 9/11/2021- Resident 99 had amputation above knee on right side due to severe vascular disease and a deep vein thrombosis (blood clot). Resident 99 was discharged back to the facility on 9/15/2021, with physician orders including Morphine (strong pain medication) for severe pain and hospice (end of life care). A review of the point of care history for Resident 99's bathing activity from 6/1/ to 9/8/2021, Resident 99 had bathed four times a month. Facility did not evaluate the reason for shower refusals. During an interview on 10/12/2021 at 2:25 pm, CNA N stated Resident 99 was hard to understand and never heard her talk, she made noises or groaned when moved or repositioned. CNA N stated Resident 99 often refused showers. CNA N stated Resident 99's legs would get very purple when she sat up in her wheelchair for too long. CNA N stated her wheelchair did not have any leg lifts or special fitting to allow legs to be elevated. CNA N stated she had not told anyone about her purple legs. CNA N worked the day shift on 9/08/2021, when Resident 9 went to the hospital. CNA N stated Resident 99 was yelling and bottom of her right foot was black and her leg was dark purple. CNA N stated yelling, moaning and refusing care could be a sign of pain. CNA N stated she changed her process of looking at skin since this happened, she always removes socks now. CNA N stated the facility had not had an inservice about the incident, she did not want this to happen again so she made changes on how she monitors residents skin. During an interview on 10/12/2021 at 2:40 pm, CNA O stated Resident 99 was quiet although would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 27 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 moan at time while in bed or in wheelchair. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/2021 at 2:50 pm, Licensed Nurse (LN) A stated Resident 99 often refused showers and medications. LN A stated nursing depends on CNAs for skin check reports on shower days. LN A stated she does not always receive the completed shower sheets from the CNAs. LN A stated their treatment nurse was also checking the skin weekly although they have been without one for awhile. LN A stated Resident 99 does moan and has Tylenol for pain. LN A stated the pain assessment in the record should include location, and a description for non verbal signs such as grimacing. Residents Affected - Some During an interview on 10/14/2021 at 12:30 pm, RN M stated he did not know Resident 99 very well. RN M confirmed on 9/5/2021, Resident 99 seemed different so he asked the Certified Nursing Assistants (CNAs), if the hours of screaming were normal for her. RN M stated the CNAs said it was not usual for Resident 99 to scream for that long. RN M confirmed he did not notify the physician of the change, and did not assess Resident 99 for skin issues. RN M stated Resident 99 could not verbally communicate and did not know where her pain could be coming from. RN M confirmed the details of his nursing progress notes, that Resident 99 was able to nod that she was in pain, just did not know where. RN M stated Resident 99 refused the Tylenol when offered. RN M stated I do not know where to document a change of condition, whether in an event note or a tablet at the nursing station, he just verbally told the day shift nurse about the events that night. During an interview on 10/14/2021 at 2 pm, the Director of Staff Development (DSD) confirmed that Resident 99's right foot was purple on the bottom and top of her foot and cool to the touch on 9/8/2021, the day she was transferred to the hospital. DSD confirmed she did not make an assessment note in the record. During an interview on 10/19/2021 at 11 am, Paramedic (PM) explained they were called to the facility for an emergency. PM stated they found Resident 99 in bed, non verbal, with a couple of employees at her bedside. PM stated Resident 99's right leg was exposed, looked atrophied (muscle wasted) and from the mid calf down was dark purple to her foot. PM could not find a pulse in her right foot. PM interview the nursing staff, nurses and certified nursing assistants and no one could state how long this had been going on and if this was a new or old injury. PM stated Resident 99 would scream out in pain and was guarded if the right leg was approached. PM stated this type of issue does not happen overnight, it takes time. During an interview on 10/19/2021 at 11:40 am, a family member (FM) stated they were present when the emergency services arrived. FM stated Resident 99's right leg was dark purple and her right ankle was turning black. FM stated when Resident 99 was touched she would scream out in pain. FM stated Resident 99 had been non verbal since earlier this year, January 2021, when she had COVID-19. FM stated Resident 99 had stopped participating in her favorite activity, bingo around the same time. During an interview on 10/14/2021 at 10:30 am, the Director of Nursing (DON) recalled observing Resident 99 on 9/8/2021 (the day Resident 99 was sent to the ER) sitting in her wheelchair in the hallway making humming and moaning noises. DON asked nursing staff if this was unusual for this resident and they responded she does this. DON confirmed her expectation for a change of condition of any resident was for the LNs to assess the resident from head to toe, notify the physician, initiate an event in the electronic medical record and make a progress note about the assessment findings. DON stated the expectation of the LN was to document a weekly progress note about skin checks. DON stated no LN chart audits for pain, skin, or activities of daily living (showers, skin issues) were happening due to having no medical record staff for a few months. DON confirmed they did not have a desk or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 28 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some charge nurse and a treatment nurse (wound care and skin checks) for a few months as well. DON confirmed there was no alert or event documentation done for Resident 99 found in the record. DON confirmed the screaming, moaning and refusals of medications, and showers could be a sign of pain. DON confirmed the pain assessments for Resident 99 did not include non verbal signs of severe pain. DON confirmed the were no care plans that addressed Resident 99's risk factors and interventions related to her peripheral vascular disease and pain. DON was not made aware of the change of condition that started for Resident 99 on 9/5/2021. A review of a facility policy titled Prevention of Pressure Ulcers/Injuries/Skin breakdown Clinical protocol revised July 2017, indicated purpose is to provide information regarding identification of pressure ulcer/injury risk factors. Risk assessment conduct a comprehensive skin assessment of areas of impaired circulation due to pressure of positioning or medical devices. Inspect skin when performing activities of daily living. Inspect pressure points buttocks and heels. Evaluate, report and document potential changes in the skin. Review the intervention strategies for effectiveness on an ongoing basis. A review of a facility policy titled Administering Pain Medications revised October 2017, indicated pain management is the process of alleviating residents pain to a level that is acceptable to the resident. Be familiar with non verbal signs of pain for example: groaning, crying, screaming, facial expressions of grimacing and frowning, changes in skin color, behaviors such as resisting care, irritability, decreased participation in activities, guarding, and loss of appetite. Wong-Baker faces pain rating scale for non verbal cognitively impaired (dementia) residents. Conduct an interview or observation for resident pain status, for severity, location, verbal and nonverbal signs of pain, general condition of resident and if pain has worsened. Evaluate the effectiveness of the non pharmacological (medication) interventions. Report other information in accordance with facility policy and standards of practice. Document the medication, dose, route, severity, and results of the medication. A review of a progress note dated 9/27/201 at 6:30 am, Resident 99 had no vital signs, hospice and responsible party were notified. 3 b. During an interview and observation on 10/11/2021, at 10:44 AM, with Resident 20, Resident 20 indicated there were open areas on her right upper leg that she scratched. Resident 20 stated she had had them for a long time (since March 2021) and that she put her own cream on them. Open red areas were noted to Resident 20's right upper thigh and she confirmed they were there. During a record review on 10/12/2021, at 9:55 AM of the facility's skin book, Resident's 20's most recent bed bath was on 10/4/2021 and there were no skin issues documented. During a record review on 10/13/2021, at 3:12 PM, by Licensed Vocational Nurse A (LN A), Resident 20's nursing weekly summary on 10/5/2021 and 10/12/2021 indicated Resident 20's skin was intact with no new skin issues. During an interview on 10/13/21, at 3:26 PM, with LN A, LN A verified she did nursing weekly summary's for the residents that included skin checks. She confirmed that she did the nursing weekly summary for Resident 20 yesterday. She confirmed that she did not actually look at Resident 20's skin and stated she would only look at her skin if Resident 20 reported something to her would. LN A confirmed that she did not look at Resident 20's skin yesterday with her nursing weekly summary. LN A verified that the weekly summary stated the skin was intact and no new skin issues. LN A was unaware that Resident 20 had open sores on her right upper leg. LN A stated the treatment nurse would have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 29 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 looked at Resident 20's skin. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/13/21, at 3:55 PM, with treatment nurse LN B, she indicated that she did not look at Resident 20's skin. She stated she does not do the skin checks for the nurses, they do their own skin checks on the weekly summaries. Residents Affected - Some During a review of Resident 20's revised care plan dated 10/12/2021 there was a skin care plan with interventions to monitor any signs of skin breakdown and weekly skin checks. A review of a facility policy titled Prevention of Pressure Ulcers/Injuries/Skin breakdown Clinical protocol revised July 2017, indicated evaluate, report and document potential changes in the skin. Review the intervention strategies for effectiveness on an ongoing basis Based on observation, interview, and record review the facility failed to ensure that nursing staff possessed the competencies and skill set necessary to provide nursing care for 3 of 12 sampled residents (Residents 20, 29 and 99) when: 1. Nursing staff did not have sufficient knowledge to appropriately assess and manage a PICC line for Resident 20 when a Peripherally Inserted Central Catheter (PICC) (a medical device that was placed into a large vein to allow access to the bloodstream) clotted two times, the tip of the PICC was not in a favorable position for IV therapy to be administered, two doses of antibiotic therapy were missed, the PICC line cap was missing, and physcian orders for catheter flush was incorrect; 2. Nursing staff did not have sufficient knowledge of sterile bladder irrigation technique for Resident 29; and 3. Nursing staff failed to do skin assessments for Resident 99 and Resident 20. Findings: 1. A review of the facility's contracted pharmacy's ( the pharmacy that provided and supported the facility's IV therapy) policy, dated 2020, section 12, titled Intravenous Therapy Peripherally Inserted Central Catheter (PICC) procedures indicated: A. Care of peripherally inserted central catheter (PICC) purpose is to provide standard for the safe maintenance of the PICC catheter in order to reduce the risk of infection or dislodging. 5. Excess catheter (the length of the PICC catheter that is exposed outside of the arm) shall have been measured, coiled and secured to injection site near the antecubital fossa(inner aspect of the elbow). Remeasure catheter if slippage of catheter is suspected for any reason. 9. Attending facility IV staff shall be knowledgeable in the care of PICC lines. 11. Caution is needed to change dressing without disturbing excess catheter. 14. Use a 10 ml (cc) or larger syringe for flushing catheter to reduce pressure on the catheter and prevent rupture of catheter. 15. When catheter is not in use, flush daily with 10 ml (cc) sodium chloride 0.9%. A review of the facility's policy and procedure titled, Central Venous Catheter Dressing Changes, dated April 2016, indicated to observe insertion site and surrounding area for complication. Document location and objective description of insertion site and to report any signs and symptoms of complications to physician, supervisor, and oncoming shift. 1b. A review of Resident 20's medical record indicated Resident 20 was re-admitted to this facility on 8/10/2021 after a hospital stay. Her diagnosis included sepsis (a potentially life-threatening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 30 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some condition that occurs when the body's response to an infection damages its own tissues) and arthritis of left knee. Resident 20's brief interview for mental status (BIMs) score was 15, indicating Resident 20 was cognitively intact. During a review of Resident 20's nursing progress notes dated 8/10/2021, at 2:14 PM, Licensed Vocational Nurse (LN) E noted that Resident 20 had a PICC line in the right upper arm. There was no mention of the measurments of the excess of the PICC line. During a review of Resident 20's nursing progress notes dated 8/10/2021, at 4:13 PM, LN M noted that Resident 20 had an order for Vancomycin (An antibiotic medication used to treat complicated bacterial infections) intravenously (IV) every 12 hours through the PICC line. During a review of Resident 20's medication administration record (MAR) on 9/2/2021, on the pm shift, the record indicated, RN I changed the PICC line dressing. There were no nursing progress notes of the dressing change, condition of the site or measurements of the exposed PICC line. During a review of Resident 20's nursing progress notes dated 9/7/2021, (5 days after the dressing change) at 3:09 PM, RN N noted due to residents' IV occlusion (a blockage, unable to use) a new order received per [physician's name] for slow Activase (a de-clotting medication) 2 mg IV fuse (flush) via PICC line my (may) repeat X 1. The order and information were faxed to the facility's PICC consultants to perform the task of de-clotting the PICC line. There was no documentation of how much of the PICC line was exposed. During a review of Resident 20's nursing progress notes dated 9/7/21 at 4:45 PM, RN N stated [Name of IV company] staff informed this nurse that Activase 2 mg may not work due to tip of IV (PICC) displacement. Received verbal order from, [physician's name] to replace PICC line to continue vancomycin IV due to non-patency of PICC. During a review of Resident 20's IV consultant's comment notes dated 9/7/2021, RN O noted PT (patient) alert and oriented. RN O had initially arrived to de-clot PICC, but he noted that since the PICC line had gone from its original exposed length of 2 cm to 13 cm (a difference of 11 cm that had been pulled out of the arm) , the PICC tip was not in a favorable position to leave in place. De-clot was canceled instead of PICC replacement. A new PICC was placed by the nurse consultant. During a concurrent interview and observation on 10/11/21, at 11:03 AM, Resident 20 was lying in bed with her right arm uncovered. There was an IV showing in her right antecubital (the surface of the arm in front of the elbow). Resident 20 verified that it was a PICC line and that they used it for some antibiotics. She stated, when the staff would change the dressing site, they would pull on the PICC line and pull some of the catheter out and it had to be replaced. During an interview on 10/12/2021, at 10:00 am, with the Director of Nursing (DON), the DON verified that there were no measurements, from her nursing staff, of the exposed length of the PICC line during their assessments. During an interview on 10/14/2021, at 3:10 pm, with the DON, the DON verified that she did not know the PICC line had been pulled out to 13 cm of exposed line and the that the tip of the PICC line was not in a favorable position for infusion. She stated, that never happened. During an interview on 10/18/2021 at 1:04 pm with RN P, director of the facility's IV consultant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 31 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some company, she verified the notes from her staff (RN O) from 9/7/2021 and stated that sometimes a PICC will get pulled out with dressing changes by the nurses. We have no way of knowing when a PICC is pulled out, so we rely on the nurses at the facility to let us know. When we put in a PICC we leave our documentation of the measurements and type of catheter with the facility and it becomes the facility's line and they have to let us know when there is a problem. We expect them to put our documentation in the chart to be referred to. If you were a prudent nurse, you would check the measurements with assessments. 1b. During a review of Resident 20's MAR dated 9/13/2021, at 9:00 AM, LN A noted that the Vancomycin 1000 mg was not administered due to a clogged IV (PICC) line. During a review of Resident 20's nursing progress notes dated 9/13/2021, at 10:11 AM, by LN A, she indicated, due to resident's IV line occlusion, new order received for Activase 2 mg, 1 dose in clogged lumen (tube) may repeat x 1. During a review of Resident 20's IV consultant's comment notes by RN Q, dated 9/13/21, at 1:20 PM, RN Q indicated arrived for de-clot, needleless connector missing (the cap that maintans pressure in the PICC line) on arrival, visible blood in line, Curo (a disinfecting cap for needleless connectors not the required cap that provides pressure) attached directly to catheter. PICC removed. Instructions given on PICC care and Nurse sup(supervisor) notified of situation. During a review of Resident 20's nursing progress notes dated 9/13/2021, at 2:46 PM, RN R noted Replace PICC line due to compromised line, No cap present. During a review of Resident 20's nursing progress note dated 9/13/2021, at 7:04 PM, RN R noted Resident missed two doses (of vancomycin) due to clogged PICC line. During an interview on 10/14/2021, at 10:46 AM, Resident 20 indicated that the PICC had to be changed twice, close to together because they pulled it out and it clotted. I did miss some vancomycin treatments because of it. During an interview on 10/14/2021, at 3:10 pm, with the DON, the DON was unaware that the needleless connector was missing on 9/13/21. She stated she was not informed of these issues. She verified that some IV therapy had been misssed. During an interview on 10/18/2021 at 1:04 pm with RN P, director of the facility's IV consultant company, she verified that on 9/13/2021 when the PICC nurse came to de-clot the line she found the needleless injection cap missing and there was blood noted in the line. This cap holds the pressure on the line and keeps things from getting in the line. If there is no pressure in the line, then anything can get up in there and there is a high chance of infection. The PICC nurse documented that she educated the nursing supervisor about this issue. Due to the cap missing the PICC needed to be changed. 1c. During a review of Resident 20's transcribed Physician orders dated, 8/11/2021, an order written indicated: IV-Flush 5cc (mL) of normal saline before and after medication administration. A review of a document in Resident 20's medical record titled [IV consultant company's name]Nursing Care for PICC Lines, dated 9/7/21, Flushing guidelines were to flush with 10 mL (cc) of normal saline (NS). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 32 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/12/2021, at 9:47 AM, with the DSD, she verified that Resident 20 had a PICC line and the orders for the PICC line were to Flush IV with 5 cc of normal saline before and after medication administration. DSD indicated that she was not aware what the standard care was for a PICC line or how much it should be flushed with. The DSD indicated that she did not do anything with PICC lines. The DSD indicated that she or the DON were responsible to verify Physician's orders. DSD indicated that she may have verified these orders. During an interview on 10/12/2021, at 10:00 am, with the DON, the DON verified that a PICC line should be flushed with 10 cc of normal saline. She verified the order was wrong. A review of the facility's policy titled Central Venous and Midline Catheter Flushing dated April 2016, the policy indicated the flushing technique was to use a syringe barrel size of 10 mL or greater when flushing an infusion catheter to avoid excessive pressure inside the catheter, to prevent potential rupture of the catheter, and to prevent dislodgement of clots. Flushing to maintain patency of catheter: 3. Connect 10 mL barrel size syringe containing saline (amount as ordered or per facility protocol) to catheter via needleless connection device 5. Slowly administer appropriate amount of saline flush (per pharmacy or facility protocol) . 1d. During a review of Resident 20's nursing progress notes dated, 9/30/2021 at 4:01 PM, RN D noted she received a written order from the doctor to stop vancomycin IV on 9/30/2021. During a review of Resident 20's MAR dated 9/30/2021, the MAR verified the last dose of Vancomycin was on 9/30/2021. During a review of Resident 20's Physician orders dated, 10/2/2021, there was an order to discontinue IV flush and the monitoring of the IV site every shift for signs and symptoms of infections. During a review of Resident 20's nursing progress notes from 9/30/2021 thru 10/11/2021, (11 days) there were no notes in the nurse's progress notes about the PICC that remained in her right upper arm. A review of Residents 20's MAR, that was generated on 10/13/2021, at 7:14 AM, for the month of October 2021, verified that the PICC was flushed with 5cc and monitored for infection on days 10/1/2021 and 10/2/2021 and there was a dressing change on 10/7/21. There were no flushes or monitoring documented on the MAR from the 3rd through the 11th of October (9 days). During an interview on 10/12/2021, at 9:47 AM, with the DSD, the DSD verified that Resident 20 currently had a PICC line in and the flush and monitoring order had been discontinued on 10/2/202 (10 days before the PICC was removed). During a review of Resident 20's physician order dated 10/12/2021 an order was written after 2:30 PM to discontinue the PICC Line. The order was 9 days after the last documented flush or monitoring for signs and symptoms of infections of the PICC line. The PICC was documented as removed on 10/12/2021 during the pm shift as verified per the MAR. 1e. During a review of three RN's competency skills checklist, two of three RN's, (RN I and RN D) checklists were incomplete due to missing evaluation dates and associate signatures. Both RN's were hired on 7/15/2020 and their training was initiated a year later, 7/15/2021. RN I had no recorded date for the training of care and maintenance for central lines and PICC lines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 33 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 10/14/2021, at 10:18 AM, with RN J, she indicated that she started working in August of 2021. She trained for about a month. She denied using any check off list for her training. She stated she was trained by a bunch of different nurses. Some were on call nurses. She stated there was no way of knowing if some training was missed because there was no paperwork involved and no check off list provided to her to keep track of what she had learned. I asked her what she knew about PICC lines and she stated that they go into the artery (the correct place was the vein) and it's a quick way to deliver medicine. She confirmed that at times she was assigned to take care of Resident 20's PICC line during her shift. She mentioned that she flushed the line with I believe it is 100 cc of saline. She denied ever measuring the exposed tubing. Event ID: Facility ID: 055092 If continuation sheet Page 34 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 3 of 5 sampled Residents were free from unnecessary psychotropic drug use (drugs that are used to control or alter mood and behavior such as antipsychotic, antianxiety, antidepressant and hypnotic medications), when they either monitored the wrong side effect for the drug, had no monitor in place, or had not monitored a target symptom (behavior). This lack of correct monitoring had the potential to negatively impact the Residents quality of life by subjecting them to unrecognized potentially life-threatening and uncomfortable adverse medication side effects and impair their mental, physical and emotional well-being. (Residents 29, 38 and 346). Findings: According to LexiComp, an online drug information site for professionals: The adverse side effects of ANTIPSYCHOTIC drugs include; Life threatening heart rhythms, Akathisia (muscle quivering and inability to sit still), Parkinsonism (tremors, stiffness, slow movements, and loss of balance), Dystonia (involuntary muscle contractions that cause twisting movements), Tardive Dyskinesia (involuntary repetitive movements such as twitching, blinking, rolling or sticking your tongue out, jerking, and waving arms), limitations in functional capacity and Neuroleptic Malignant Syndrome (NMS), a life-threatening reaction to antipsychotic drugs where you get a very high fever of 102-104 degrees, rapid heartbeat, rapid breathing, stiff muscles, changes in mental state such as agitation, drowsiness and confusion, excessive sweating, trouble swallowing and either high or low blood pressures. The adverse side effects of ANTIDEPRESSANT drugs include; dry mouth, blurred vision, confusion, sedation, fatigue (tiredness), dizziness, headache, dry eyes, appetite changes, nausea, diarrhea, nervousness, falls and suicidal thoughts. The adverse side effects of ANTISEIZURE drugs include; dizziness, drowsiness, fatigue, confusion, impaired cognition, agitation, dry mouth, nausea, vomiting, constipation, poor appetite, tremor, incoordination, blurred vision, worsening of a mood, flat mood, depression, suicidal thoughts, hallucinations, bruising, fever, liver damage, rash, pancreatitis (swelling and pain in the pancreas), falls, significant sedation, subdued behavior (very quiet), withdrawal from normal activity, and limited functional capacity. The adverse side effects for HYPNOTIC drugs include; headache, nausea, short-term forgetfulness, ineffectiveness, dry mouth, hallucinations, dizziness and drowsiness. 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included; the surgical repair of a fractured right arm, Unspecified dementia with behavioral disturbances, malnutrition, Schizophrenia, depression, high blood pressure, Parkinson's disease (a disorder of the nervous system that causes tremors and rigid movement), and falls. On 10/11/2021 at 2:53 PM, Resident 38 was observed calmly lying on her bed. She was alert, smiling, and non-verbal. She was nicely dressed in her own clothes and well-groomed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 35 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 38's physician's orders for 10/2021 showed that on 9/12/2021, Seroquel (an antipsychotic medication)100 milligrams (mg) at bedtime was ordered for angry outbursts and a side effect monitoring order for an Antidepressant. On 10/13/2021 at 9:20 AM, and interview and concurrent record review was conducted with Licensed Nurse (LN) A. Resident 38's Electronic Medication Administration Record (EMAR) showed that she had been monitored for the side effects of an antidepressant, not an antipsychotic, since 9/12/2021. LN A confirmed that Resident 38 had been monitored for the incorrect side effects for an antipsychotic for one month. LN A stated, this monitor is not correct and I had not recognized this. 2. Resident 346 was admitted to the facility on [DATE] with diagnoses that included; Adult failure to thrive, hypothyroidism (the thyroid gland is underactive), depression, constipation, weakness, and memory loss. On 10/11/2021 at 10:43AM, Resident 346 was observed lying on top of her bed. She was fully dressed in her own clothes and well-groomed. She had a quarter-size scab to her forehead and she stated I fell. She was calm and pleasant. A review of Resident 346's Physician's Orders for 10/2021 was conducted. On 9/30/2021, Depakote 125mg (an antiseizure medication that is commonly used to stabilize mood or behavior problems) was ordered to be given three times a day for episodes of crying and Zyprexa 10mg (an antipsychotic medication) to be given at bedtime also for crying. Both Depakote and Zyprexa included orders to monitor for adverse side effects of an Antidepressant instead of the correct drug class of an antiseizure and an antipsychotic. On 10/13/2021 at 9:25 AM, an interview and concurrent record review was conducted with LN A. Resident 346's EMAR showed that she had been monitored every shift for the side effects of an antidepressant medication since 9/30/21, for both Depakote and Zyprexa. LN A stated, these monitors are not correct and I had not recognized that. 3. Resident 29 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a disease where the immune system eats away at the protective covering of the nerves and disrupts the communication from the brain to the body), pressure ulcers, Schizoaffective disorder (a combination of depression, delusions, hallucinations, and mania- high energy periods), Mood disorder, seizures, anxiety, chronic pain syndrome, neurogenic bladder (bladder does not empty and requires a tube to drain urine) and insomnia (inability to fall or stay asleep). A review of Resident 29's physician's o rders for 10/2021 was conducted. On 4/9/2020, Ambien 5mg (a hypnotic or sleeping pill) was ordered for insomnia and the order did not contain monitors for adverse side effects or a behavior symptom (such as how many hours she slept to determine if the medication was effective). On 10/11/2021 at 10:02 AM, Resident 29 was observed lying on her air bed. She was calm, pleasant and talkative. On 10/13/2021 at 12:22 PM, and interview and concurrent record review was conducted with the DSD (Director of Staff Development). The DSD confirmed that adverse side effects and a behavior had not been monitored for the use of Ambien, and stated that they should have been. The DSD confirmed that in order to determine if the Ambien was effective for Resident 29's insomnia, her hours of sleep would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 36 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm have to be monitored. The DSD added, It looks like it just fell off [of the physician's order] and no one noticed. The facility's policy titled, Psychotropic Medication Use revised March 2018, was reviewed. The policy directed: Residents Affected - Few 1. A Psychotropic drug is any drug that affects the brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Antipsychotic, Antidepressant, Antianxiety and Hypnotic. 8. Psychotropic medication management involve the interdisciplinary team consideration for the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing (where possible), identifying, and responding to adverse consequences; and identifying person-centered non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of Psychotropic medication. 12. Monitoring of a resident receiving Psychotropic medication will include evaluation of the effectiveness of the medication, as well as an assessment for possible adverse consequences. Behavioral symptoms are reevaluated periodically to determine the potential for reducing or discontinuing the drug based on therapeutic goals, and any adverse effects or possible functional impairment. A review of the facility's policy titled, Antipsychotic Medication Use revised December 2016, directed that; 14. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: a. General/Anticholingergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain or; d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia, stroke or TIA. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 37 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on Dietetic Services observation, Registered Dietitian and Dietary Services Supervisor interview, and departmental document review, the facility failed: Residents Affected - Some 1) To ensure the Dietary Services Supervisor (DSS) completed the required 6 hours of State regulatory training prior to assuming the leadership role. 2) To ensure the Registered Dietitian and/or Dietary Services Supervisor provided comprehensive oversight and staff guidance when: 2A) Staff did not perform food safety procedures such as food thawing, labeling and dating, food temperature monitoring, according to professional standards of practice. 2B) There was not an effective system in place to ensure cooks prepared adequate food to meet resident nutrition needs and preferences. 2C) There was not an effective system in place to ensure staff initial training, competency, and adequate monitoring of competence or performance during day to day operations. These failures have to potential to result in foodborne illness and to negatively impact meal satisfaction, meal intake and overall health of residents who receive food from the facility food services. Findings: 1) During an interview and concurrent record review with the Dietary Services Supervisor (DSS) on 10/11/21 at 11:00 AM he stated he obtained his DSS education from a university in another state. He had not completed 6 hours of Title 22 education prior to hire or currently. A review of the California Health and Safety Code §1265.4 shows the Dietary Services Supervisor/ Certified Dietary Manager is required to have completed and documented at least 6 hours of Title 22 education prior to hire. 2) The Registered Dietitian (RD) and/or Dietary Services Supervisor did not provide comprehensive oversight, monitoring and staff guidance when: 2A) Observations in the kitchen from 10/11/21 at 9:00 AM through 10/13/21 at 2:00 PM showed staff did not perform food safety procedures such as food thawing, labeling and dating, and food temperature monitoring, in accordance with professional standards of practice when: Cook-A and Cook-C did not monitor food cooking and serving temperatures consistently to ensure food safety and palatability. Meat, deli meat, food resembling chicken nuggets, peas and food resembling biscuits stored in refrigerators and freezers were not labeled, dated or discarded timely. Health Shakes, meat, and vegetables were not thawed properly. Staff did not follow infection control practices while consuming beverages and keeping personal belongings in food production areas (Cross Reference F812,

F802). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 38 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the DSS on 10/12/21 at 9:10 AM he stated food serving temperatures are to be documented each meal and one staff has a problem with not documenting lunch temperatures. A review of documents titled Daily Food Temperature Logs from September and October 2021 (to date) had many blanks. Further review showed food temperatures missing 55 out of 90 meals in September, and 24 out of 34 meals (to date) in October. There were no logs present for the weeks 9/20 through 9/26 and 10/4 through 10/10. Review of a policy titled Meal Service, dated 2018 showed The Food and Nutrition services staff member will take the food temperatures prior to service of the meal and recorded on the daily therapeutic menu in the temperature column .of each food served. The temperatures may also be recorded on a temperature log. Review of a policy titled Sanitation dated 2018 showed Correct temperatures for the storage and handling of foods are used. Thermometers will also be used to check the food at mealtimes. Documents titled Consultant Dietitian Monthly Report dated 3/30/21, 4/30/21, 5/27/21, 6/30/21, 7/30/21 and 8/27/21 were reviewed. Comments from the Registered Dietitian (RD) showed: cooks not recording meal temps prior to serving meals, meal temp logs were missing or empty, and the RD spoke with the cooks and DSS about the requirement for documenting serving temperatures before each meal (3/30/21, 5/27/21, 6/30/21, 7/30/21, 8/27/21). Test Tray Evaluation .puree foods not hot enough 4/30/21. 2B) There was not an effective system in place to ensure cooks prepared adequate food to meet resident nutrition needs and preferences when: During observations and interviews in the kitchen from 10/11/21 at 9:00 AM through 10/13/21 at 2:00 PM, Cooks A, B, and C all had different responses regarding how to figure out how much food to prepare for residents. Menu spreadsheets weren't consistently followed, and Cooks A and C ran short on prepared food during lunch tray line on 10/11/21 and 10/12/21. (Cross Reference F802). During an interview with the DSS on 10/13/21 at 11:00 AM - Interview DSS he stated cooks were trained to figure out how to prepare enough food by looking at the spreadsheets and census to calculate the amounts. 2C) There was not an effective system in place to ensure staff initial training, competency, or monitoring of competence or performance during day-to-day operations. During observations in the kitchen from 10/11/21 at 9:00 AM through 10/13/21 at 2:00 PM, menu spreadsheets weren't consistently followed, and Cooks A and C ran short on prepared food during lunch tray line on 10/11/21 and 10/12/21. (Cross Reference F802). During observations in the kitchen 10/11/21 at 8:45 AM through 10/13/21 at 2:00 PM, the kitchen was not sanitary. There was buildup of food debris and a gray fuzzy material resembling dust on many food preparation surfaces including but not limited to cabinet shelves and equipment in the cold food preparation area, shelves and food containers in the cook's area. Pans storing scoops, spatulas and whips were soiled with grime and crumbs. The blender base had a buildup of grime, the inside of the microwave oven was soiled, and trash cans were not clean. (Cross Reference F812). Review of a facility policy titled Sanitation dated 2018, showed All utensils, counters, shelves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 39 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and equipment shall be kept clean. The FNS (Food and Nutrition Services) Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. During an interview with Dietary Aide-C (DA-C) on 10/12/21 at 9:10 AM he was asked about their system for keeping the kitchen clean. He stated there was no checklist, but they have a routine for cleaning at the end of each day. They just use the job duty statement (job description) and training. During an interview with the DSS on 10/12/21 at 9:10 AM regarding staff training, he stated when staff are hired, they complete a 2-day Human Resources orientation. In the kitchen staff train a minimum of 3 days in each position they will work. Staff with the most longevity and knowledge in the position do the training. If the new staff is comfortable with their training, he turns them loose, but if they need more training, he provides that. They train to the Job Description (Job Duty Statement) and staff do a short, written competency test. Review of an in-service provided 7/16/21, titled Survey Readiness, Staff Competencies, showed the RD provided 2 different competency tests titled Competency Test for Cooks and FNS (Food and Nutrition Services) to staff that included a total of 25 true/false or short answer questions. The tests included one question each about these topics: labeling and dating, thawing, and portion control. There was no evidence provided that showed cooks were trained, assessed, and monitored for competency in calculating quantities of food to prepare, or taking tray line food temperatures before each meal. Review of a document titled Job Description: Cook revised 9/1/16 showed the cook is responsible to ensure that foods are prepared and served at the proper temperature and at the proper time. Works with the Dietary Services Supervisor to allocate resources in an efficient and economic manner so that each resident receives food in the amount, type, consistency and frequency to maintain acceptable body weight, nutritional values, and quality of life. Essential Job Functions include Follow recipes and prepares foods that correspond to menu cycles and recipes prepared by the Dietitian. Frequently clean food service work areas as food preparation and service is done, and between tasks. Prepare and maintain supply of food substitutes to accommodate resident choices, cultural, ethnic and religious preferences. Follow proper cleaning techniques. Job Functions include Working knowledge of food handling, preparation and storage techniques that comply with county state and federal laws and regulations, as applicable. Review of a document titled Job Description: Dietary Aide revised 9/1/16 showed The Dietary Aide is to assist the [NAME] in the preparation and service of meals. It includes Essential Job Functions such as Set up trays, Prepare hot and cold food and beverages, Follow recipes and posted menus, Clean food preparation utensils, dishes and preparation areas after use, Practice infection control policies and procedures of the department and facility. These job descriptions provide general descriptions of tasks staff do in the positions, but do not show or document position specific tasks staff were trained to do, or dates when staff were trained and competency in completing those tasks were assessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 40 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review the facility failed to ensure staff were competent to perform food preparation and food safety processes according to professional standards when: Residents Affected - Some 1. Two staff did not monitor food cooking and serving temperatures consistently to ensure food safety and palatability. 2. Two staff did not follow menu spreadsheets or prepare and serve adequate amounts of food to meet menu requirements and resident needs. 3. Staff did not correctly label and date food. 4. Staff did not use safe food thawing processes. Failure to ensure staff are competent to complete essential job and food safety functions increases the potential for foodborne illness to occur and also increases the risk that meals provided will not meet the nutritional needs and preferences of residents. It has the potential to negatively impact resident's meal satisfaction, meal intake and overall health. Findings: Review of a document titled Job Description: Cook showed the cook is responsible to ensure that foods are prepared and served at the proper temperature and at the proper time. Works with the Dietary Services Supervisor to allocate resources in an efficient and economic manner so that each resident receives food in the amount, type, consistency and frequency to maintain acceptable body weight, nutritional values, and quality of life. Essential Job Functions include Follow recipes and prepares foods that correspond to menu cycles and recipes prepared by the Dietitian. Frequently clean food service work areas as food preparation and service is done, and between tasks. Prepare and maintain supply of food substitutes to accommodate resident choices, cultural, ethnic and religious preferences. Follow proper cleaning techniques. Job Functions include Working knowledge of food handling, preparation and storage techniques that comply with county state and federal laws and regulations, as applicable. Review of a document titled Job Description: Dietary Aide showed The Dietary Aide is to assist the [NAME] in the preparation and service of meals. It includes Essential Job Functions such as Set up trays, Prepare hot and cold food and beverages, Follow recipes and posted menus, Clean food preparation utensils, dishes and preparation areas after use, Practice infection control policies and procedures of the department and facility. 1. Two staff did not monitor food cooking and serving temperatures consistently to ensure food safety and palatability. During an observation on 10/11/21 at 12:00 PM Cook-A did not take lunch meal serving temperatures prior to tray line. During an observation on 10/12/21 at 11:05 AM Cook-C removed a pan of chicken breasts from the oven and did not check the cooked food temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 41 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/12/21 at 11:52 AM Cook-C continued to not check food cooking temperatures to ensure adequate temperature for food safety. During an observation with concurrent interview on 10/12/21 at 12:00 PM Cook-C and the surveyor measured the serving temperature of the chicken breasts. Initial temperatures were 140°F and 147.7°F respectively. The chicken was re-temped in a different area of the pan and was 119°F and 165°F respectively. Cook-C stated when he took the chicken out of the oven it was 170°F. Review of the 2017 Food and Drug Administration (FDA) Food Code 3-401.11 shows Raw animal foods such as eggs, fish, meat, poultry and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with .methods based on the food that is being cooked .165°F or above for <1 second for poultry. During a record review and concurrent interview with the DSS on 10/12/21 at 9:10 AM documents titled Daily Food Temperature Logs from September and October 2021 (to date) were noted to have many blanks. The DSS stated food serving temperatures are to be documented each meal and one staff has a problem with not documenting lunch temperatures. Further review showed food temperatures were missing 55 out of 90 meals in September, and 24 out of 34 meals (to date) in October. It was noted there were no logs present for the weeks 9/20 through 9/26 and 10/4 through 10/10. Documents titled Consultant Dietitian Monthly Report from March through September 2021 were reviewed. On 3/30/21, 5/27/21, 6/30/21, 7/30/21 and 8/27/21 the dietitian commented about cooks not recording meal temps prior to serving meals, meal temp logs were missing or empty, and the RD spoke with the cooks and DSS about the requirement for documenting serving temperatures before each meal. On 4/30/21 it showed Test Tray Evaluation .puree foods not hot enough. On 5/27/21 it showed .missing .food temps logs. On 7/30/21 it showed recurring issues Missing .food temps logs. Logs not filled in daily. Meal temps not recorded. On 8/27/21 it showed Missing logs for food temps. Meal temps not recorded prior to service. Review of a policy titled Meal Service, dated 2018 showed The Food and Nutrition services staff member will take the food temperatures prior to service of the meal. The food will be served on tray line at the recommended temperatures as below and recorded on the daily therapeutic menu in the temperature column .of each food served. The temperatures may also be recorded on a temperature log. Review of a policy titled Sanitation dated 2018 showed Correct temperatures for the storage and handling of foods are used. Thermometers will also be used to check the food at meal times. Review of an in-service provided 7/16/21, titled Survey Readiness, Staff Competencies, showed competency tests titled Competency Test for Cooks and FNS (Food and Nutrition Services) were provided but included no questions about the need to check cooking or serving temperatures prior to tray line. No evidence was provided that showed cooks were trained, assessed and monitored for competency in taking tray line food temperatures before each meal. 2. Two staff did not follow menu spreadsheets or prepare and serve adequate amounts of food to meet menu requirements and resident needs. During an interview on 10/11/21 at 9:00 AM Cook-A stated lunch was served at 12:00 but tray line started at 11:50 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 42 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the DSS on 10/11/21 at 11:05 AM he stated they were substituting a beef tips menu at lunch that day because the pot roast didn't come in with the delivery. The RD approved the substitution. During an observation and concurrent interview with Cook-A on 10/11/21 at 11:30 he stated he looks at the menu spreadsheet to know portion sizes and figure out what scoops to use. The DSS gathered the scoops for lunch tray line. During an observation on 10/11/21 at 11:40 AM the surveyor overheard Cook-A tell the DSS I don't have any vegetarian (entree). They conferred and Cook-A started making Vegetarian Stir-Fry. I have 2 vegetarians. Cook-A poured vegetarian (imitation) meat, frozen vegetables and seasonings into a pan. There was no recipe or measuring. During an observation of tray line on 10/11/21 at 12:10 PM it appeared Cook-A was running short of prepared food. Portions were less than level with the scoop. The tray ticket for Resident-29 showed Double Veggies and Cook-A served a full portion of spinach and a half portion of carrots. Another tray ticket directed Double Protein and Cook-A served two scoops approximately ¾ full (not level portions) of beef tips. During an observation on 10/11/21 at 12:20 PM Cook-A added more butter to the pot to melt for fortified diets. Cook-A had to scrape the bottom of the pan to provide beef tips for the last plates. There were no beef tips left to prepare the requested regular and pureed test trays for survey. During an interview on 10/11/21 at 3:00 PM Cook-B was asked how she knew how much food to make for tray line? She stated the first thing she does each shift is tally the tray tickets and use that information with the menu spreadsheets and recipes. That way she knows what she needs and doesn't run out or have any surprises. She has tried to get other cooks to do that but they don't. During an interview with Cook-C on 10/12/21 at 8:45 AM he stated he had been a cook at the facility since 2017. When asked how he knew how much food to make for tray line he stated he looks at the recipe, the scoop size (portion) and number of residents, and then pads the count so he has a little bit extra. He does texture modification as he goes (during tray line) so the texture modified foods have all the same flavor as the regular food. During an observation of tray line on 10/12/21 at 12:00 PM, Cook-C looked at the recipe binder as the DSS verbally reviewed scoop sizes with him, and then selected the scoops and spoodles (food portion control serving spoons) for Cook-C to use. During an observation of tray line on 10/12/21 at 12:00 PM, Cook-C used a ½ cup spoodle approximately half full (1/4 cup) to provide small portions of vegetables for Res-13 (spinach) and Res-2 (peas). Review of lunch meal tray tickets printed showed Res-13 had a diet order for a Regular diet with small portions, no dislikes or preferences. Res-9 had a diet order for NAS (no added salt), Small Portions, Regular diet and dislikes spinach cooked. Review of the lunch menu spreadsheets for Tuesday 10/12/21 showed small portions should be ½ cup of vegetables for both regular and NAS diets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 43 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation of tray line on 10/12/21 at 12:46 PM [NAME] C ran out of mechanical soft chicken. The DSS prepared more in in the Robo Coupe. During an observation of tray line on 10/12/21 at 12:50 PM the DSS stated they had no more pureed chicken to use for the requested survey test trays. He further stated they only had 1 resident with a pureed diet so there was no more pureed food for a test tray. During an interview on 10/12/21 at 1:05 PM, Cook-A was asked how he knew how much food to make for tray line. He stated all training is on the job. When asked again how he knew how much food to cook he replied Look at the portions on the (menu) spreadsheet. Review of a policy titled Menu Planning dated 2020 showed Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. Review of an in-service provided 7/16/21, titled Survey Readiness, Staff Competencies, showed competency tests titled Competency Test for Cooks and FNS (Food and Nutrition Services) were provided and included one question about portions: One of the reasons portion control is important because it assures the correct amounts of food are provided for special diets (True/False). Five out of 5 staff competency tests reviewed showed the correct answer (True). Review of an in-service provided by the RD on 9/23/21 titled How to Read and Use a Menu Spreadsheet shows Cook-B and Cook-C attended. The curriculum shows instruction on how to read a spreadsheet was provided but did not include education on how to calculate quantities of food to prepare using a spreadsheet. Cook-B completed a post-test dated 7/23/21. No post-test was provided for Cook-C. No further evidence was provided that showed cooks were trained, assessed and monitored for competency in ensuring adequate food is prepared to meat the needs of residents and that portion control was accurate. 3. Staff did not correctly label and date food. The 2017 FDA Food Code 2017, 3-501.17 (A) (B) (C) (D) discusses required food labeling and dating. It states the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. The 2017 FDA Food Code, 3-302.12 states Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. During an observation of the 3-door reach-in refrigerator near the cooks' area on 10/11/21 at 9:20 AM a package labeled Turkey - Pull on 10/2 (Pull means date removed from freezer) had no use-by date. Two packages of fully thawed raw meat, approximately 5 pounds each, resembled ground beef and had no labels and no dates. A package of deli roast beef was labeled opened 9/29, and deli turkey was labeled opened 10/5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 44 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a facility document titled Refrigeration Guidelines posted on the refrigerator door showed Meat Taken From Freezer to Thaw and Maximum Refrigeration Time Once Thawed: poultry and ground meat maximum 2 days; luncheon meats, maximum 5 days. During an observation and concurrent interview 10/11/21 at 11:00 AM, the Dietary Services Supervisor (DSS) stated the turkey had unknown dates and discarded it. He stated it was unknown how long the 2 fully thawed packages of ground beef had been in the refrigerator, and discarded them. The DSS stated the opened deli roast beef and turkey meats were outdated and should have been tossed. An observation of the freezers near the back door of the kitchen on 10/11/21 at 9:40 AM showed an unlabeled, undated bag of food resembling chicken nuggets, an opened package of green peas with no opened-on or use-by date, and an unlabeled, undated bag of food resembling biscuits. A review of the policy titled Labeling and Dating dated 2020 states All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows guidelines. Documents titled Consultant Dietitian Monthly Report from the past 6 months were reviewed. The 6/30/21 report showed RD continues to go around kitchen and fix the labeling and dating found. The 7/30/21 report showed Label and dating still an issue, we need labeling and dating done on all items. Findings from daily checklist are items not labeled and dated or covered correctly. Review of an in-service provided 7/16/21, titled Survey Readiness, Staff Competencies, showed competency tests titled Competency Test for Cooks and FNS (Food and Nutrition Services) were provided and included one question about labeling and dating: All opened food needs to be labeled with a received by date and the date it was opened (True/False). Five out of 5 competency tests reviewed had the correct answer (true). No further evidence was provided that showed staff were trained, assessed and monitored for competency in labeling and dating food. 4. Staff did not follow safe food thawing processes. During an observation and concurrent interview in the kitchen on 10/11/21 at 9:00 AM health shakes in the refrigerator near the coffee machine were labeled prepared on (thawed on) 10/11, were fully thawed and did not feel cold. DA-A stated Diet Aide B (DA-B) thawed the shakes on the counter. (cross-reference

F812). During an observation of the 3-door reach-in refrigerator near the cooks' area on 10/11/21 at 9:20 AM a tub on the bottom shelf contained a package labeled Turkey - Pull on 10/2 (Pull means date removed from freezer) with no use-by date. The tub also contained 2 packages of fully thawed raw meat, approximately 5 pounds each, that resembled ground beef and had no labels and no dates. (cross-reference F812). Review of a facility document titled Refrigeration Guidelines posted on the refrigerator door showed Meat Taken From Freezer to Thaw and Maximum Refrigeration Time Once Thawed: poultry and ground meat maximum 2 days. During an observation and concurrent interview with the Corporate Food Service Efficiency Expert (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 45 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (FSE) in the Cooks' area on 10/12/21 at 9:25 AM, Cook-C thawed frozen spinach under running water in a 3-compartment sink that did not have an air gap. The FSE agreed the sink must have an air gap if used for food preparation and the cook should have used the food preparation sink instead. During an observation in the Cooks' area on 10/12/21 at 10:52 Cook-C emptied thawed bags of green peas into a colander set in a bowl in the 3-compartment wash sink. He moved them to the cook's food prep sink when he noticed the surveyor observing. Review of a policy titled Food Preparation Thawing of Meats dated 2018 showed meat can be thawed in a refrigerator. Label defrosting meat with a pull and use by date. Thaw similar items together (i.e., stew meat with ground beef). Never thaw chicken (poultry) and beef on the same tray. The policy further shows if thawing food by submerging under running water at 70°F or less Thaw food in a clean and sanitized food sink separate from wash sinks. Review of an in-service provided 7/16/21, titled Survey Readiness, Staff Competencies, provided two different tests titled Competency Test for Cooks and FNS (Food and Nutrition Services) Staff and had 25 total questions. One question stated: Frozen meat can be properly thawed on the counter top (True/False). Five out of 5 completed tests had the correct answer (false). No further evidence was provided that showed staff were trained, assessed and monitored for competency in safely thawing food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 46 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a menu in accordance with physicians' orders, cultural/ethnic needs and/or resident preference for 3 out of 3 residents (Residents 27, 39 and 195) with a vegetarian diet order. This failure increased the risk that meals provided to vegetarian residents would not meet their nutritional needs and had the potential to negatively impact resident's meal satisfaction, meal intake and overall health. Findings: A tray ticket is a document placed on each resident's meal tray every meal. It provided direction for what staff should place on each resident's tray. It showed the resident's name, room number, diet order, food allergies/dislikes, beverages/special equipment to be provided, and food preferences. During an observation, concurrent record review, and interview with the Registered Dietitian (RD) on 10/11/21 at 9:15 AM, the RD was asked to provide a copy of the facility menu titled Good For Your Health Menus Fall, Week 2, dated October 11-17, 2021 that was posted in the kitchen on the refrigerator near the stove. The menu showed the 3 meals to be served daily during the week of October 11-17, 2021 and did not show any alternate menu choices. The RD also provided copies of the facility menu spreadsheets that showed food and portion sizes to be served for diets ordered in the facility: Regular, Mechanical Soft, Pureed, Dysphagia Mechanical (for difficulty swallowing), 2Gm Na (low sodium), CCHO (consistent carbohydrate), Renal Diets (for kidney disease), Low Fat/ Cholesterol, and Finger Foods (foods that can be eaten with your hands). During an observation and concurrent record review on 10/11/21 at 09:50 AM, Diet Aide-A (DA-A) set up resident trays to be ready for lunch. The tray tickets of 3 residents (Res-27, Res-39, Res-195) included a vegetarian diet order. During an interview on 10/11/21 at 11:30 AM, the Dietary Services Supervisor (DSS) stated the alternate menu choices were posted in the hall and usually they (residents or nursing) tell the kitchen about an hour before tray line when they want something different. During an observation at 10/11/21 at 11:40 AM the surveyor overheard Cook-A tell the DSS I don't have any vegetarian (entree). The two conferred and Cook-A started making Vegetarian Stir-Fry. I have 2 vegetarians. He poured some ingredients (vegetarian imitation meat product, frozen vegetables, seasoning) into a pan with no recipe and no measuring. During an interview and concurrent record review on 10/11/21 at 11:45 AM the DSS stated We have a vegetarian menu; but they (vegetarian residents) often just ask for grilled cheese or cottage cheese. During an interview on 10/11/21 at 11:45 AM Diet Aide-C (DA-C) stated vegetarian residents often look at vegetarian (imitation) meat and think it's meat, or say what is this? They don't want the vegetarian meat products. During an observation in the corridor on 10/11/21 at 12:30 PM, a facility menu titled Good For Your Health Menus, dated September 27 - October 3, 2021, and October 4 - October 10, 2021 were posted. The current menu for October 11-17, 2021 was not posted. Additionally, a document titled Meal Service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 47 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Alternative Choices was dated Summer 2021 and included a Deli Meat or Chicken Patty sandwich, or a Chicken Caesar Salad. During an interview and concurrent record review with the DSS on 10/11/21 at 03:00 PM he stated, We have a vegetarian menu, but they (vegetarian residents) usually just pick what they want in advance. He stated there was no recipe for the Veggie Crumble (called Vegetarian Stir Fry by Cook-A) entrée made for the vegetarian lunch that day. The DSS provided a menu titled Good For Your Health Menus, Fall, dated October 11 - 17, 2021 that resembled the previously posted menu with the same dates, but now showed Vegetarian Alternate Menus added. The DSS stated they had a vegetarian menu but were still working with their vendor to get the recipes and nutrient analysis. During an interview and concurrent record review with Cook-B on 10/11/21 at 3:15 PM in the cook's area she stated she had never seen the vegetarian menu provided by DSS and had not prepared the foods listed on it. She did not have recipes for the vegetarian items listed on the menu in her recipe binder. She stated they were out of veggie burgers for dinner that night. A review of the facility menu spreadsheets titled Fall Menus Week 2 (Monday through Thursday) and dated 9/13/21 through 11/08/21 showed there was no vegetarian menu and that a Smokey Turkey Burger for dinner on 10/11/21. During an interview on 10/12/21 at 10:30 AM, Resident 39 (Res-39) indicated he speaks [NAME] and does not speak English. Licensed Nurse -B (LN-B) agreed to translate for the interview. She shared that Res-39 had poor vision and needed to be fed. Res-39 stated the food here is kind of OK. When asked how he liked the vegetarian food here he replied sometimes it's good and sometimes it's not. He likes Indian food and they don't offer it here. Res-39 stated he doesn't like the vegetarian (imitation) meats. He does not like tofu. He likes whole wheat tortillas, lentils and soups. His family brings Indian food from home but couldn't bring it the past 2 weeks when there was a COVID-19 resident at the facility. He usually receives drinks he likes coffee and teas - but it depends on the person (caring for him). Review of the lunch menu spreadsheet for Tuesday 10/12/21 showed residents with a CCHO (consistent carbohydrate) diet were to receive [NAME] Sugar Baked Chicken (small portion is 2 oz., regular portion is 3 oz.), Seasoned Pasta (1/4 cup) with Creamy Italian Sauce (2 oz.) and Spinach Augratin (1/2 cup). During an observation of lunch tray line (meal assembly) on 10/12/21 at 12:00 PM the vegetarian residents received a product resembling vegetarian chicken nuggets (5 nuggets for regular portion, 3 nuggets for small portion), corn and carrots. They did not receive the seasoned pasta, Creamy Italian sauce, or Spinach Augratin shown on the menu spreadsheets. During an interview with the DSS on 10/13/21 at 11:00 AM he was asked how he goes about obtaining and working with resident food preferences. He stated when residents come into the facility, he goes to see them the next day, asks them about their usual diet at home, what they like or dislike. He puts that information into the computer and usually follows up again in a couple of weeks. He does a walk through and checks in with residents about every 2 weeks or if they request a visit. Beyond that he does the quarterly report. When asked why, other than with newly admitted residents, there would be no preferences on resident tray tickets he responded, Some residents say they like everything so there's no need to write anything. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 48 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Res-39's OBRA Annual assessment dated [DATE] showed Res-39 had lived at the facility for 2 years (admitted [DATE]), and his primary language was [NAME]. Further review of Res-39's lunch meal tray ticket showed a diet order for Vegetarian, Fortified, CCHO (consistent carbohydrate), NAS (no added salt), Small portions. It listed meat as a dislike. It listed food preferences as Sugar Free Health Shake, Banana and Sugar Free pudding. There was no indication that Res-39 disliked vegetarian (imitation) meat and tofu, or that he preferred soups, stews, lentils and Indian food. Review of Res-27's OBRA Quarterly Review dated 7/21/21 showed she had lived at the facility for 7 years (admitted [DATE]). Further review of her lunch meal tray ticket showed a diet order for Vegetarian, Fortified (extra calories), CCHO (consistent carbohydrate), Regular diet. Dislikes listed were egg and fish. Nothing was listed in the food preferences column. Review of Res-195's MDS 3.0 Entry Tracking Record showed he was newly admitted on [DATE]. Further review of his lunch meal tray ticket showed a diet order for Vegetarian, Mechanical Soft, CCHO, NAS. There were no food preferences or dislikes listed. A review of 40 current resident lunch meal tray tickets provided by the DSS on 10/13/21 at approximately 11:00 AM showed 20 out of 40 tray tickets contained zero resident food dislikes, and 23 out of 40 tickets provided zero resident food preferences. During an interview with the DSS on 10/13/21 at 11:15 AM he was asked how they work with food for the East Indian/[NAME] residents? He replied I tell them we have a designated menu, and we stick to it. If you want something else the family can bring it in. I tell them we don't have a cultural menu here. During an interview with the DSS on 10/13/21 at 11:15 AM he was asked why the vegetarian residents received corn and carrots and no pasta with sauce or spinach at lunch on 10/12/21. He stated They are supposed to get the same as the other plates - just with the vegetarian meat. When asked how much carbohydrate can be served on a CCHO diet and how do staff know what to provide he stated They follow the foods and portions on the spreadsheet. During an interview with the Registered Dietitian (RD) on 10/13/21 at 12:07 PM - she stated the diet manual shows consistent carbohydrate diets are to receive 55-65 grams of carbohydrate at lunch. When asked about the Vegetarian residents receiving vegetarian chicken nuggets, corn and carrots on their plates, and not pasta with sauce or spinach, she replied It's not necessary restrict vegetarian diets as much. The carb content would still be about the same with the different sides. Review of a document titled Substitution Log showed two entries dated 9/15/21 and 10/11/21. The entry dated 10/11/21 showed Beef Tips substituted for Pot Roast due to the wrong meat being pulled (pulled from the freezer and thawed). It was signed off by the RD. The document showed no approved substitutions for the items served to the vegetarian residents at lunch on 10/12/21 when pasta and spinach were on the menu, and these were not listed as dislikes on the resident tray tickets. Review of a policy titled Food Preferences dated 2018 showed Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 49 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a policy titled Menu Planning dated 2020 showed All daily menu changes with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a log book may be kept .The dietitian is to sign and date spreadsheets when changes are made. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. The menus are planned to meet nutritional needs of residents in accordance with national guidelines, Physician's orders, and to the extent medically possible .the (recommendations of) Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle. Menus are planned to consider the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups. Review of a document titled Facility Assessment Tool for Yuba City Post Acute 06/2020 through 05/2021 updated 6/30/2021 shows: The intent of the facility assessment is for the facility to evaluate its resident population and identify resources needed to provide the necessary person-centered care and services the residents require. It further shows average census 48, with 4 residents who identify as Asian and 3% of residents who require an interpreter. Part 2 of the document under Services and Care We Offer Based on our Residents' Needs shows General Care Topic: Nutrition with Specific Care or Practices: Individualized dietary requirements, liberal diets, specialized diets .cultural or ethnic dietary needs, assistive devices. It also shows General Care Topic: Provide person-centered/directed care: with Specific Care or Practices: Psycho/social/spiritual support: Find out what resident's preferences and routines are .and incorporate this information into the care planning process. Provide culturally competent care: learn about resident preferences and practices with regard to culture and religion; stay open to requests and preferences and work to support those as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 50 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when: Residents Affected - Some 1) Food was not thawed, labeled, dated, or discarded appropriately. 2) Cooked food temperatures were not consistently monitored or documented. 3) Food service equipment was not clean, and manufacturer's instructions were not followed when sanitizing fixed equipment. 4) Staff personal food and personal possessions were in use in food preparation areas. These practices have the potential to result in foodborne illness for residents consuming food from the facility food services. Findings: 1) Food was not thawed, labeled, dated, or discarded appropriately. 1.A. Thawing Nutritional Shakes - During an observation in the kitchen on 10/11/21 at 9:00 AM the single door reach-in refrigerator near the coffee machine contained a plastic bin of individual cartons of nutritional shakes dated Prepared on date 10/11. The shakes were completely thawed and did not feel cold. The external temperature indicator read 33 degrees (°) Fahrenheit (F). The thermometer inside the refrigerator read 46°F. A new additional thermometer was placed inside the refrigerator and read 39°F. During an interview with Dietary Aide -A (DA-A) on 10/11/21 9:45 AM, she stated the nutritional shakes prepared on 10/11 meant they were pulled from the freezer at 5 AM that morning. When asked why the shakes were already thawed DA-A stated She (DA-B) leaves them on the counter to thaw for a bit and then puts them in the refrigerator. During an observation and concurrent record review and interview with the Dietary Services Supervisor (DSS) on 10/11/21 at 11:00 AM the new internal thermometer read 31°F. The DSS temped the nutritional shakes at 43°F. The Surveyor temped the shake at 41°F. DA-B admitted she changed the prepared-on date on the nutritional shakes to 10/5 after the morning survey observation. The DSS reviewed directions on the nutritional shake carton showing the date the shake is taken from the freezer is day 1 and it is to be used within 14 days. The DSS stated the shakes are often thawed in another refrigerator but not at room temperature on the counter. He agreed that since staff reported earlier that shakes are thawed on the counter, it probably does happen. 1.B. Thawing, Labeling and Dating Meat - During an observation of the triple-door reach-in refrigerator near the cooks' area on 10/11/21 at 9:20 AM there was a white tub on the bottom shelf containing a clear plastic container of a foil-wrapped package labeled Turkey - Pull on 10/2 (Pull means date removed from freezer). There was no use-by date. The tub also contained 2 chubs (a type of container formed by a tube of flexible packaging material) of fully thawed raw meat, approximately 5 pounds each, that resembled ground beef. The chubs had no labels and no dates. An additional square plastic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 51 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 tub contained 1 package deli roast beef opened 9/29, and one package and deli turkey opened 10/5. Level of Harm - Minimal harm or potential for actual harm Review of a facility document titled Refrigeration Guidelines posted on the refrigerator door showed Meat Taken From Freezer to Thaw and Maximum Refrigeration Time Once Thawed: poultry and ground meat maximum 2 days; luncheon meats, maximum 5 days. Residents Affected - Some During an observation and concurrent interview with the DSS on 10/11/21 at 11:00 AM, meat items in the 3-door refrigerator near the cooks' area were viewed and discussed. The DSS stated the foil wrapped turkey had unknown dates and discarded it. He stated it was unknown how long the 2 chubs of ground beef had been in the refrigerator, they were fully thawed, and he discarded them. The DSS stated the opened roast beef and turkey deli meats were outdated and should have been tossed. 1.C. Thawing under running water - During an observation and concurrent interview with the Corporate Food Service Efficiency Expert (FSE) in the Cooks' area on 10/12/21 at 9:25 AM, Cook-C was thawing frozen spinach in a tub with running water in the 3-compartment sink. The 3-compartment sink did not have an air gap required for food preparation sinks. The FSE agreed the sink must have an air gap if used for food preparation and stated the cook should have thawed the spinach in the cooks' food prep sink instead. During an observation in the Cooks' area on 10/12/21 at 10:52 Cook-C emptied thawed bags of green peas into a colander set in a bowl in the 3-compartment wash sink. He moved them to the cook's food prep sink when he noticed the surveyor observing. 1.D. Labeling and Dating - An observation of the freezers near the back door of the kitchen on 10/11/21 at 9:40 AM showed they contained an unlabeled, undated bag of food resembling chicken nuggets, an opened package of green peas with no opened-on or use-by date, and an unlabeled, undated bag of food resembling biscuits. Review of a policy titled Food Preparation Thawing of Meats dated 2018 shows meat can be thawed in a refrigerator. Label defrosting meat with a pull and use by date. Thaw similar items together (i.e., stew meat with ground beef). Never thaw chicken (poultry) and beef on the same tray. The policy further shows that if thawing food by submerging under running water at 70°F or less Thaw food in a clean and sanitized food sink separate from wash sinks. A review of the facility policy titled Labeling and Dating dated 2020 states All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows guidelines. Documents titled Consultant Dietitian Monthly Report from the past 6 months were reviewed. While the 3/30/21 report showed an in-service on food labeling and dating was provided by the FNSD (Food and Nutrition Services Director) on 3/5/2021, the 6/30/21 report showed RD continues to go around kitchen and fix the labeling and dating found. The 7/30/21 reoirt showed Label and dating still an issue, we need labeling and dating done on all items. Findings from daily checklist are items not labeled and dated or covered correctly. 2) Cooked food temperatures were not consistently monitored or documented. During an observation on 10/11/21 at 12:00 PM Cook-A did not take lunch meal serving temperatures prior to tray line. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 52 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 Level of Harm - Minimal harm or potential for actual harm During an observation on 10/12/21 at 11:05 AM Cook-C removed a pan of chicken breasts from the oven and did not check the temperature. During an observation on 10/12/21 at 11:52 AM Cook-C continued to not check food cooking temperatures to ensure it reached an adequate temperature for food safety. Residents Affected - Some During an observation and concurrent interview on 10/12/21 at 12:00 PM, Cook-C and the surveyor measured the serving temperature of the chicken breasts. Initial temperatures were 140°F and 147.7°F respectively. The chicken was re-temped in a different area of the pan and was 119°F and 165°F respectively. Cook-C stated when he took the chicken out of the oven it was 170°F. Review of the 2017 Food and Drug Administration (FDA) Food Code 3-401.11 shows Raw animal foods such as eggs, fish, meat, poultry ad foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with .methods based on the food that is being cooked .165°F or above for <1 second for poultry. During a record review and concurrent interview with the DSS on 10/12/21 at 9:10 AM, documents titled Daily Food Temperature Logs for September and October 2021 were noted to have many blanks. The DSS stated food serving temperatures are to be documented each meal and one staff has a problem with not documenting lunch temperatures. Further review showed food temperatures were missing for 55 out of 90 meals in September, and 24 out of 34 meals (to date) in October. It was noted there were no logs present for the weeks 9/20 through 9/26 and 10/4 through 10/10. Documents titled Consultant Dietitian Monthly Report from the past 6 months were reviewed. On 3/30/21 it showed AM cook still not recording meal temps prior to serving meals. Need to be recorded before service. FNSD (Food and Nutrition Services Director) and RD (Registered Dietitian) went over that meal temps need to be recorded prior to meal service. Logs that were found empty by RD, were corrected by FNSD. On 4/30/21, it showed Test Tray Evaluation .puree foods not hot enough. On 5/27/21, it showed .missing .food temps logs. On 6/30/21, it showed Spoke with (Cook-C) about recording all meal temps prior to meal service. On 7/30/21, it showed recurring issues Missing .food temps logs. Logs not filled in daily. Meal temps not recorded. On 8/27/21, it showed Missing logs for food temps. Meal temps not recorded prior to service. 3) Food service equipment was not clean, and manufacturer's instructions were not followed when sanitizing fixed equipment. A review of the FDA Food Code 2017 showed: 4-603.14 Equipment food-contact surfaces and utensils shall be effectively washed to remove .soils. 4-603.16 showed Washed utensils and equipment shall be rinsed so that abrasives are removed and cleaning chemicals are removed. 4-701.10 showed Equipment food-contact surfaces and utensils shall be sanitized. 4-702.11 showed Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning. During an observation and concurrent interview in the cold food prep area on 10/11/21 at 9:50 AM - a stainless-steel upper shelf and large clear plastic tub with lids stored on a low shelf had a buildup of a fuzzy gray substance resembling dust. There were crumbs and an orange gooey substance on the shelves inside the cabinet above the food preparation counter containing green baskets labeled activities snacks. A fan directed toward the dish area had a buildup of black grime on the blades. Scissors on a magnetic holder on the wall were not clean. DA-B stated the soiled scissors were used to open packages in the cold food preparation area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 53 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and concurrent interview with Cook-A in the cooks' area on 10/11/21 at 10:05 AM, a wheeled rack contained two deep metal pans holding scoops and spatulas. The pans were soiled with grime and crumbs. Cook-A agreed they were soiled and sent them to the dish room. Further observation showed the floor sink was not clean. The stainless-steel shelf above the cook's sink had oil across it and dripping off. A red tray contained soiled scissors. A plastic tub of peanut butter had peanut butter dripping out around the edges of the lid. The blender base had a buildup of grime. Four out of 4 blue-lidded plastic tubs stored cereal and were covered with a gray fuzzy substance resembling dust. The microwave oven was soiled inside. The exterior of three trash cans in the kitchen were soiled. These are all potential sources of cross contamination. During an observation and concurrent interview with Cook-C on 10/12/21 at 11:25 AM a heavily soiled clear plastic rectangular container containing whips was on the storage rack next to the stove. Cook-C and the DSS confirmed it was not clean. During further observation and concurrent interview on 10/12/21 at 11:25 AM, Cook-C wiped down the edges of the cook's counter using a green bucket of solution and disposable cloths. He stated the bucket contained sanitizer and the sanitizer was new just a few minutes ago. He explained We don't have soap. The soap (detergent) dispenser jug on the floor was empty, so he was just using sanitizer. Cook-C stated they test the sanitizer concentration every morning. He explained the testing process is to dip the test strip into the sanitizer for 2-3-4 seconds, then pull it out and match to the colors on the test strip container. It should be at 200 ppm (parts per million). The current bucket of sanitizer tested 100 ppm. A second test strip was inserted for 5 seconds per manufacturer's instructions and tested 100 ppm. The DSS dispensed a new bucket of sanitizer and test-strip color results showed less than 200 ppm but more than 100 ppm. During an observation and concurrent interview in the kitchen on 10/12/21 at 1:30 PM - two representatives from the facility chemical vendor stated, The soap solution (detergent) should be here today. They explained the detergent was only used during emergencies so if there was an emergency staff could move the detergent from the dish machine to the 3-compartment sink. So technically they're not out. The DSS stated they only use the detergent to soak dishes and pans in the 3-compartment sink or for emergencies (when the dish machine doesn't work). They don't use the detergent for anything else. During an interview and concurrent record review with the DSS on 10/13/21 at 11:00 AM, he was asked what the process was for staff to clean fixed equipment such as counters. He replied, Wash with detergent from dispenser, rinse, sanitize, sit until dry - it's not much time to air dry - seconds. When asked what the wet time (amount of time sanitizer must stay wet to effectively sanitize a surface) was supposed to be for the sanitizer, the DSS reviewed the sanitizer Butler Sani-Tech label instructions titled Directions for Use that said to allow wet time 10 minutes. Further review of the sanitizer instructions showed the label provided directions for disinfection (kill all microorganisms) but not for sanitization (reduce number of microorganisms to safe levels) of surfaces. The directions stated To disinfect food service establishments or restaurant food contact surfaces: countertops, outside of appliances, tables, add 3 ounces of this product per 5 gallons of water. For heavily soiled areas, a pre-cleaning step is required. Apply solution .so as to wet all surfaces thoroughly. Allow the surface to remain wet for 10 minutes, then remove contact liquid and rinse the surface with potable water. Do not use on utensils, dishes, glasses or cookware. Review of sanitizer label instructions emailed to the Department by the Administrator on 10/21/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 54 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 2:08 PM, showed To sanitize pre-cleaned public eating establishment surfaces (counters, tables, finished wood or plastic cutting boards) apply a 200-400 ppm active quaternary solution .making sure that the surface remains completely wet for at least 60 seconds. A photo of the front label of the product was not provided, so it is unknown if the updated label was for the same sanitizer product. During an observation on 10/13/21 at 12:06 PM, the detergent dispenser jug at the 3-compartment sink in the cook's area was still empty. Review of a facility policy titled Sanitation dated 2018, showed All utensils, counters, shelves and equipment shall be kept clean. The FNS (Food and Nutrition Services) Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. Documents titled Consultant Dietitian Monthly Report from the past 6 months were reviewed. On 04/30/21, it showed Quat logs still not being filled in, missing logs. On 8/27/21, i showed (The DSS) set up the cleaning schedule and then in-serviced all FNS staff on the new cleaning schedule. 4) Staff personal food and personal possessions were in use in food preparation areas. During an observation in the kitchen cold food preparation area on 10/11/21 at 9:10 AM, a drawer under the counter contained a black cell phone touching the bundle of resident lunch meal tray tickets. A cabinet under the counter contained beverage pitchers, a bin of plastic lids, and a Styrofoam cup half-full of brown liquid resembling coffee. The container had no lid. During an observation and concurrent interview on 10/13/21 at 9:20 AM, a black cell phone was on top of a box of gloves on the air conditioner in the dish room. DA-C was asked what the policy was about staff personal property in the kitchen and where staff put their personal things. He replied staff put their personal items in the DSS office. They're not supposed to have any personal items out in the kitchen. DA-C was asked if staff are allowed to have personal drinks in the kitchen. He replied they are allowed to have personal drinks in the kitchen as long as they are closed or have a lid and straw. Staff are allowed to put drinks with caps in the refrigerators to stay cold. During an interview with the DSS on 10/13/21 at 11:00 AM he was asked, What is your policy about staff personal belongings and beverages in the kitchen? He replied They are stored in the office. Open drinks are kept in the office. Drinks are allowed to be put in the refrigerators as long as they are sealed closed and can't spill. If they have been opened and reclosed that is ok. Review of a policy titled Dress Code for Women and Men showed No cell phones in kitchen area. Review of the 2017 FDA Food Code 2-401.11 Eating, Drinking, or Using Tobacco shows (A) An EMPLOYEE shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection cannot result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 55 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 2017 FDA Food Code 6-305.11 (B) showed Lockers or other suitable facilities shall be provided for the orderly storage of EMPLOYEES' clothing and other possessions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 56 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have an effective process in place to ensure one of three sampled residents (Resident 39) and all residents that had food items brought into the facility, were able to receive safe and sanitary food brought in by family or others, and receive assistance with reheating and preparation of food when: Residents Affected - Some 1. Food was not allowed if it did not comply with the resident's diet order. 2. Hot food brought in by family or others was discarded if not eaten within an hour. 3. Nursing would not reheat food for residents. Findings: During an observation of tray line on 10/11/21 at 9:50 AM, the tray tickets (list resident diet order, allergies, food preferences) showed 3 residents (Res) (Res-27, Res-39, Res195) had diet orders including Vegetarian. During an observation and concurrent interview on 10/12/21 09:58 AM, a small, white, refrigerator for storage of resident food was in the nursing station medication room. It contained nutrition supplement beverages, juice pouches, 3 beers, and soda. A box of Uncrustables ready-to-eat sandwiches had a green dot with date 10/8/21. The DSD stated the green dot date is the date the food was brought in. She added it was strange the box of food was still in the refrigerator because normally they only keep food for 72 hours. When asked how food brought from home was handled for residents, the DSD replied staff check to make sure the food is appropriate for the resident's diet. They try to make sure hot food is not in the residents' room for more than an hour. They also keep track of snacks at bedside. When asked what happens when a family brings prepared food in (like casseroles or soups or stews) the DSD stated staff are not to reheat resident food because staff don't check the food temperatures at the microwave. She further stated staff can't take resident food to the kitchen for heating or storage because of the potential for cross contamination. We usually just keep everything for 72 hours. During an interview on 10/12/21 at 10:30 AM, Res-39 stated he is East Indian/[NAME] and does not speak English. Licensed Nurse -B (LN-B) agreed to translate for our interview. When asked how he liked the vegetarian food here Res-39 replied Sometimes it's good and sometimes it's not. He likes Indian food, and they don't offer it here. Res-39 stated he doesn't like the vegetarian (imitation) meats or tofu served there. He likes whole wheat tortillas, lentils and soups. Family brings Indian food from home, but they weren't allowed to bring it when there was a COVID resident at the facility. During an interview with the Dietary Services Supervisor (DSS) on 10/12/21 at 11:00 AM, he stated no food brought in by resident families is allowed into the kitchen. They don't store it or heat it for residents. During an interview with the DSS on 10/12/21 at 11:15 AM, he was asked how the facility worked with food preferences for the East Indian/[NAME] residents? He replied I tell them we have a designated menu, and we stick to it. If you want something else the family can bring it in. I tell them we don't have a cultural menu here. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 57 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Registered Dietitian (RD) on 10/13/21 at 12:07 PM, she stated she only started working there the previous week, and it was her 4th day here. She didn't know yet how the facility worked with resident food brought in by family or the cultural food needs of residents. During an interview at the nursing station on 10/13/21 at 2:40 PM, LN-A stated the nurses do the new admission facility orientation. She stated they tell the residents about their mealtimes and alternative meal choices but it's the RD's responsibility to talk to residents and families about food from home. She stated We (the facility/nursing staff) don't encourage residents/families to bring food from outside because of their special diets. Many are diabetic or renal (kidney disease). We tell them about their diet orders. Families must follow the diet orders. They (nurses) don't do any education about food safety with residents or families. Review of a document titled Foods Brought by Family/Visitors revised October 2017 showed: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format he or she can understand. Family/visitors are asked to prepare and transport food using safe food handling practices, including: safe cooling and reheating processes; holding temperatures; preventing cross contamination with raw or undercooked foods; hand hygiene. The nursing staff will discard perishable foods on or before the use by date. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. Review of a document titled Consultant Dietitian Monthly Report dated 3/30/21 showed RD and FNSD and Administrator met to go over the Policy of foods brought in from home. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 58 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to ensure that their Quality Assurance and Performance Improvement plan (QAPI) committee identified and developed action plans to correct the deficient practices in the delivery of quality nursing care, prior to the survey findings. These failures resulted in a substandard quality of nursing care and actual harm to one resident (Resident 99). These failures had the potential to further affect the health, safety and well-being of all of the residents in the facility and leave them vulnerable to poor quality nursing care. Findings: On 10/14/2021 at 1:15 PM, a concurrent interview and review of the facility's QAPI binder was conduced with the Admin. The Admin stated that it is the responsibility of each department manager to identify resident care areas that need improvement. The department manager should then bring their quality of care concerns to the QAPI committee meetings that are held monthly and quarterly. The purpose of the meetings were to identify and develop action plans to correct these deficient areas. This should be done by utilizing training, monitoring tools and direct observation by the department manager. If an action plan does not produce the desired results, then a new action plan woud be developed. This process is ongoing until the quality deficient areas of resident care are corrected. -The Admin stated that the Director of Nursing (DON) had not brought any indicators of deficient nursing care and services to the QAPI committee meetings. Refer to F580, F636, F656, F658, F684, F697, and

F726. -The Admin stated that the nursing concerns currently being discussed in the QAPI meetings were about hiring nurses and the retention of those nurses. He was not aware of the competency of those nurses. The Admin was not aware that Resident 29 had received unsterile bladder irrigations because the nursing staff lacked knowledge regarding sterile procedures. (Refer to F880). -The Admin was not aware that the nursing staff had insufficient knowledge of how to care for a PICC line (a peripherally inserted central catheter that is inserted in the upper arm for long term intravenous therapy-IV) for Resident 20. He was not aware that the DON had made policy changes and was not using the Pharmacy's IV Therapy/management policy and procedures. (Refer to F684). -The Admin was not aware of the repeated incompetent care and lack of nursing assessments that Resident 99 had received which subsequently contributed to her death. (Refer to F684) During an interview on 10/14/2021 at 10:30 AM, the DON stated the Admin had been managing two facilities since July 2021. DON stated he spent about 50 percent of the time between the two facilities, unless one of the facilities needed more support. DON stated she had not brought any issues to the QAPI about nursing services related to pain or skin assessments due not having a medical record staff member until recently to perform the audits. A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Plan revised April 2014, directed the following: This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 59 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 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 0867 quality, and resolve identified problems. Level of Harm - Minimal harm or potential for actual harm Objectives: Residents Affected - Many 1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 3. Provide structure and processes to correct identified quality and/or safety deficiencies; 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; Authority: 2. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. Implementation: 2. This committee shall meet routinely to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. 4. The committee shall approve any corrective actions, including changes in policies and/or procedures, employment practices, standards of care, etc., and shall also monitor all corrective activities for appropriateness and/or the need for alternative measures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 60 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their infection prevention policies and procedures for 3 of 7 sampled residents when: Residents Affected - Some 1. They performed bladder irrigations (using a large syringe with a solution to flush out sediment and matter that may plug the drainage of the catheter) on the resident without using a sterile technique (creating a sterile (germ free) field for the procedure) or sterile supplies (sterile gloves and sterile bladder irrigation kits) and; 2. Nursing staff provided incontinent care (cleansing after emptying the bowel and bladder) without changing gloves or sanitizing their hands before continuing with other care and; 3. Oxygen tubing was observed on the floor beneath the oxygen concentrator (a machine powered by electricity that separates oxygen from the air and delivers it to the resident via the tubing). These failures had the potential to negatively impact the resident's quality of life and quality of care by exposing them to unnecessary bacteria which could cause the residents an infection. (Residents 6, 29, and 30) Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included; Multiple Sclerosis (MS-a disease where the immune system eats away at the protective covering of the nerves and disrupts the communication from the brain to the body), pressure ulcers, Schizoaffective disorder (a combination of depression, delusions, hallucinations, and mania- high energy periods), Mood disorder, seizures, anxiety, chronic pain syndrome, neurogenic bladder (neurological damage to a bladder which causes it not to empty and requires a tube to drain the urine) and a suprapubic catheter (a soft tube that is inserted directly into the bladder through an opening in the lower abdomen to drain urine). On 10/11/21 at 3:16PM, during an observation and interview with Resident 29, a 60 milliliter (ml) syringe in a plastic bag was taped to the foot of her bed. Resident 29 had no knowledge of why the syringe was there. She was observed to have a urinary catheter drainage bag with clear yellow urine hanging from the bed frame. Resident 29 stated that she had MS which is why she had a suprapubic catheter. A review of Resident 29's Physician's Orders for 10/2021, showed that on 10/6/2021 an order was written for Acetic Acid (a vinegar solution commonly used to irrigate bladder catheters and prevent blockage from matter) 0.25 percent (%), Irrigate supra pubic catheter with 30ml (milliliters) BID (twice a day) due to excessive sediment. A review of Resident 29's Treatment Administration Record (TAR) reflected that the original physician's order was obtained on 7/15/2020 and then revised on 10/6/21, for the bladder irrigation. There were no additional directions or instructions on performing this procedure. Nothing in the Physician's Orders or TAR indicated that the nurse should be using sterile technique and sterile supplies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 61 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/13/21 at 9:50AM, LN (Licensed Nurse) B was interviewed. LN B was asked to describe how she performed the bladder irrigation on Resident 29. LN B took the Acetic Acid 0.25% from her treatment cart. She was asked if the solution was sterile or non-sterile. She stated that she did not know and after reading the label determined that the solution was sterile. She then went to the supply room and showed the 60ml syringe that she used to draw up the Acetic Acid solution. When asked if the syringe was sterile, she did not know. The syringe was not sterile. LN B was asked how she created a sterile field for the procedure, she stated I don't. LN B then confirmed that the facility did not have sterile irrigation trays (a manufactured sterile tray of all supplies need to irrigate a catheter including the sterile drapes, syringe and sterile gloves) or sterile gloves available. LN B described that she disconnected the catheter tubing with gloved hands, cleaned the catheter tube with alcohol, drew up 30ml of Acetic Acid 0.25% that she had poured into a non-sterile cup and then irrigated the bladder with a non-sterile 60ml syringe. LN B stated that she was not aware that irrigating a bladder was a sterile procedure. LN B added, I only became the treatment nurse last week and I have not had any training, this is my first job. On 10/13/21 at 10:31AM the Director of Nursing (DON) was interviewed. The DON stated that she was not aware that LN B had not been using sterile technique when irrigating Resident 29's suprapubic catheter. The DON stated, It should be done using sterile technique. A review of the facility's policy titled, Irrigation of Suprapubic Catheter undated, directed the following: The purpose of a proper suprapubic catheter irrigation is to assist in ensuring that the resident's bladder is empty, reduce the chance of infection and keep the device functioning effectively. Procedural Preparation 4. Prepare the necessary equipment and supply; a. Disposable Irrigation set b. Gloves c. Sterile, normal saline solution or Acetic Acid 0.25% Solution d. Alcohol wipes Procedure 1. First, open the irrigation set, which includes a sterile irrigation tray and 60cc catheter tip syringe 2. Fill the tray with the saline or Acetic Acid 0.25% solution (Make sure that the sterility of the tray and solution is maintained, as this will prevent infection). 3. A review of Resident 6's clinical record showed admission to the facility on 3/10/2021 with diagnoses that included cellulitis (a skin infection) of both lower legs, malnutrition due to lack of calories and protein, and heart failure (inability of the heart to pump adequately). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 62 of 63 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yuba City Post Acute 1220 Plumas St Yuba City, CA 95991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a physician's order, dated 3/10/2021, indicated that Resident 6 had oxygen to use as needed. A second order dated 3/26/2021 instructed staff to change Resident 6's oxygen tubing once a week on Saturdays. During an observation, on 10/11/21, at 11:47 AM, an oxygen nasal cannula (the prongs that went in the nose) and tubing were connected to an oxygen concentrator next to Resident 6's bed. The nasal cannula end of the tubing was on the floor and underneath the wheels of the machine. During a concurrent observation and interview, on 10/11/2021, at 12:34 PM, CNA G and CNA H confirmed the oxygen tubing and nasal cannula were on the floor beneath the wheels of the oxygen concentrator. During an interview, on 10/13/21, at 10:35 AM, the Director or Staff Development stated that the oxygen tubing got changed once a week, and if it fell on the floor it was thrown away. 2. During a concurrent observation and interview on 10/12/21, at 11:11 AM, with Certified Nursing Assistant (CNA) P, during incontinence care for Resident 30, CNA P put on gloves and removed Residents 30 soiled brief. CNA P wiped urine and stool from the resident and discarded soiled items. With those soiled gloves on, she placed a clean brief on Resident 30, pulled up Resident 30's covers, handled the bed remote control to adjust the bed, and adjusted the bedside table. CNA P then removed her soiled gloves and washed her hands. CNA P verified that she did not remove her soiled gloves and sanitize her hands when she finished doing the soiled procedure and before doing the clean procedure. CNA P confirmed that she should have done this to prevent contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055092 If continuation sheet Page 63 of 63