Health inspection·January 12, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some forgotten. Confidential Resident 2 indicated again, a staff member would answer the call light but not help the resident, stating, they didn't know who was assigned to that resident and then just left without any explanation. Confidential Resident 2 indicated that made her feel like a non-person, almost invisible. Confidential Resident 2 indicated when she wanted to be put back in bed it was also a challenge as staff would again indicate they needed help or didn't know who was assigned and then leave without following up to ensure her needs were met. During an interview on 1/12/24 at 12:06 p.m., with Director of Nursing (DON), DON indicated there had been measures put in place to better answer the resident call lights and provided an example that during mealtimes, the department managers were expected to answer call lights. DON indicated this would result in a staff member indicating the assigned staff member would be contacted but had thought there would have been follow up with the residents. DON referenced the Call Light Pledge document which all department managers were to sign and agree to adhere to its contents. DON indicated she was not aware of call lights being answered but no follow up regarding the resident needs not being addressed. DON indicated she had not been made aware of staff not being respectful to residents. A review of the facility's, Call Light Pledge Team Approach, not dated, indicated, if you are unable to address the resident's need, inform the resident that you will get someone to help them, the call light should remain on while you find the appropriate staff member responsible for the need. If they are busy and unable to attend the needs, ask someone else. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 2 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one sampled residents' (Resident 18) Responsible Party (RP) Family Member X was able to participate in care conferences. This failure resulted in Resident 18's RP Family Member X not being involved in the overall plan of care with regard to Resident 18's decline in health. Findings: Review of Resident 18's, admission Record, dated 5/3/19, indicated Resident 18 has been admitted to the facility on [DATE] with a history of unspecified dementia, chronic kidney disease and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems). The admission Record document indicated Resident 18's RP was listed as Family Member X. During an interview on 1/9/24 at 5:26 p.m., with Resident 18's Responsible Person (RP) Family Member X, RP Family Member X, indicated he had wondered when the next care conference was scheduled since he wanted to discuss some issues regarding Resident 18's decline in health. RP Family Member X, indicated Resident 18 was able to use a motorized wheelchair and was able to transition to the bathroom with assistance to urinate and or defecate but recently had not had the strength in his legs to transfer. RP Family Member X, indicated Resident 18 had to have a device to hoist him from the wheelchair to the toilet and Resident 18 did not understand this new change and was very frustrated when he had to wait for the hoist. RP Family Member X, indicated that the discussion took place with a member of the management team who then instructed RP Family Member X that if RP Family Member X, wanted to be apart of care conferences, he would have to make special arrangements to be invited. RP indicated in the past (prior to 2023), he had been invited to all of the care conferences held for Resident 18 but only in the last year had he not been invited and was surprised he was being instructed to schedule a care conference. Review of Resident 18's, Multidisciplinary Care Conference dated, 8/12/22, 1/20/23, 2/7/23, 5/19/23, 8/21/23 and 11/22/23 indicated RP or family were invited to care conferences. The care conference dated 1/20/23 was the only care conference which indicated that the RP Family Member X had attended the care conference. The other care conferences did not indicate if Resident 18's RP Family Member X or of another family member attended the care conferences. During an interview on 1/11/24 at 9:48 a.m. Social Services Director (SSD) indicated that the process for the facility to invite the RP to attend care conferences was to contact them by telephone and leave a message with the date and time of the care conference. SSD indicated the facility did not keep track of the responses to the invitations; for example, if the RP had to work that day or if there were other scheduling conflicts. SSD indicated the care conference would document who was invited and then there would be documentation as to who attended as well. Review of the facility's policy and procedure, titled, Comprehensive Person-Centered Care Planning, dated 11/18, indicated II. Interdisciplinary Team (IDT) .v. To the extent practicable, the resident and the resident's representative(s). An explanation must be included in a resident's medical record if participation of the resident and their representative is determined not practicable for the development of the residents' care plan .F. Each resident and/or resident representatives will actively remain engaged in his or her care planning process through the resident's rights to participate in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 3 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0553 Level of Harm - Minimal harm or potential for actual harm the development of, and be informed in advance of changes in the plan of care .A. The facility must provide the resident and representative, if applicable reasonable notice of care planning conferences to enable resident and representative participation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 4 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interview and record review the facility failed to safeguard one of one sample residents when Resident 18 had lost his glasses and the facility did not know nor replace his glasses. This failure resulted in Resident 18 wearing non- prescription glasses until his eyes were re-examined and potentially injuring himself by running into obstacles not in focus. Findings: During an observation an interview and observation on 1/8/24 at 1:19 p.m., with Resident 18, he indicated he was not aware how long he had resided at the facility. Resident 18 indicated during the interview that his memory was not so good anymore. Resident 18 was observed wearing glasses with a clear lens so as not to be confused with sunglasses on his face. During a telephone interview on 1/9/24 at 5:26 p.m., Resident 18's Responsible Party (RP) indicated Resident 18 had an eye appointment and received new prescription glasses, but the glasses were lost approximately a year and half ago. Resident 18's Responsible Party indicated he had contacted the facility and had been waiting for the facility to find the glasses or replace them. Resident 18's RP indicated Resident 18 was wearing glasses but those were purchased at a store and not prescription. Resident 18's RP indicated the facility was aware of the prescription glasses because the facility had arranged transportation to the various appointments to obtain the glasses. Resident 18's RP indicated he had not had any resolution regarding the lost glasses, and there was no communication regarding any resolution. During an interview on 1/10/24 at 10:26 a.m., with Social Services Director (SSD), SSD indicated she was not aware that Resident 18 had lost his prescription glasses. SSD indicated Resident 18 had an eye appointment back in November but did not think Resident 18 had received new glasses. During a review of Resident 18's, Resident's Clothing and Possessions from, dated 3/18/20, indicated Resident 18 had glasses on his belonging's list but no indication of any identifying feature which would help in locating the glasses indicated on the form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 5 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to: 1. Replace the roof which had been leaking for at least three years, and 2. Had shower doors which locked and were not easily accessed by staff. These failures resulted in residents living in an environment that was visibly in need of repair and upkeep. Findings: 1. During a phone interview on 1/9/24 at 11:09 a.m., a confidential family member stated she felt the facility looked neglected and could use a good cleaning and paint job. She stated whenever she came here to visit her mom she wanted to bring her gardening gloves and pruning sheers and go to work on the grounds. During an observation on 1/10/24 at 8:25 a.m., while rain was falling on the roof of the facility, the rain gutter and eave midway toward the entrance of the facility looked broken/rotten. Rain water was pouring over the gutter like a waterfall in front of a resident's window as the rain was coming down. Note: a photo was taken of the rotten gutter and eave. During an observation on 1/10/24 at 9:54 a.m., heavy rain was falling on the roof of the facility. A trash can was noted in the lobby of the facility in the middle of the floor outside the billing office with a yellow caution cone next to it. The trash can had water dripping into it from the ceiling and had approximately one to two inches of water inside. During an interview on 1/11/24 at 11:35 a.m., the Maintenance Director was asked about the broken/rotten gutter and eave midway toward the entrance of the facility and the water pouring over the gutter like a waterfall in front of a resident's window as the rain was coming down. The Maintenance Director stated the facility had quotes for the roof and gutters. The Maintenance Director stated he had to go up and clean the gutters during the fall to winter (2.5 months) daily because of the wind and debris from the surrounding trees. During an interview on 1/11/24 at 11:55 a.m., Director of Nursing (DON) stated she had been working at the facility for five years and the roof of the facility had been leaking for the past three years. DON verified the roof was leaking into the lobby, and had also been leaking when one of the surveyors was at the facility in November 2023. DON stated they had had five to seven roofing companies come out to the facility recently to make bids on replacing the facility roof. DON stated some of the roofing companies that came out had told them, We already gave you bids, and she was hoping that with the new administrator, they will finally accept one of the bids and get the new roof. During an interview on 1/11/24 at 4:20 p.m., Administrator stated he had two bids from the five companies that came out to evaluate the roof. Administrator stated he was expecting three more bids and once they were all in, he would pick one to do the job. When queried, Administrator stated he had the roofing companies come out because the roof just looked like it needed to be replaced and it looked like it had needed to be done for a while. He stated he did not understand why it was not done a long time ago since some of these roofing companies already came out before and gave bids but the job was never done. Review of provided roof replacement bids indicated one roofing company provided their proposal on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 6 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0584 12/27/23 and a second company provided their proposal on 12/6/23. Level of Harm - Minimal harm or potential for actual harm Review of facility policy Resident Rooms and Environment, last revised 1/1/12, indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment. Residents Affected - Some 2. During an interview on 1/10/24 at 2:26 p.m. Confidential Resident 34 indicated there had been at least three separate instances where the staff assisting in showering a resident had to leave and the resident had been locked in the shower and the key to unlock the door was not readily available. Confidential Resident 34 indicated the first instance occurred when a staff member was assisting a resident in the shower and had to leave for a second to grab something and the door going into the shower was locked so when the staff left the shower room, the door remained locked. The staff member could not get back into the shower room and the resident in the shower could not manage to independently open the door from the inside. Confidential Resident 34 indicated the door to the shower room had a lock on the outside for which a key would open the door and from the inside there was button type device to unlock the door from the inside. The room was large with multiple showers and room for wheelchairs and to leave the shower staff would require navigating multiple feet to access the door to then open it. Residents, who would be wheelchair bound and seated in a shower chair would not be able to navigate a wet slippery floor or residents who do not use assistive devices would find it dangerous to navigate a slippery floor to open the door or risk falling. Confidential Resident 34 indicated there was a scramble to find the key and then open the shower door to finish showering the resident. Confidential Resident 34 indicated it happened at another time where the resident was able to open the door from the inside after the key to access the door was not readily available. Confidential Resident 34 indicated the third time the same scenario occurred, the staff had determined the key to open the shower door was taken home by management and they had to come back to the facility open the door. Confidential Resident 34 indicated that since the issue had occurred multiple times and the facility was aware of the issue; there was no reason for this to keep happening and it would be scary to be locked in the shower room. During an interview on 1/10/24 at 4:30 p.m., with Licensed Staff G, Licensed Staff G indicated she was not sure who had the key to shower room and thought the unlicensed staff members would have the key. Licensed Staff G indicated she had just asked an unlicensed staff member for the shower key and that person did not have key to the shower room. Licensed Staff G indicated a key ring from the nursing station which had many keys on it, none of which were labeled and thought the key might be one of those, but she would have to check each key to see if one of the keys would open the lock. During an interview and concurrent observation on 1/10/24 at 4:36 p.m., with Licensed Staff H, Licensed Staff H indicated she had the key for the shower and then proceeded to attempt to unlock the door. The key was able to be inserted into the locked door but the key did not unlock the door after multiple attempts. During a concurrent observation and interview with Licensed Staff G, Licensed Staff H and Maintenance Director in front of the East Shower room door, Maintenance Director compared his key to the shower room door with Licensed Staff H's key and the markings were observed to be identical. Maintenance Director proceeded to use Licensed Staff H's key to unlock the shower room door and again the key would enter the lock but not unlock the door. Maintenance Director further examined the key and observed there was a light bend in the tip of the key, indicating that's why the key did not unlock the door. Licensed Staff G attempted to find the shower key on the key ring and found the key to unlock the door after multiple attempts with other keys on the key ring. Maintenance Director indicated he had made numerous copies of the shower keys for the licensed and unlicensed staff but had asked an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 7 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0584 unlicensed staff prior to the interview and the staff member did not have the shower key on their person. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/10/24 at 4:51 p.m., with Director of Nursing (DON) indicated she was not aware of the issue with the shower keys. DON indicated there could be a large safety concern if a resident was locked inside the shower and the key could not be accessed readily. DON indicated the Administrator should be included in the conversation. Residents Affected - Some During a concurrent interview on 1/10/24 at 4:56 p.m., with Administrator and DON, Administrator indicated there could be a serious safety harm situation if a resident was locked in the shower room and the key was not readily available. Administrator indicated he was going to have a conversation with the Maintenance Director to come up with a safer plan with regards to the shower room doors. During an observation and interview on 1/10/24 at 6:03 p.m., with Administrator, he was observed to place a shower key which was attached to a large green label placed in a plastic sleeve, Shower Key on a hook hanging next to the shower room. Administrator indicated each shower room had the same key, meaning each key would fit all the shower doors and each shower room had the same key and identifier so any resident who might get locked into the shower room would have readily available access to enter the shower room. The key was placed high enough so residents would not be able to enter the shower room while someone was in the shower but low enough that all staff would able to access the room in an emergency. During a review of the facility's policy and procedure titled, Residents Rooms and Environment, dated 1/1/12, Purpose to provide residents with a safe, clean, comfortable and homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 8 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review the facility failed to keep one of one sampled resident (Resident 38), safe from verbal abuse. This failure resulted in Resident 38 suffering verbal abuse from a staff member. Findings: During a review of a facility-reported event to the Department, dated 12/26/23 , between Resident 38 and Unlicensed Staff E, it indicated Unlicensed Staff E was speaking disrespectfully to Resident 38 as described, stop and eat your lunch, you are a grown ass man. Unlicensed Staff E was indicated to then slam the desert on Resident 38's lunch tray causing it to fall on the ground. Unlicensed Staff E was indicated to state, now I have to go an get you another one. During a review of Resident 38's, admission Record, dated 9/26/23, indicated Resident 38 was admitted to the facility on [DATE], with a history of end stage liver disease , hepatic encephalopathy, chronic diastolic heart failure and chronic hepatic failure for which he was place on end of life care. Multiple attempts were made to interview Resident 38 on 1/8/24 at 3:29 p.m., on 1/9/24 at 10:00 a.m., 1/9/24 at 1:45 p.m. and 1/10/24 at 2:05 p.m. and Resident 38 would not engage in speaking with surveyor. During a concurrent interview and record review on 1/12/24 at 10:22 a.m., with Director of Staff Development (DSD), DSD indicated Unlicensed Staff E had been terminated. During a review of Five Day Investigation, dated 12/27/23 indicated the allegation was found to be substantiated and Unlicensed Staff E was terminated. A review of Corrective Action Memo, dated 1/3/24 indicated the allegation of abuse had been substantiated and Unlicensed Staff E had been terminated. DSD indicated Unlicensed Staff E had been employed at another local facility and a similar incident had occurred but the decision to hire Unlicensed Staff E was based upon giving Unlicensed Staff E another chance. A review of, Background Check dated 11/29/23 indicated there were no reports of physical or mental issues which would preclude Unlicensed Staff E from being hired at the facility to provide safe resident care. A review of the facility's policy and procedure titled, Abuse-Prevention, Screening, & Training Program, dated 7/18, The facility does not condone any form of resident abuse .The Facility obtains at least two (2) reference checks from previous or current employers of applications prior to hire .The Facility does not knowingly continue to employ individuals who have been found guilty of abuse .or mistreatment or had a disciplinary action taken against his/her professional licensure .The Facility conducts observation rounds on each shift to observe for adequate lighting, resident (s) congregating in areas where observations is not possible or where potential conflicts can arise .The Facility identifies, corrects and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 9 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or their responsible party with a summary of the resident's Baseline Plan of Care for two of 24 sampled residents (Resident 21 and 102). This failure had the potential to limit communication with the resident and/or their responsible party on how the facility planned to manage the resident's needed services and treatments while at the facility, which could have led to the resident feeling stressed, uneasy and lack of trust with the staff providing care, leading to negatively affecting the resident's physical and psychosocial well-being. Findings: 1. A review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis including CHF (Congested Heart Failure: long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Non-Stemi Myocardial Infarction (Partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle), Atrial Fib (extremely fast and irregular beats from the upper chambers of the heart), abnormalities of gait (person's manner of walking) and mobility, muscle weakness, cellulitis of the groin (a bacteria infection that develops in your skin), amongst others. A review of Resident 21's Progress Note - MD (Doctor of Medicine) History and Physical, date 12/28/23, indicated: History of Present Illness: CHF, COPD (Chronic Obstructive Pulmonary Disease: is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), tobacco dependence, and history of colon cancer, who presented at the hospital with shortness of breath and weakness and was treated for acute CHF and failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) . During his hospitalization the patient was declining a lot of medications, so he was educated about the importance of medication compliance . Assessment/Plan: . He had been in atrial fib at the hospital secondary to CHF. Returned to a normal sinus rhythm (rhythm of a healthy heart) after diuresis (increase urine output) . He was on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting) although no longer is on and unclear details why: Continue Apixaban as ordered, monitor for sign/symptoms of bleeding, continue monitoring heart rate and rhythm with vital signs specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), and with each visit, weigh benefits versus risks of chronic anticoagulation . A review of Resident 21's Admitting MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 12/25/23, indicated Resident 21s BIMS (Brief Interview of Mental Status) of 13 (cognitively intact: the ability to clearly think, learn, and remember). A review of Resident 21's Baseline Care Plan - V2, signed and dated by DON (Director of Nursing) on 12/20/23, indicated Resident 21 wanted to return to the community, occasionally incontinent of urine and bowel, on a diuretic and anticoagulant (blood thinner to prevent clots from forming), on Black Box medications (added to the labeling of drugs or drug products by the Food and Drug Administration when serious adverse reactions or special problems occur, particularly those that may lead to death or serious injury), medication list provided to Resident 21, admitted with two UTDs (Unstageable Full Thickness Skin or Tissue Loss - Depth Unknown) on right buttocks, physical therapy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 10 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some occupational therapy to improve functional status, amongst other information and goals. Under 5. Baseline Care Plan Summary and Signatures: B.: Resident Signature and Date, Resident 21's name was typed in and no date. There was no indication Resident 21 received a copy of his Baseline Care Plan. During an interview on 1/9/24 at 8:48 a.m., Resident 21 could not recall if he received a copy of his Baseline Care Plan indicating his goals and if he signed the care plan. Resident 21 stated he did get a list of the medications he was being administered. 2. A review of Resident 102's admission Record, indicated Resident 102 was admitted to the facility on [DATE], with a diagnosis including pneumonia caused by streptococci (infection of the lungs caused by a bacteria), COPD, acute duodenal ulcer with hemorrhage (bleeding open sore located in the first part of the small intestines), abnormalities with gait and mobility, depression, moderate protein-calorie malnutrition (lack of proper nutrition), chronic CHF, Type Two Diabetes (blood sugar to high), amongst others. A review of Resident 102's Baseline Care Plan - V2, signed and dated by DON on 1/6/23, indicated Resident 102's vision was impaired, preferred a shower, family or significant other involvement in care discussions, initial discharge goals: return to the community, substantial/maximal assistance with oral care, dependent on toilet hygiene, shower, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and mobility, history of falls prior to admission, stage three pressure ulcer (deep, crater-like wound in the skin extend through the skin into deeper tissue and fat but does not reach muscle, tendon, or bone) on right buttocks, amongst other information and goals. Under 5. Baseline Care Plan Summary and Signatures: B.: Resident Signature and Date, Resident 102's name was typed in and no date. There was no indication Resident 102 received a copy of his Baseline Care Plan. During an interview on 1/10/24 at 2:49 p.m., the Director of Nursing (DON) stated the resident Baseline Care Plan was an IDT (Interdisciplinary Team: brings together knowledge from different health care disciplines to help people receive the care they need) effort. The DON stated the appropriate staff and disciplines based on the resident's needs such as nursing, dietary, activities, social services, physical therapy and so on, would meet with the resident and go over their part of the resident's Baseline Care Plan, which included goals and interventions. The DON stated a copy of the resident's medication list was given to the resident. When the DON was asked how one would know if the various disciplines met with the resident and/or their responsible party and went over the resident's immediate healthcare treatment/interventions and goals if the resident or responsible party did not sign, date and receive a copy the resident's Baseline Care Plan, the DON stated she thought the resident just needed to be provided their medication list. The facility Policy/Procedure titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated: . Ill. Baseline Care Plan Summary: . b. A copy of the baseline care plan summary will be provided to the resident and/or resident representative . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 11 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 - Few 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 interview and record review, the facility failed for have an individualized care plan for two of 24 sampled residents (Resident 21 and 23) when: 1. Resident 21 was not care planned for being on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting). 2. Resident 23 was not care planned for Hospice [A type of care and philosophy of care that focuses on the palliation (easing the severity of a pain or a disease without removing the cause) of a chronically ill, terminally ill, or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs]. The lack of care plans had the potential for direct care staff not to monitor, treat, and reassess and/or prevent: 1. Resident 21 for blood thinner side effects, which include higher risk of bleeding, bruise more easily, may take longer than usual for any bleeding to stop, and may have a higher risk of bleeding if resident takes blood thinners in combination with other medicines that increase ones risk of bleeding, unexpected pain, swelling or joint pain, headaches or weak or dizzy, serious fall or hit on the head. In adequately monitoring of the side effects or injuries could impact one's physical wellbeing, lead to harm and even death. 2. Resident 23 for palliative care and interventions in coordination with the Hospice provider to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the resident. Findings: 1. A review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis including CHF (Congested Heart Failure: long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Non-Stemi Myocardial Infarction (Partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle), Atrial Fibrillation (extremely fast and irregular beats from the upper chambers of the heart), amongst others. A review of Resident 21's Progress Note - MD (Doctor of Medicine) History and Physical, date 12/28/23, indicated: History of Present Illness: CHF, COPD (Chronic Obstructive Pulmonary Disease: is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), tobacco dependence, and history of colon cancer, who presented at the hospital with shortness of breath and weakness and was treated for acute CHF and failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) . During his hospitalization the patient was declining a lot of medications, so he was educated about the importance of medication compliance . Assessment/Plan: . He had been in atrial fib at the hospital secondary to CHF. Returned to a normal sinus rhythm (rhythm of a healthy heart) after diuresis (increase urine output) . He was on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting) although no longer is on and unclear details why: Continue apixaban as ordered, monitor for sign/symptoms of bleeding, continue monitoring heart rate and rhythm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 12 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 - Few with vital signs specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), and with each visit, weigh benefits versus risks of chronic anticoagulation . A review of Resident 21's Order Summary Report, dated 1/10/24, indicated Resident 21 was on Apixaban 5 mg (milligrams) one tablet by mouth two times a day for atrial fibrillation, start date 12/18/23. Resident 21's MAR (Medication Administration Record), dated 12/2023, indicated Resident 21 started on Apixaban 12/18/23 at 9 p.m. During a concurrent interview and record review of Resident 21's Care Plan on 1/10/24 at 9:54 a.m., the DON (Director of Nursing) stated, Yes, Resident 21 should have a Anticoagulant care plan because he was on Apixaban, but she could not find one. The DON stated she would start the resident's Anticoagulant care plan upon the resident's admission because blood thinners were high risk medications, whereby a resident needed to be monitored closely for bruising/bleeding, but she missed Resident 21's. During an interview on 1/10/24 at 3:58 p.m., the DON stated any nurse could have started a care plan for Anticoagulant. During an interview on 1/12/24 at 9:15 a.m., the Infection Preventionist (IP) stated if a resident was started on a blood thinner, any nurse receiving the order could start the Anticoagulant care plan. The IP stated sometimes a traveling nurse would miss doing the care plan. The IP stated the admin group such as the DON, DSD (Director of Staff Development), or Stat Nurse (helps with Admissions) would start the care plan including the Anticoagulant care plan. The IP stated they have a 24-hour report (all new orders including new admits) are reviewed at their Stand-up meeting in the morning. The IP stated the DON would delegate at the Stand-up meeting, Monday through Friday, the resident's care plan to be implemented to her, the MDS (Minimum Data Set) Coordinator or the DSD (Director of Staff Development). 2. A review of Resident 23's admission Record indicated Resident 23 was admitted on [DATE], with a diagnosis including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), neuralgia (intense, typically intermittent pain along the course of a nerve, especially in the head or face) and neuritis (inflammation of a peripheral nerve or nerves, usually causing pain and loss of function), major depression, stage three chronic kidney disease (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), muscle weakness, amongst others. A review of Resident 23's orders indicated Resident 23 was ordered to be admitted to Hospice, dated 6/16/23. A review of Resident 23's Nutrition/Dietary Note, dated 6/16/23, indicated Resident 23 was down 35.6 pounds (19.2%) weight over the past six months. Resident 23 had an overall decline in condition, appetite and meal intakes had gradually declined as had Resident 23's ability to feed self. Resident 23's physician was notified about weight loss and Resident 23 had been admitted to Hospice. A review of Resident 23's Certification Statement for the first 90-days (the hospice provider must maintain an initial certification that the patient is terminally ill in the patient's medical records), indicated Resident 23 was admitted to Hospice on 6/16/23, and Resident 23's first benefit period (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 13 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 was 6/16/23 to 9/13/23. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review of Resident 23's Care Plan on 1/10/24 at 9:54 a.m., the DON stated there was a MDS Significant Change in Status, dated 6/23/23, because Resident 23 was placed on Hospice Care, but Resident 23's Hospice care plan was not started. The DON stated it was a combination of herself per her audits and the MDS Coordinator, who were responsible for the Hospice care plans. The DON stated the Hospice care plan should show a plan of care and end of life wishes, which should coincide with the Hospice provider care plan, so everyone involved in Resident 23's care were on the same page and were honoring Resident 23's wishes. Residents Affected - Few During a concurrent interview and record review on 1/12/24 at 10:20 a.m. The MDS Coordinator stated Significant Change in Status would automatically be triggered when a resident went on Hospice. The MDS Coordinator stated when she completed Resident 23's Significant Change in Status MDS, dated [DATE], because Resident 23 was admitted to Hospice, she should have started a Hospice care plan for Resident 23. The MDS Coordinator stated any nurse could have started Resident 23's Hospice care plan and added to the care plan per Resident 23's needs. The MDS Coordinator stated she would send out an e-mail notifying the various departments that the resident was now on Hospice so they can add to the care plan. The facility Policy/Procedure titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated: . Policy: It is the policy of this Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing . IV. Comprehensive Care Plan: . c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MOS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems, ii. Change of condition, iii. In preparation for discharge, iv. To address changes in behavior and care, and v. Other times as appropriate or necessary . The facility Policy/Procedure titled, Hospice Care of Residents, revised 1/2012 indicated: . Procedure: . III. B. The Hospice and Facility will collaborate on a Care Plan for the resident . The facility job description titled, DON, undated, indicated: . Supervision: . Assures that a resident Plan of Care is established for each resident and that the plan is reviewed and modified as needed . The facility job description titled, LVN Staff Nurse, undated, . Clinical: . Assists in developing, reviewing, revising, and updating resident Plans of Care as indicated. Contributes to the evaluation of the patient's progress towards specific goals and the adjustment of the nursing plan of care as necessary . The facility job description titled, RN Staff Nurse, undated, indicated: . Clinical: . Conducts daily resident rounds to assess and evaluate the resident's physical, medical and emotional status and to implement or revise nursing interventions to the resident plan of care . Initiates, reviews, revises, and updates resident Plans of Care as indicated. Evaluates the patient's progress toward specific goals and adjusts the nursing plan of care, as necessary . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 14 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 The facility job description titled, Medicare/MDS Coordinator, undated, indicated: . General Duties and Responsibilities: Clinical: . Coordinates development, implementation and evaluation of plan of care . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 15 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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: 1. Verify the identity of a resident prior to medication administration; and 2. Carry out a physician order for a referral to an out-of-town physical therapy clinic (Resident 19). These failures had the potential to result in a medication error or delay treatment for Resident 19's back pain. Residents Affected - Few Findings: 1. During an medication pass observation and concurrent interview on 1/10/24 at 5p.m., Licensed Staff D entered a resident's room with a cup of medications. Licensed Staff D greeted the resident and the resident took her medications with water. Licensed Staff D returned to the medication cart to document the medications. When queried, Licensed Staff D stated she identified the resident by greeting her with her name and the resident answered. Licensed Staff D stated the facility did not have arm bands for the residents, so she did not have any other way to verify their identity. During an interview on 1/11/24 at 3:22 p.m., Director of Nursing (DON) stated it was her expectation that the nurses verify residents' identity prior to medication administration by using the residents' pictures on their profile in the electronic medical record and use their wrist band with their name or ask the resident to state their name. DON stated that for residents without a wrist band or unable to state their name, the nurse should have a second staff verify their identity. DON stated the facility does have arm bands but some residents choose not to wear them. DON stated Licensed Staff D's way of identifying the resident (greeting the resident with their name) was not a formal identity check because the resident might respond to be polite, not because the nurse said their correct name. Review of facility policy and procedure Medication - Administration, last revised 1/1/12, indicated, The Licensed Nurse will verify the resident's identity before administering the medication. The procedure did not describe how the resident's identity will be verified. 2. During an interview on 1/8/24 at 3:29 p.m., Resident 19 stated he was not getting the treatment he needed in Santa [NAME] for his SI (sacroiliitis, a condition that causes pain in the lower back, buttocks, or down the legs). He stated he had been asking for two years, but no one would get him down there. Review of Resident 19's facesheet revealed he had been admitted to the facility on [DATE] with multiple diagnoses including above-the-knee amputations of the left leg, below-the-knee amputation of the right leg, chronic pain syndrome, and phantom limb syndrome with pain (sensation of pain in a limb that is no longer there). Review of Resident 19's physician orders revealed an order dated 8/29/23, Please refer patient to [clinic named] PT (physical therapy) in Santa [NAME] for back pain with degenerative disc disease [phone number written] (Patient will arrange transportation with Partnership. Review of Resident 19's physician progress note dated 8/29/23 indicated, Like to go to Santa [NAME] for Madek Machine for the back exercise. Will order [clinic named] PT in Santa [NAME] [phone number written]. Resident 19's physician progress note dated 9/19/23 indicated, He thinks physically if his SI joints to be adjusted [sic]. MADAC machine can stretch his spine be more ROM (range of motion) [sic] he'll be able to transfer self. Review of Resident 19's physician progress note dated 11/10/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 16 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 Residents Affected - Few indicated, Want to send x-ray in [local hospital named] to Santa [NAME] [clinic named]. Plan: . Obtain xray report . send to Santa [NAME]. Resident 19's physician progress note dated 12/19/23 indicated, Awaiting for Santa [NAME] response. During an interview on 1/11/24 at 2:20 p.m., Social Services Director (SSD) stated she had sent the referral to the Santa [NAME] clinic on 9/1/23 and 9/12/23 and sent an email last Friday and all are not going through, they get sent back. She stated attempts to call the clinic have failed, she gets an error message that the call is out of area. SSD stated, He's just going to need to go to outpatient therapy here. It's going to be very difficult to arrange transport down to Santa [NAME]. When queried, SSD stated that since she was unable to make the referral, she needed the doctor to tell her what to do because she cannot get a hold of the clinic. SSD denied asking anyone else to help her with getting through to the clinic. Review of the clinic's website on 1/11/24 at 2:51 p.m. revealed the phone number listed matched the phone number written in the physician's order dated 8/29/24. The survey team was able to successfully call the clinic. During an interview on 1/11/24 at 3:22 p.m., Director of Nursing (DON) stated that it was her expectation that if SSD was unable to carry out the order for Resident 19's referral, she should reach out to her for help. DON stated it was also her expectation that if an order for a referral could not be carried out that SSD notify the physician. DON stated the potential outcome to Resident 19 if he did not get the treatment at the clinic was he would not meet his goals and he could decline in function. Review of facility policy and procedure Referrals to Outside Services, last revised 12/1/13, indicated, Purpose: To provide residents with outside services as required by physician orders or the Care Plan. Policy: The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 17 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide an annual review for one (Unlicensed Staff F) out of one sampled unlicensed staff. This failure had the potential for unlicensed staff working in the facility to be either incompetent or inappropriately working with residents. Residents Affected - Few During a concurrent interview and record review on 1/12/24 at 10:22 a.m. with Director of Staff Development (DSD), DSD indicated that Unlicensed Staff F was initially hired at the facility on 3/16/16. DSD was unable to locate the annual review document for 2022 or 2023. DSD indicated Unlicensed Staff F had been terminated as of 10/24/23 but could not locate the paperwork to indicate cause for termination. DSD was reviewing piles and piles of loose papers in folders and unable to locate the annual review documents or cause for termination. DSD was able to locate in-service training through labeled binders but nothing further. Review of the facility's policy and procedure titled, Staff Competency Assessment, dated 3/17/22, indicated, Competency assessments will be performed upon hired during the employee's 90-day employment period, annually, or anytime .Competency assessment is completed in order to evaluate an individual's performance, evaluate group performance, meet standard set by regulatory agencies, address problematic issues .Each department manager or supervisor will be responsible to see that staff have competency assessments performed for their respective staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 18 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 one of 24 sampled residents (Resident 21) was being monitored closely while on Eliquis (Apixaban: blood thinner (anticoagulant) medicine that reduces blood clotting). Not monitoring for the risks for blood thinner side effects, which include higher risk of bleeding, bruise more easily, may take longer than usual for any bleeding to stop, and may have a higher risk of bleeding if resident takes blood thinners in combination with other medicines that increase ones risk of bleeding, unexpected pain, swelling or joint pain, headaches or weak or dizzy, serious fall or hit on the head could impact one's physical wellbeing, lead to harm and even death. Residents Affected - Few Findings: A review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis including CHF (Congested Heart Failure: long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Non-Stemi Myocardial Infarction (Partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle), Atrial Fibrillation (extremely fast and irregular beats from the upper chambers of the heart), amongst others. A review of Resident 21's Progress Note - MD (Doctor of Medicine) History and Physical, date 12/28/23, indicated: History of Present Illness: CHF, COPD (Chronic Obstructive Pulmonary Disease: is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), tobacco dependence, and history of colon cancer, who presented at the hospital with shortness of breath and weakness and was treated for acute CHF and failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) . During his hospitalization the patient was declining a lot of medications, so he was educated about the importance of medication compliance . Assessment/Plan: . He had been in atrial fib at the hospital secondary to CHF. Returned to a normal sinus rhythm (rhythm of a healthy heart) after diuresis (increase urine output) . He was on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting) although no longer is on and unclear details why: Continue apixaban as ordered, monitor for sign/symptoms of bleeding, continue monitoring heart rate and rhythm with vital signs specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), and with each visit, weigh benefits versus risks of chronic anticoagulation . A review of Resident 21's Order Summary Report, dated 1/10/24, indicated Resident 21 was on Apixaban 5 mg (milligrams) one tablet by mouth two times a day for atrial fibrillation, start date 12/18/23. Resident 21's MAR (Medication Administration Record), dated 12/2023, indicated Resident 21 started on Apixaban 12/18/23 at 9 p.m. During a concurrent interview and record review, dated 1/10/24 at 9:54 a.m., the DON (Director of Nursing) stated upon the resident's admission, high risk medications such as diabetic (lowers one's blood sugar) medications, blood thinners and psychotropics (drugs that affect one's mental status) are entered into the resident's MAR (Medicine Administration Record) for the nurses to monitor for the various side effects every shift. The DON stated Resident 21 should have had monitoring every shift for bleeding and the various side effects in place on Resident 21's MAR because he was on the blood thinner, Apixaban. The facility Policy/Procedure titled, Drug Regimen Review, revised 12/2016, indicated: . Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 19 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few . IV. Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- . Without adequate monitoring . The facility job description titled, DON, undated, indicated: . General Duties and Responsibilities: General: . Assumes ultimate responsibility for coordinating plans for the total care of each resident which comply with physician's orders, governmental regulations, and facility resident care policies . The facility job description titled, LVN, undated, indicated: . General Duties and Responsibilities: General: . Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being. Provides clinical data and observations to contribute to the nursing plan of care . The facility job description titled, RN, undated, indicated: .General Duties and Responsibilities: General: Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being utilizing the nursing process of assessing, planning, implementing, and evaluating patient care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 20 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 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's Quality Assurance and Performance Improvement (QAPI) Committee failed to : Residents Affected - Some 1. Identify failure of staff to follow hand hygiene procedure (Cross Reference F880), 2. Identify failure to provide new residents and families with baseline care plans (Cross Reference F655), 3. Identify the failure of staff to respond to residents' requests for help (Cross Reference F550). These failures prevented the QAPI committee from developing, implementing, and evaluating action plans to correct systematic deficient practices. Finding: During an interview on 1/12/24 at 11:30 a.m. with Administrator and Director of Nursing (DON), Administrator stated the QAPI committee found projects through surveys, complaint investigations, things come up at the meetings, inspections rounds, and floor staff could bring projects. Administrator stated once the committee identified it (a project) we work to fix it. DON stated hand hygiene and baseline care plans were not projects they were currently working on. Administrator stated the committee was not tracking residents' perception of staff response to requests for assistance. Review of facility document 2024 Quality Assurance and Performance Improvement (QAPI) Plan for [facility named], not dated, indicated, The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners . The QAPI team at [facility named] will decide what data to monitor routinely. Areas to consider may include, but not limited to the following examples: Clinical care areas (i.e. pressure ulcers, falls, infections) . Resident satisfaction . Care plans . The document further indicated the committee had two Focus Items: Re-opening the 49 suspended beds and falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 21 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that its staff performed hand hygiene when entering and exiting residents' bedrooms and between doffing and donning of gloves when providing resident care as indicated in the facility's policy and procedure on hand hygiene. This failure had the potential to lead to the spread on infection among other residents. Residents Affected - Few During an observation on 01/09/24 at 08:35 a.m., Unlicensed Staff (Staff B) entered a resident's shared room without performing hand hygiene. Staff B picked up a meal tray and brought it to the cart in the hallway. No hand hygiene was observed being performed by Staff B. During an observation on 01/09/24 at 08:38 a.m. Staff B returned to pick up another meal tray and did not perform hand hygiene prior to entering the resident's room. Staff B proceeded to bring to the meal tray to the cart in the hallway at the nurse's station. Staff B did not perform hand hygiene and went on to perform another task. During an observation on 01/09/24 at 10:06 a.m. in the [NAME] Hallway, Licensed Staff A (Staff A) walked out of a resident's room with gloves on. Staff A was observed removing the gloves while walking towards the nurse's station. Upon removing the gloves and throwing them in a trash can, no hand hygiene was performed. Staff A returned to the [NAME] Hallway, grabbed a pair of gloves from a wall mount and without performing hand hygiene, donned the gloves. Staff A then proceeded into a resident's room to assist with ambulating them. During an observation on 01/10/24 at 12:41 p.m., Licensed Staff (Staff C) was observed walking into a resident's room with a medicine cup in their hand. Upon entering the room Staff C did not perform hand hygiene. Staff C handed the medicine cup to the resident and exited the room without performing hand hygiene. Staff C proceeded to the nurse's station where she performed hand hygiene. During an interview with the Infection Preventionist (IP) on 01/11/24 at 03:01 p.m., when asked about the expectation on hand hygiene for staff when attending to residents, the IP stated, staff are expected to perform hand hygiene whenever they are in contact with a resident or when they enter or leave the residents room. The IP confirmed that all staff at the facility are trained on hand hygiene. During a concurrent interview and record review on 01/11/24 at 03:03 p.m., the IP stated, the facility conducts regular spot check audits to monitor all staff on hand hygiene. While reviewing the documentation on audits, the IP did reveal that there was at least one particular staff member that needed constant reminding on performing hand hygiene. On 01/11/24 04:03 p.m., an Interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed that they (meaning staff) needed to perform hand hygiene when providing residents with care. The DON stated, we have training on hand hygiene annually and with new staff. The DON also confirmed that the facility does regular audits on hand hygiene by conducting spot checks on staff. On 01/12/24 at 11:29 a.m., a review of the facility's policy and procedure titled, Hand Hygiene Infection Control Manual, dated September 1, 2020, the policy read in part, the need for staff to follow the hand hygiene procedures when caring for the residents. Additionally, the policy listed that the wearing of gloves does not replace hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 22 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 A review on one of the facility's referenced sources from the Center for Disease Control and Prevention (CDC) on hand hygiene states, Hand hygiene protects you and those receiving the care you provide. The simple act of cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics. [Reference: https://www.cdc.gov/handhygiene/providers/index.html]. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 23 of 24 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review the facility failed to offer COVID-19 ( an infectious disease caused by the SARS-CoV-2 virus and those infection could experience mild to moderate or severe respiratory illness) immunizations (a process by which a person becomes protected against a disease through vaccination.) as appropriate to four (Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3) out of 12 sampled residents. This failure had the potential for residents to acquire COVID-19 and suffer a more serious illness without the added benefit of having the vaccine in their system. Findings: During a concurrent interview on 1/10/24 at 2:26 p.m. with Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3 all indicated they had wanted to COVID-19 vaccine but were denied by the facility. Resident 30 indicated the facility had indicated the resident would be vaccinated after training for the nurses had taken place but that was back in October of 2023. Confidential Resident 30 indicated the residents were in waiting mode to hear further information about when they would receive the vaccine. Confidential Resident 30 indicated there was fear and concern about the delay in obtaining the vaccine since the facility had just had an outbreak of COVID-19. Confidential Resident 34 indicated there was agreement about the concern and fear of not having the COVID -19 vaccine. Confidential Resident 2 indicated there was frustration and anger about having to wait so long and it didn't make sense that training the nurses would take so long. Confidential Resident 3 indicated frustration about waiting for the COVID-19 vaccine as well. During an interview on 1/11/24 at 2:09 p.m. with Infection Preventionist (IP), IP stated the residents had not been offered the COVID-19 booster due to the corporation requiring testing for the nurses on how to handle and store the vaccine appropriately. IP indicated there was no time frame with regards to training and had no idea when the training would take place. IP indicated there could be a vaccine clinic through multiple agencies who would come and administer the COVID-19 vaccine but that was not put in place due to the pending training. IP confirmed there was no scheduled training or plan to administer the COVID-19 vaccine. During a review of the facility's policy and procedure, titled, COVID-19 Vaccination Program, dated 3/15/22, indicated, Support the safe and efficient distribution of COVID-19 vaccines to Residents and Health Care Personnel .A vaccine administration clinic may be held when there are multiple Residents or Health Care Personnel who require vaccination .COVID-19 vaccine and booster doses of vaccine will be provided by the Facility free of charge . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 24 of 24