Inspection·February 28, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm might be complaining of [Resident 13's] using it. LN 2 stated the facility had their own air freshener spray, however he did not offer it to the resident. LN 2 stated the resident agreed that it was okay for him to discard the spray for which Resident 13 replied, Yes, I agreed to it, but I didn't really have any choice you've told me its unacceptable to use it here. LN 2 acknowledged he was aware the air freshener was the resident's property and he should not have discarded it in the trash. Residents Affected - Few A review of the facility's policy titled, Quality of Life - Dignity, revised 8/2009, indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect .Residents shall be treated with dignity and respect at all times .Residents' .property shall be respected at all times .Demeaning practices .that compromise dignity are prohibited. During an interview with the Director of Nursing (DON) on 2/25/22, at 11:45 a.m., the DON stated the LN 2's actions were inappropriate. The DON stated the staff should not toss the resident's belongings, no matter if they explained why they do it or not. The DON added this was an unacceptable practice .It might have special meaning to the resident .I can understand why the resident was so upset. They should not toss it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 2 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respect the rights of three residents (Resident 9, Resident 17, and Resident 80) for a sample of 24 when: 1. Resident 9's Physician's Orders for Life-Sustaining Treatment (POLST, a written medical order that gives people control over their own care by specifying the types of medical treatment they want to receive during serious illness) was not updated to reflect her wishes; 2. Resident 17's POLST did not contain her signature indicating she wished to receive life-saving treatments; and 3. Resident 80's expressed wishes to receive full treatment in a life saving emergency reflected on the resident's POLST form was not reflected on the resident's physician order and electronic record. Findings: 1. According to Resident 9's admission Record, she was admitted to the facility originally in 2010 and re-admitted in 2011 with multiple diagnoses which included convulsions (uncontrolled muscle contractions) and schizophrenia (mental illness). The admission record indicated her brother was her responsible party (RP, decision maker). A review of Resident 9's Physician's Orders, dated [DATE] indicated, DNR [do not resuscitate]/NO CPR[no cardiopulmonary resuscitation/no chest compressions]/LIMITED INTERVENTIONS [do not intubate]/NO ARTIFICIAL NUTRITION BY TUBE *SEE POLST FOR DETAILS. Further review of Resident 9's clinical record reflected a POLST form signed and dated by the physician and the resident's mother on [DATE], and indicated the resident could have CPR, Full treatment and a defined trial period of artificial nutrition by tube. Review of the facility's undated Advanced Health Care Directives . policy guidelines directed, The IDT [Interdisciplinary, a team of professionals managing resident's care] shall review the resident's wishes at the quarterly care plan conference. If there is any change in the resident's status or desires, the physician shall be notified to reassess the patient. During an interview and concurrent record review on [DATE] at 11:37 a.m., with the Director of Nursing (DON), he stated Resident 9's POLST form should have been reviewed and updated during her care conference and the life sustaining choices updated. 2. According to the admission Record, Resident 17 was admitted to the facility in the fall of 2021 with multiple diagnoses which included depression. Resident 17's clinical record indicated the resident had the capacity to make healthcare decisions. A review of the Minimum Data Set (MDS, resident's assessment tool), dated [DATE], Section S, indicated Resident 17's POLST form was signed by the physician. The MDS indicated the POLST form was not signed by the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 3 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the physician orders for Resident 17 failed to reveal an order addressing resident's wishes for treatment in an emergency. Resident 17's chart, including the electronic chart, did not contain an advance directive. A review of resident 17's POLST form signed by the resident's physician on [DATE], indicated the resident wanted to be resuscitated and to have full treatment, including the trial period of artificial nutrition and feeding tubes. The POLST form failed to contain Resident 17's signature. During a concurrent interview and record review with the LN 1( Licensed Nurse) on [DATE], at 9:30 a.m., LN 1 stated Resident 17 was able to make decisions for herself. The LN 1 further stated the nurses followed the physician's order when the resident has a change in condition. Upon reviewing Resident 17's electronic chart, the LN 1 stated, I can't find her code status (POLST). Usually code status is documented in the resident's profile, below the resident's name. It's not there. LN 1 stated he was not able to find the advanced directive and acknowledged that the POLST form was not signed by the resident. LN 1 stated, If [the POLST] is not signed by the resident, it's not valid. During a concurrent interview and record review with the Social Services Director (SSD) on [DATE], at 9:45 a.m., the SSD stated the POLST form should be completed by the admission nurse or as soon as possible after the admission. The SSD acknowledged that the POLST was not signed by Resident 17. The SSD stated the POLST form was not valid if not signed by the resident and added, It is not valid. Absolutely not. The doctor can write whatever, but it might not reflect the resident's wishes. The SSD stated the facility reviewed POLST forms and discussed residents' code status during their quarterly care conference meetings. The SSD stated, I guess we missed addressing her [Resident 17's] POLST. During an interview with the Director of Nursing (DON) on [DATE] at 3:40 p.m., the DON stated that each resident must have a code status (POLST) documented in their chart. The DON stated, It's very important to have a POLST signed by the physician and resident .Without either of them signed, the POLST is not valid. 3. Review of Resident 80's admission Record indicated he was admitted to the facility in the Fall of 2021, with diagnoses which included a partial amputation of the left leg, heart disease, and dementia (a decline in mental and functional capabilities). The admission Record indicated Resident 80 designated a family member as his Responsible Party (RP,decision maker). During a review of Resident 80's electronic medical record on [DATE], the resident profile included a picture of Resident 80, his name, date of birth , room number, physician name, allergies, and code status as No CPR [Cardio Pulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating]. Review of physician orders for Resident 80 included an order, dated [DATE], which indicated No CPR/No Intubation [a plastic tube inserted through the mouth to the lungs to assist in breathing]. Review of a document in Resident 80's medical record titled Physician Orders for Life-Sustaining Treatment (POLST), indicated the following orders to be carried out during a life-saving emergency: Attempt Resuscitation/CPR .Full Treatment - primary goal of prolonging life by all medically effective measures. The document included the signature of Resident 80's Responsible Party, dated [DATE]. During an interview with the Director of Nursing (DON) on [DATE], at 10:48 a.m., the DON confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 4 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the physician order and the electronic medical record for Resident 80 indicated No CPR/No Intubation. The DON confirmed the POLST indicated CPR and Full treatment. The DON stated nursing staff should have updated the order in the electronic medical record to reflect the resident's wishes indicated on the POLST. A review of the undated facility's policy titled, Advance Health Care Directive, indicated the purpose of the policy was to protect each resident's right to participate in health care decision making. The policy stipulated, All residents .will be encouraged to execute an Advance Health Care Directive (AHCD), .to complete the Physicians order for life sustain treatment .The IDT [Interdisciplinary Team] shall review the resident's wishes at the quarterly care plan conference. If there is any change in the resident's status or desires, the physician shall be notified to reassess the patient. Event ID: Facility ID: 055438 If continuation sheet Page 5 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure privacy was maintained during care for one of 24 sampled residents (Resident 83). Residents Affected - Few This failure had the potential to diminish Resident 83's dignity and self worth. Findings: According to Resident 83's 'admission Record' the facility admitted him over 2 years ago with multiple diagnoses which included dementia and diabetes. The most recent quarterly Minimum Data Set (MDS, an assessment tool) indicated the resident required extensive assistance of 2 or more staff to transfer from the bed to wheelchair and to use the toilet. The MDS also indicated Resident 83 scored 3 out of 15 in a Brief Interview for Mental Status (a screen used to assist with identifying a resident's current cognition) which indicated he had severe cognitive impairment and was not interviewable. On 2/23/22, at 8:54 a.m., Resident 83 was observed lying in bed dressed in a hospital gown during a Medication Administration Observation for his roommate. Resident 83 asked for assistance from Licensed Nurse (LN ) 3 to transfer to his wheelchair. LN 3 was observed holding Resident 83's hand to get him from a lying position to a sitting position towards the edge of the bed. LN 3 did not close the privacy curtains and nor did he close the door to the room. Resident 83 was not wearing pants and his genital area was exposed and visible to the staff noted passing by the hallway. During a concurrent interview with LN 3 on 2/23/22, shortly before 9 a.m., LN 3 stated he should have closed the door to Resident 83's room and closed the privacy curtains when providing care to Resident 83. A review of the facility's 'Quality of Life-Dignity' policy revised 8/2009 indicated in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care . An interview conducted on 2/23/22, at 11:46 a.m., with the Director of Nursing (DON) and with the Assistant DON present, the DON stated the resident's privacy should be maintained during care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 6 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 comprehensive person-centered care plans for two of twenty four sampled residents when: 1. Resident 34 was admitted to the facility with hospice services and did not have a care plan that addressed his hospice needs until 59 days after admission to the facility; and 2. Resident 35, a smoker, did not have a care plan in place that addressed smoking activities. These failures had the potential for the residents' emotional needs and safety needs to go unmet. Findings: 1. A review of Resident 34's admission Record indicated he was admitted to the facility in December 2021 with multiple diagnoses including chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe) and chronic respiratory failure (ineffective exchange of oxygen and carbon dioxide in the blood). A review of Resident 34's Minimum Data Set (MDS-an assessment tool) Cognitive Patterns, dated 1/9/22, indicated he had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 that indicated he was cognitively intact. A review of Resident 34's Order Summary Report, reflected an order ADMIT to hospice .Order Date 12/24/2021. Resident 34's Care Plan Anticipatory Grieving r/t [related to] perceived death-on hospice was initiated on 2/21/22, fifty nine days after admission. During an interview and record review on 2/23/22 at 8:57 a.m. with the Social Services Director (SSD), the SSD acknowledged that Resident 34's care plan, related to hospice, was not initiated until 2/21/22, which was almost two months after Resident 34's admission to the facility with hospice services. The SSD stated the care plan should have been in his chart by the 21st day. During an interview and record review on 2/24/22 at 9:24 a.m. with the Director of Nursing (DON), the DON acknowledged that Resident 34's hospice care plan, initiated 2/21/22, was not done timely. He stated that the expectation is that the care plan would be done soon after admit. The current hospice care plan was completed by the DON on 2/21/22, after he was notified that it had not been done. He stated, at times, the care plan gets missed. If the care plan is missed, this has the potential for the staff not to be aware of the plan of care. 2. A review of Resident 35's admission Record indicated he was admitted to the facility in October 2021 with multiple diagnoses including alcohol induced dementia (a form of dementia, loss of memory and judgement, related to excessive alcohol use) and schizoaffective disorder (a mental health disorder). A review of Resident 35's MDS, dated [DATE], indicated he had a BIMS score of 9 out of 15 that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 7 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 indicated he was moderately cognitively impaired. Level of Harm - Minimal harm or potential for actual harm A review of Resident 35's Progress Note, dated 2/22/22, indicated Resident is part of the smoking program daily on the North Patio. Resident has been given the smoking rules, explained rules and gave smoking times. Resident will be supervised for all smoking activities within this group. Residents Affected - Some During an interview on 2/22/22 at 2:23 p.m. with Resident 35, he stated he smokes five times a day on the smoking patio. He wheels himself to the patio. He stated some people wear a smoking apron, but he does not. During an interview on 2/24/22 at 10:32 a.m. with the Activities Director (AD), she acknowledged that Resident 35 did not have a care plan that addressed smoking in the electronic chart. It may be in the paper chart or in the overflow chart. She stated that a Progress Note, dated 2/22/22, is in place of a smoking assessment. She stated she reviewed the rules with Resident 35. He refuses to wear a smoking apron so he is closely supervised on the smoking patio by the activities assistants or the Certified Nursing Assistants (CNA) . His conservator is aware that he refuses to wear a smoking apron. The AD stated that Resident 35 should have a care plan that addressed smoking. During an interview on 2/24/22 at 10:46 a.m. with the Activities Assistant (AA), she stated not all residents use a smoking apron. She supervises residents closely. Resident 35 refuses to wear a smoking apron. Resident 35 has not had any smoking accidents. The AA controls the cigarettes and lighters. They are stored in a locked cabinet when not in use. During an interview on 2/24/22 at 10:55 a.m. with Licensed Nurse (LN) 3, he acknowledged that a smoking care plan for Resident 35 was not in the paper chart or in the electronic chart. LN 3 stated Resident 35 wheels himself to the patio. Resident 35 knows the smoking schedule. Resident 35 has not had any issues with smoking. During an interview on 2/24/22 at 1:40 p.m. with the Medical Records Staff (MRS), she stated there is not a smoking care plan for Resident 35 in the overflow chart. A review of the facility policy titled Hospice Care, revised 6/22/09, indicated The hospice agency and facility shall collaborate on a revised, integrated care plan. A review of the facility policy titled Care Planning/Interdisciplinary Team Care Planning, undated, indicated To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions .All residents will have a comprehensive care plan to meet their individual needs that is prepared by an Interdisciplinary Team within 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments .Care planning shall include review of clinical issues, discharge planning, coordination of care and management of resources . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 8 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 Based on observation, interview and record review, the facility failed to ensure the nursing staff followed their policies and procedures during medication administration for a census of 100 when: Residents Affected - Some 1. Blood sugars, blood pressure (BP) and pulse were not obtained during medication administration for Resident 60, and 2. Pulse, respirations and lung sounds were not checked prior and during inhalation treatment for Resident 34. These failures had the potential to negatively impact the management of the resident's medical conditions. Findings: 1. During a Medication Administration Observation on 2/23/22, starting at 9 a.m., Licensed Nurse (LN) 5 was observed as she prepared and administered medication to Resident 60. LN 5 stated she usually started by preparing and giving the insulin first (a medication given by injection to manage diabetes, high blood sugar). LN 5 stated she would give Resident 60 ten units (units, a measurement) of insulin for a blood sugar of 232 mg/dL (milligrams per deciliter, unit of measurement). LN 5 stated the blood sugar was obtained by the night shift nurse and documented at 7 a.m. LN 5 administered the insulin to Resident 5 at approximately 9:38 a.m. LN 5 prepared Resident 60's medications which included 2 types of BP pills. LN 5 stated she would give the blood pressure medications as ordered. LN 5 further stated the resident's BP and pulse rate had been obtained and documented by the night shift Certified Nursing Assistants (CNAs) and were within normal range. LN 5 was observed as she gave the 2 BP medications including 2 types of diabetic medications among others at 9:45 a.m. According to Resident 60's admission Record, the facility admitted her last year with diagnoses of diabetes with high blood sugar levels and hypertension. Resident 60's physician order printed on 2/23/22 indicated she was on NovoLOG Insulin Aspart (a fast-acting insulin) that was given depending on the level of blood sugar obtained before meals. The insulin was to be given with meals at 7:30 a.m. (breakfast), 12 noon (lunch) and 5 p.m.(dinner). A review of Resident 60's Blood Sugar documentation indicated her blood sugar of 232 was documented at 6:10 a.m., and the insulin was given at 9:33 a.m The facility's undated DIABETIC CARE policy indicated, Licensed Nurse shall monitor blood glucose per physician's order and administer medication as indicated. LN 5 did not obtain Resident 60's blood sugar prior to breakfast and gave her insulin 2 hours after breakfast. During an interview with LN 5 on 2/23/22 at 11:40 a.m., LN 5 stated the blood sugars for diabetic residents are always obtained by the night shift. LN 5 further stated she gave Resident 60 insulin at 9:38 a.m. instead of 7:30 a.m. as ordered by the physician. Regarding the blood pressure medications given to Resident 60, LN 5 stated, I probably should have checked . [her blood pressure and pulse]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 9 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 - Some A review of Resident 60's physician orders, printed on 2/23/22, reflected an order dated 9/21/21 for Lisinopril (a medication for high blood pressure) 5 mg (milligram, unit of measurement) once daily to be held if the systolic (heart contracts to pump blood out through the blood vessels) BP was less than 110 and Verapamil 120 mg daily ordered on 10/5/21 and to be held if SBP less than 110 or pulse/heart rate less than 55 beats per minute. Both medications were ordered for a diagnosis of hypertension, a cardiovascular disease. A review of the facility's undated 'Medication Administration' policy indicated, When administration of the drug is dependent upon vital signs or testing, the vital signs/testing shall be completed prior to administration of the medication and recorded in the medical record . BP, pulse . blood glucose [sugar] monitoring . 2. During a Medication Administration Observation on 2/23/22, starting at 8:30 a.m., LN 3 was observed as he prepared and administered 4 types of inhaled medications (delivered through a hand-held device with a mouthpiece and connected to a nebulizer machine; the medications loosen secretions and eases the work of breathing) to Resident 34. LN 3 did not check the resident's pulse, respirations and lung sounds prior to administering the treatment to establish the baseline and the effects of the inhaled medication as per policy. LN 3 did not obtain the resident's pulse in 5 minutes after beginning the inhalation treatment. In a concurrent interview conducted on 2/23/22, shortly after 8:30 a.m., with LN 3, when he was asked to verbalize the process of administering the nebulization treatments, he stated Resident 34 had chronic lung disease and he knew how to administer his own treatments and the staff were monitoring him prior to allowing him to self administer. LN 3 did not verbalize the need to check the resident's baseline vitals prior, during, and after the medication administration. A review of the facility's policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer revised 10/2010 indicated, The purpose of this procedure is to safely and aseptically administer aerosolized [in the form of spray or mist] particles of medications into the resident's airway. The policy directed staff to obtain the baseline pulse, respirations and lung sounds prior to the treatment and to obtain the pulse 5 minutes after treatment begins. The policy further directed the nursing staff to monitor for medication side effects including rapid pulse throughout the treatment. During an interview on 2/23/22, at 11:46 a.m., with the Director of Nursing (DON), the DON stated he expected the nursing staff to administer medications as directed by the policies and procedures which were also the standard of practice. The DON stated he expected the LNs administering the medications to obtain the vital signs and blood sugars as a standard of nursing practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 10 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 necessary nail care for one of 24 sampled residents (Resident 51). Residents Affected - Few This failure resulted in Resident 51 having long, uneven, and jagged nails and had the potential to result in skin problems and injuries. Findings: According to the admission Record, Resident 51 was admitted to the facility in the fall of 2009 with multiple diagnoses which included diabetes (high blood sugar). Resident 51 was listed as his own responsible party. A review of the quarterly Minimum Data Set (MDS, an assessment tool) dated 2/6/22, indicated that Resident 51 had clear speech and was able to express ideas and wants. According to the assessment, Resident 51 scored 15 out of 15 on a Brief Interview for Mental Status, which indicated he was cognitively intact. Resident 51 was assessed as requiring assistance from staff for most of his Activities of Daily Living (ADL) including hygiene and bathing. During a concurrent observation and interview on 2/22/22, at 2:10 p.m., Resident 51 was sitting on the edge of the bed, alert, and conversant. Resident 51's fingernails were observed long with uneven jagged edges and had a brown substance underneath the nails. Resident 51 stated, They are very long and jagged, they catch on everything . Last time my nails were cut weeks ago. Resident 51 stated he wanted his fingernails to be cut and added, I have to bug them to cut my nails or toenails .Talked to . my nurse a few days ago and asked to cut them. She said that she was too busy that day and promised to cut them later, when she had time. Not done yet. A review of Resident 51's Weekly Summaries dated 1/18, 1/25, 2/14, and 2/21/22 indicated the nurses documented that resident's nails were trimmed and clean. A review of Resident 51's shower sheets dated 2/22, 2/18, 2/8, 1/28, 1/25, and 1/14/22 had checkmarks placed that the resident's fingernails were clean and did not need clipping. During a concurrent observation and interview with Licensed Nurse 9 (LN 9) on 2/24/22, at 3:10 p.m., LN 9 acknowledged that resident's fingernails were long, jagged, and dirty. LN 9 stated Resident 51's nails needed to be clipped and added, Will cut later today. LN 9 stated that because Resident 51 was diabetic, nurses were responsible for trimming resident's nails. During a follow up observation and interview on 2/24/22, at 5:30 p.m., Resident 51's nails were not clipped. Resident 51 stated he was very uncomfortable with jagged edges because every time I put my clothes on, it catches on it. A review of the undated facility's policy titled, Diabetic Care, indicated, All residents shall receive and the facility must provide the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well being .Licensed Nurses will assure that resident receives nail care from trained staff .as indicated in resident's plan of care. A review of the facility's policy titled, Care of Fingernails/Toenails, dated 10/10, indicated, The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 11 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .Proper nail care can aid in the prevention of skin problems around the nail bed. During a concurrent observation and interview on 2/25/22, at 11:45 a.m., the Director of Nursing (DON) acknowledged that the resident's nails were long and dirty and needed to be clipped. The DON stated his expectations were that the certified nursing assistant inspected the resident's nails during shower and notified the nurse that resident's nails needed to be clipped and for the nurses to trim them as soon as they were notified. The DON added, Telling the resident I don't have time to clip your nails is unacceptable. The DON acknowledged that Resident 51 was diabetic and having long nails with jagged edges could result in injuries leading to infections. Event ID: Facility ID: 055438 If continuation sheet Page 12 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow their wound and skin management policy to identify pressure ulcer development for one of 24 sampled residents (Resident 18). Residents Affected - Few This failure resulted in Resident 1 developing stage 2 (superficial skin breakdown that presents as an abrasion or blister) buttocks pressure ulcers that were not identified by the the nursing staff. Findings: According to Resident 18's admission Record, her most recent admission to the facility was over 3 years ago with multiple diagnoses which included abnormality of gait/mobility, generalized muscle weakness and stroke late last year. Resident 1's most recent quarterly Minimum Data Set (MDS, an assessment tool) dated 12/11/21, indicated she scored 15 out of 15 in a Brief Interview for Mental Status (a cognitive screening test) which indicated she was cognitively intact. The MDS also indicated she was at risk for developing pressure ulcers and had unhealed pressure ulcers. During the Initial Pool on 2/22/22 at 9:57 a.m., Resident 18 was observed resting in bed fully awake. Resident 18 stated she had a pressure ulcer to the buttocks area. On 2/25/22, at 9:45 a.m., the facility's Wound Nurse (WN) was interviewed and she stated Resident 18 had not developed pressure ulcers in the recent months. The WN further stated the resident had a history of recurrent pressure ulcers and the Licensed Nurses (LNs) completed a weekly skin check and the Certified Nursing Assistants checked the resident's skin during showers twice a week. During a follow up observation on 2/25/22, at 9:50 a.m., Resident 18 was in bed working on a crossword puzzle. Resident 18 was laying on her back and reported she had not developed pressure ulcers recently. An interview conducted with LN 5 on 2/25/22, at 10 a.m., LN 5 stated Resident 18 had no pressure ulcers. A review of the 'Resident Matrix' report indicated Resident 18 had no pressure ulcers. During a follow up interview with the WN on 2/25/22, at 11:39 a.m., the WN stated she had checked Resident 18's skin after speaking to the Department and noted the resident had developed in-house pressure ulcers to the buttocks. During an observation of Resident 18's buttocks on 2/25/22, at 2:45 p.m., accompanied by LN 6, two open areas were noted to the right and left buttocks and some redness was noted to the sacral (the bones above the tailbone) area. The LN stated the CNAs checked the skin during care and during showers. LN 6 stated the facility had recently started using electronic documentation and the CNAs did not know where to document the skin observation as there were no manual shower sheets to document. A review of Resident 18's most recent Weekly Summary, dated 2/20/22. which was completed and signed by a Registered Nurse showed there were no wounds or skin conditions documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 13 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 18's physician orders, dated 2/25/22, indicated the left and right buttocks had a stage 2 pressure ulcers measuring 1.3 by 0.5 centimeters(cm, unit of measurement) and 1 by 0.5 cm respectively. A review of Resident 18's Activities of Daily Living (ADL) documentation printed on 2/25/22 at 12:42 p.m., reflected one documented shower/bath on 2/3/22. There were no other documented showers or baths from 2/4/22 through 2/25/22. The undated Bath Schedule reviewed indicated Resident 18 was to receive showers/baths twice per week on Mondays and Thursdays. During an interview with the Director of Nursing (DON) on 2/25/22, at 12:10 p.m., the DON stated he expected the CNAs to document the skin observation during showers twice a week and report the changes to the LNs. The DON further stated the LNs were expected to assess the resident's skin condition weekly and document any changes. The DON was unable to locate shower sheets completed by Resident 18's CNAs in the past two weeks. The facility's undated 'Wound And Skin Management' policy guidelines was reviewed and indicated in part, It is the policy of this facility that any resident who enters the facility without pressure sores will have appropriate preventative measure taken to insure that the resident does not develop pressure ulcers . Licensed nurse will assess each resident's skin condition daily with care and weekly . and document findings in the weekly progress notes and/or on the skin sheet. CNAs will complete body checks on resident's daily with care and on shower days and report findings to charge nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 14 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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. Based on observation, interview, and record review, the facility failed to protect one resident (Resident 80) in a sample of 24 from falls when the staff did not develop a care plan to prevent falls from occurring until after Resident 80 had four falls at the facility. This failure increased the risk of falls. Findings: Review of Resident 80's admission Record indicated he was admitted to the facility in the Fall of 2021, with diagnoses which included partial amputation of the left leg, heart disease, and dementia (a decline in mental capabilities). Review of Resident 80's care plans revealed a care plan, initiated on 10/14/21 and canceled on 11/23/21, which indicated, The resident has had an actual fall at home prior to admission with no injuries. The care plan had interventions, which included, Continue interventions on the at-risk plan. The care plan did not have documented evidence of interventions to prevent future falls from happening. Review of Resident 80's admission Minimum Data Set (MDS, an assessment tool), dated 10/25/21, indicated Resident 80 had a fall in the last month prior to admission. The MDS indicated several care plans needed to be developed including a care plan for falls. Review of an Incident Note, dated 10/25/21, indicated Resident found on floor faced (sic) down to ground .No injuries noted. Review of an IDT [Interdisciplinary Team] Fall Review note, dated 10/28/21, indicated, NEW INTERVENTIONS: Resident screened by PT [Physical Therapy], as part of ongoing therapy. Review of an Incident Note, dated 11/22/21, indicated, Heard the help sound from room and Found resident sitting on the floor next to bed .No injury noted at this time. Review of an IDT Fall Review note, date 11/23/21, indicated, PREVENTATIVE MEASURES PRIOR TO EVENT: Bed in low position, Fall matt next to bed .NEW INTERVENTIONS IMPLEMENTED: Bed Alarm added to bed. Review of an Incident Note, dated 11/27/21, indicated, CNA [Certified Nurse Assistant] went to res. [resident] room and found that the res was sitting on the [floor by the] left side of the bed yelling for help to go home. Review of an IDT Fall Review note, date 11/29/21, indicated, PREVENTATIVE MEASURES PRIOR TO EVENT: LAL [low air loss] Mattress and bed alarm .NEW INTERVENTIONS IMPLEMENTED: Will continue to follow current plan of care. Review of an Incident Note, dated 12/16/21, indicated, Aids found him [Resident 80] on the floor at 0600 [6 a.m.] with in (sic) back against the bed and legs facing the door. No new injuries . Review of an IDT Fall Review note, date 12/16/21, indicated, PREVENTATIVE MEASURES PRIOR TO EVENT: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 15 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 Bed in low position. Fall mat next to bed. Bed alarm .NEW INTERVENTIONS IMPLEMENTED: Neuro [neurological] checks started. Review of a care plan, initiated on 1/27/22 (greater than 2 months after the resident's first fall), indicated, The resident is at risk for falls .The resident will not sustain serious injury . The care plan interventions were, Anticipate and meet The resident's needs .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .PT evaluate and treat as ordered. The interventions identified in the IDT Fall Review Notes were not included in this care plan. During an observation of Resident 80 and concurrent interview with CNA 5 on 2/24/22, at 1:25 p.m., Resident 80 was lying in his bed. When asked the height of Resident 80's bed, CNA 5 stated it was at medium height. When asked if there was a fall mat on the ground next to Resident 80's bed, CNA 5 stated there was no fall mat on the ground, and she was unable to locate the fall mat. During an interview and concurrent record review with the Director of Nursing (DON), on 2/24/22, at 1:30 p.m., the DON reviewed Resident 80's care plan for fall risk and confirmed it was initiated on 1/27/22, which was three months after his admission to the facility. The DON stated the fall risk care plan was not comprehensive or specific to Resident 80. The DON stated It needed more. The DON confirmed Resident 80 had four falls at the facility before the fall risk care plan was initiated, and was unable to locate a care plan for falls that included the interventions indicated in the IDT Fall Review notes. Review of an undated facility policy and procedure titled Fall Prevention Program, indicated, All residents shall be assessed for being at risk for falls. Any resident identified as being at risk for falls shall have an individual plan of care that includes interventions to prevent falls from occurring .A licensed nurse will assess all residents on admission and quarterly for risk factors for falls and will initiate a care plan for all residents at risk for falls .The IDT, if indicated, will further update care plan to minimize the risk of falls .Documentation will be maintained in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 16 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to comprehensively care for one resident (Resident 80) in a sample of 24 who had an indwelling urinary catheter (plastic tube inserted into the bladder to continuously drain a person's bladder of urine). This failure had the potential to contribute to Resident 80's urinary tract infections. Findings: Review of Resident 80's admission Record indicated he admitted to the facility in the Fall of 2021 with diagnoses, which included partial amputation of the left leg, heart disease, dementia (a decline in mental capabilities), and a urinary tract infection (UTI). Review of an admission Minimum Data Set (MDS, an assessment tool), dated 10/18/21, indicated Resident 80 did not have an indwelling urinary catheter and was always incontinent of bladder [inability to control outflow of urine]. Review of a hospital Physician Order Form, dated 2/9/22, indicated Resident 80 had a new diagnosis of a urinary tract infection, and a new prescription for antibiotic therapy. The Physician Order Form indicated, FOLEY [name brand for an indwelling urinary catheter] CARE .Normal Saline: Use 60cc's [cubic centimeter, a unit of measurement] to irrigate - prn [pro re nata, meaning as needed] occlusion or decreased output .Proceed same as Previous/Prior to Hosp [hospital] Admission. Review of a Nurse Practitioner note, dated 2/10/22, indicated, [Resident 80] was recently hospitalized for increased confusion after his urology appt [appointment] found to have recurrent E. Coli [Escherichia coli, a type of bacteria that normally lives in human intestines] UTI .now discharged w/ [with] cefuroxime [antibiotic] .His Foley catheter is flowing clear yellow urine today .Assessment/Plan .Chronic indwelling Foley catheter .placed at urology appt due to inability to void .Problem List/Past Medical History .recurrent urinary tract infection. Review of Resident 80's physician orders indicated no documented evidence of an order for placement or care of an indwelling urinary catheter. Review of Resident 80's care plans indicated no documented evidence of a care plan for an indwelling urinary catheter and the risk of developing a catheter associated urinary tract infection. Review of Resident 80's Treatment Administration Record for February 2022 indicated no documented evidence of care provided to Resident 80's indwelling urinary catheter. Review of Resident 80's nurses notes for February 2022 indicated nurses began documenting the existence of an indwelling urinary catheter on 2/10/22. The nurses notes did not indicate documented evidence of catheter care provided to Resident 80. During an observation of Resident 80 on 2/22/22, at 3 p.m., Resident 80 was lying in his bed. He had an indwelling urinary catheter, which hung on the right side of his bed. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 17 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2/25/22, at 4:45 p.m., the ADON confirmed there were no orders for an indwelling urinary catheter or care for the catheter. The ADON stated there needed to be an order for an indwelling urinary catheter and care needed for the catheter in the resident's medical record. The ADON confirmed there was no care plan for an indwelling urinary catheter. The ADON stated the nurses would not be prompted to provide care to the resident's indwelling urinary catheter, because there was no order in the resident's record. When asked when Resident 80 had a urinary catheter inserted and the reason for the catheter, the ADON was unable to provide an answer. The ADON stated it was the facility's practice to monitor and document daily fluid intake and urine output on all residents with indwelling urinary catheters for the first 30 days. The ADON confirmed there was no documented evidence of nurses monitoring Resident 80's daily fluid intake and urine output. Review of an undated facility policy and procedure titled CATHETER CARE, Urinary, indicated, PURPOSE .To prevent catheter-associated urinary tract infections .DAILY CATHETER CARE .Using gloves, clean peri area with mild soap and water, clean away from the urinary meatus [opening leading to the interior of the body], rinse and dry well on a regular basis (at least daily) and PRN (i.e. after each Bowel Movement) .INTAKES AND OUTPUT .Fluid intake and output shall be recorded on each resident with an indwelling catheter. Intake and output records shall be evaluated at least weekly and each evaluation shall be included in the licensed nurses progress notes .RECORD KEEPING .Documentation of foley catheter care shall be maintained in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 18 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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. Based on interview and record review, the facility failed to provide documentation of Certified Nursing Assistant's (CNA) competency of the skills necessary to care for residents' needs for a census of 100 residents. This failure had the potential for the needs of the residents to be unmet. Findings: During an interview on 2/25/22 at 10:23 a.m. with the Director of Staff Development (DSD), she stated she was new to the job. She was unable to find staff competencies. She provided a binder with inservices planned for the year (2022). During an interview on 2/25/22 at 10:50 a.m. with the Administrator (ADM), he stated that competencies were demonstrated by attending inservices. He stated these were done monthly and quarterly. During a subsequent interview on 2/25/22 at 3:30 p.m. with the ADM, requested staff competencies for nurses and CNAs. The ADM reviewed nurse competencies. He stated he was unable to find competencies for CNAs. He stated the inservices demonstrated competency. Reviewed the difference between inservices and competency documentation. He acknowledged that he did not have competencies for CNAs. During an interview on 2/25/22 at 4:00 p.m. with CNA 3, she stated she was oriented to the job for two to three weeks including classroom instruction and hands on training. There was not a paper for check off of skills. She demonstrated her skills to another CNA while on the floor performing hands on care. Requested facility policy for staff competency documentation. The Medical Records Staff (MRS) stated they do not have a policy for staff competency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 19 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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. Based on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 25) was evaluated by the physician for the need to continue using haldol (a medication used to treat certain mental disorders) on as needed (PRN) basis beyond 14 days and as per their policy. This failure placed Resident 25 at risk for adverse side effects from use of the medication. Findings: According to Resident 25's admission Record, the facility admitted her last year with multiple diagnoses which included diabetes (high blood sugar) and end stage renal disease (gradual loss of kidney function at an advanced state) and was on dialysis (the process of removing excess water, solutes, and toxins from the blood) 3 times per week. During the Initial Pool on 2/22/22, at 11:59 a.m., Resident 25 was observed resting in bed and responded to prompts in another language. A review of Resident 25's physician orders reflected an orde, dated 1/31/22, for haldol 0.5 milliliter (unit of measurement) to be given every 4 hours as needed for agitation manifested by constant yelling and another haldol order, dated 12/3/21, to give the haldol 0.5 milliliter in the morning on Monday, Wednesday and Friday for agitation and irritability prior to dialysis. Resident 25 had no documented mental disorder diagnosis and there was no duration of use for the haldol as per the Federal requirements. During an interview on 2/24/22, at 2:04 p.m., with Licensed Nurse (LN) 4, he stated the physician ordered haldol due to a request from the family. LN 4 stated Resident 25 had behavior of yelling on dialysis days due to anxiety and talking to the family on the phone calmed her down. An interview and concurrent record review with the Director of Nursing (DON) on 2/24/22, at 2:40 p.m., he stated Resident 25's clinical record did not contain documentation to support the use of haldol. A review of the 'Consultant Pharmacist's Medication Regimen Review' dated 2/1/22 and 2/23/22 included Resident 25's recommendation which indicated, The PRN Haldol is now more than 14 days old, and, initiated 1/31/22, must be renewed with justification or DC [discontinued] per CMS (Centers for Medicare Services] regs [regulations]. During an interview on 2/24/22, at 2:53 p.m. with the Pharmacist Consultant (PC) and with the DON present, the PC stated he would not recommend the use of haldol due to it's side effects. The PC stated he had recommended to the physician to review the use of as needed haldol as it had exceeded 14 days. The PC stated he was not sure if the facility had notified the physician of the recommendation. The facility's Antipsychotic Medication Use policy revised 12/2016 was reviewed and indicated, PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 20 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents received dental services in a timely manner for one of 24 sampled residents (Resident 44), when resident's broken lower dentures were not repaired. Residents Affected - Few This failure resulted in Resident 44 having difficulties with chewing food. Findings: According to the admission Record, Resident 44 was admitted to the facility in 2020 with multiple diagnoses including high blood pressure. A review of Resident 44's Minimum Data Set (MDS - an assessment and screening tool), dated 1/9/22, indicated resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. During an observation and concurrent interview, on 2/22/22, at 11:30 a.m., Resident 44 was observed sitting at her bedside. Resident 44 stated, My lower dentures are not fixed yet. It's been two months since they found them on the floor broken in half .Nobody knows what happened .I can't chew my food, only upper dentures, hard to eat. Resident 44 opened her mouth and showed she was missing her lower dentures. Resident 44 explained that the Social Services Director (SSD) had her dentures and when she inquired about it, he explained that the dentist could not come to the facility because of the pandemic. Resident 44 stated she was not sure when she would get her dentures fixed and stated she could not understand why does it have to be that long to fix them, glue together? Resident 44 stated she was not sure if she had lost any weight, but some days she barely ate any food due to chewing problems. Resident 44 stated the staff would just take her tray away with uneaten food and nobody questioned her why she did not eat. A review of Resident 44's weekly nursing summaries dated 12/4/21, 12/25/21, 1/8/22, 1/29/22, and 2/4/22 indicated the resident had dentures and had no chewing problems. A review Resident 44's weekly nursing summaries dated 2/12/22 and 2/19/22 indicated the nurses documented that resident had no dentures. During an interview on 2/23/22, at 1:49 p.m., a Certified Nursing Assistant 6 (CNA 6) stated Resident 44 had upper and lower dentures. CNA 6 stated sometimes Resident 44 consumed all food on her tray and some days barely ate. CNA 6 stated she was not aware that Resident 44 did not have her lower dentures or had difficulties with chewing. A review of the Resident 44's clinical records failed to reveal any documentation regarding her broken dentures. During an interview and concurrent record review of Resident 44's medical record on 2/24/22, at 9:45 a.m., the SSD stated he was responsible for arranging ancillary services, including dental consults. The SSD stated Resident 44 was not on a list to be examined by a dentist coming to the facility on 2/25/22. The SSD stated, Her broken dentures are in my possession Not fixed yet. Did not contact dentist yet. Did not arrange for emergency dental services to fix the dentures .Not aware that she has trouble chewing food. The SSD stated he could not remember for sure when the dentures were turned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 21 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few over to him and added, At least two weeks ago. The SSD stated he did not document in the resident's medical record that Resident 44's lower dentures were broken and there was no documentation indicating that the facility contacted the dentist to fix the resident's damaged dentures. The SSD acknowledged that he should have documented and communicated with dental office regarding fixing resident's dentures. A review of the undated facility's policy titled, Oral Healthcare and Dental Services, indicated the purpose of the policy was to provide routine and emergency dental care to all residents. The policy stipulated, Social Services/designee will be responsible for making necessary dental appointments. All requests for .emergency dental services should be directed to social services to assure that appointments can be made in a timely manner .Residents with .damaged dentures will be promptly referred to a dentist .Records of dental care provided shall be made a part of the resident's medical record. During an interview with the Director of Nursing (DON) on 2/24/22, at 3:15 p.m., Resident 44's concern with damaged lower denture were discussed. The DON stated, Resident should not have to wait even a week for her dentures to be fixed. The DON stated his expectations were that the dentist should be contacted by social services immediately and resident's dentures fixed, especially if resident has trouble chewing food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 22 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to provide a diet that met the needs of one resident (Resident 398) in a sample of 24 when the facility provided a pureed textured diet (A diet designed for residents who have difficulty chewing or swallowing. The food is blended in a blender or food processer, and the texture is smooth and moist with no lumps) to Resident 398 instead of a regular textured diet as ordered by the physician. This failure resulted in Resident 398 not enjoying his meals, reducing his food consumption, and had the potential to contribute to weight loss. Findings: Review of Resident 398's admission Record indicated he admitted to the facility in the Winter of 2022, with diagnoses which included Parkinson's disease (a progressive and debilitating neurological disease), kidney disease, and diabetes (high blood sugar). Review of Resident 398's admission orders, dated 2/8/22, indicated Diet .Diabetic Diet. The admission diet orders did not indicate a texture. Review of a Dietary Communication slip, dated 2/8/22, indicated Diet Order CCHO [consistent carbohydrate], Pureed. Review of Resident 398's orders indicated an order, dated 2/9/22, for Regular texture, Thin consistency, Low carbohydrate diet. Review of Resident 398's care plans indicated a care plan, initiated 2/9/22, which indicated, The resident has a swallowing problem r/t [related to] Dysphagia [difficulty swallowing]. The care plan had interventions, which included, All staff to be informed of resident's dietary and safety needs .Alternate small bites and sips. Use a teaspoon for eating. Do not use straws .Check mouth after meal for pocketing food and debris. Report to nurse. Provide oral care to remove debris .Diet to be followed as prescribed .Monitor/document/report PRN [as needed] and s/sx [signs/symptoms] of dysphagia .Refer to Speech therapist for Swallowing Evaluation .Resident to eat only with supervision. Review of a Dietary Profile for Resident 398, dated 2/15/22, indicated, Current Diet Order Regular CCHO .Current texture of food .Regular. Review of a Registered Dietitian Assessment, dated 2/15/22, indicated Resident 398's diet order was Regular CCHO .Evaluation .Rt [Resident] with fair PO [per os, meaning by mouth] intake, not meeting nutrition needs. Spoke with rt, states he doesn't eat much but likes most things. Doesn't like mashed potatoes and gravy - will relay to kitchen. Rec [recommend] fortified and SF Healthshake, 4oz [ounce] BID [twice daily] at AM/PM snack time. Will cont [continue] to monitor prn. Review of Resident 398's orders indicated an order, dated 2/17/22, for Regular texture, Thin consistency, CCHO/Fortified. Review of Resident 398's amount of pureed meals eaten between 2/9/22 to 2/24/22, indicated 4 meals were consumed at less than 25%, 15 meals were consumed at 26 to 50%, 12 meals were consumed at 51 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 23 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0805 75%, and 12 meals were consumed at 76 to 100%. Level of Harm - Minimal harm or potential for actual harm During an interview of Resident 398 on 2/23/22, at 9 a.m., Resident 398 stated he was not happy with his pureed diet. Resident 398 stated he did not know why he was getting a pureed diet and believed it may be because of his voice. Residents Affected - Few During an interview and concurrent record review with the Dietary Services Supervisor (DSS) on 2/24/22, at 3:40 p.m., the DSS provided the dietary communication slip he had for Resident 398. The DSS stated he received the slip from nursing staff on 2/8/22. The DSS confirmed the slip indicated Resident 398 was to receive a pureed diet. During an interview with the Registered Dietitian (RD) on 2/24/22, at 3:45 p.m., the RD stated she assessed Resident 398 on 2/15/22, and believed he was on a regular textured diet. The RD stated she reviewed the resident's medical record prior to her assessment and did not find documentation of Resident 398's dysphagia diagnosis, and was not aware he was receiving a pureed diet. During an interview and concurrent record review with the Director of Nursing (DON) on 2/24/22, at 3:50 p.m., the DON stated he gave the DSS the Dietary Communication slip and wrote pureed on the slip because he thought the admission order indicated pureed. The DON reviewed Resident 398's admission orders and confirmed the diet order indicated diabetic diet and did not indicate pureed. The DON confirmed Resident 398 had a care plan for swallowing problems and dysphagia and stated he did not know why the care plan was created. The DON reviewed the hospital discharge paperwork and confirmed there was no diagnosis of dysphagia. During an observation and concurrent interview with Resident 398 on 2/24/22, at 5:15 p.m. Resident 398 was sitting up in his bed independently eating his dinner. The food items on his meal tray were of pureed texture. Resident 398 stated he wished the food was thicker, and stated he did not eat much because he did not like the consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 24 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 identify and prevent hazards at specific points of food handling when: Residents Affected - Many 1. The fruit and vegetable wash sink lacked an air gap; 2. Water pitchers were found wet inside, stored in the ready to use area; 3. Two ice machines found with black build-up in the area containing ice; 4. Discolored cutting boards found in the ready to use area; 5. Spills on kitchen floor were not cleaned up for over 30 minutes; 6. Emergency food was stored under waste pipes; and 7. Tuna and egg salads were not monitored and documented for temperature control after preparation. These failures had the potential to put 100 vulnerable residents receiving food from the kitchen at risk for foodborne illnesses. Findings: 1. During the initial tour of the kitchen on 2/22/22 starting at 9:00 a.m., accompanied by the Dietary Services Supervisor (DSS) and Registered Dietitian (RD), an air gap was not observed under the sink which was used for cleaning vegetables and fruits. In a concurrent interview with DSS and RD, the RD confirmed that they did not have an air gap under this sink. A review of the facility's policy titled, Accident Prevention- Safety precautions, dated 2018, indicated, . An air gap is the most reliable backflow prevention device. It is the physical separation of the potable and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks . other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink . According to the Food and Drug Administration (FDA) Food Code 2017, Section 4-901.11 Equipment and Utensils, Air Gap, .If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system . According to FDA, Food Code 2017, Section 5-202.14 Backflow Prevention Device, Design Standard, .A backflow or back siphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device . 2. During the initial tour of the kitchen on 2/22/22 starting at 9:00 a.m., accompanied by the Dietary Services Supervisor (DSS), 2 out of 14 water pitchers were observed with moisture inside though in the ready to use area. The DSS confirmed that they were wet inside and that this can alter the sanitation of the water pitchers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 25 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 - Many A review of the facility's policy titled, Dishwashing, dated 2018, indicated, .Dishes are to be air dried in racks before stacking and storing . 3. During the initial tour of the kitchen on 2/22/22 starting at 9:00 a.m., accompanied by the Dietary Services Supervisor (DSS), the Project Manager (PM) opened the kitchen ice machine. Upon wiping the inside lip of the ice shoot this area felt gritty and a black substance was observed on the paper towel. The DSS noted the discolored paper towel and stated that the company had cleaned the ice machine last week. The PM then opened a second ice machine located on nursing unit one. Again, black marks were seen on the paper towel after wiping the lip of the ice shoot. The RD acknowledged the markings and stated the ice was used for resident water pitchers. A review of the facility's policy titled, Sanitation, dated 2018, indicated, .Ice which is used in connection with food or drink shall be from a sanitary source . 4. On 2/23/22 at approximately 10:40 a.m., a trail of water was observed in two different locations on the floor between the fruit and vegetable wash sink and the refrigerator. Staff continued to prepare lunch for more than 30 minutes without attending to the spills. In an interview with the DSS, he stated that he expected that the spills on the floor were taken care of right away as it is a safety risk. A review of the facility's policy titled, Accident Prevention- Safety precautions, dated 2018, indicated, .Fall prevention practices .keep floors clean, dry and free of obstructions. Mop and dry mop small areas at a time and control traffic around mop areas . 5. On 2/23/22 at approximately 11:20 a.m., five cutting boards (3 white, 1 red and 1 green) were observed with black marks and discoloration on the surface. DSS acknowledged this and tossed the cutting boards in the trash. A review of the facility's policy titled, Sanitation, dated 2018, indicated, . After each use, chopping boards shall be thoroughly cleaned and sanitized . According to the Food and Drug Administration (FDA) Food Code 2017, Section 4-501.12 Cutting Surfaces, surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. 6. On 2/23/22 at approximately 12:15 a.m., the emergency food was observed in boxes in the basement. Above these stacked boxes of food were several pipes. In a concurrent interview with DSS, he stated that some of these pipes contained sewage. A review of the facility's policy titled, Storage of food and supplies, dated 2018, indicated, .Storage areas should be free from exposed pipes, drains, and mechanical equipment . Store all food and supplies at least 18 from the ceiling for fire sprinkler clearance. According to the Food and Drug Administration (FDA) section 2017 4-401.11 Equipment, .Contamination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 26 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 - Many Prevention. Food equipment and the food that contacts the equipment must be protected from sources of overhead contamination such as leaking or ruptured water or sewer pipes, dripping condensate, and falling objects. 7. During an observation and interview on 2/23/22 at 3:00 p.m. with Dietary Aid 1 (DA 1) as she prepared sandwiches, DA 1 was asked how egg and tuna salad were prepared. She stated ingredients were obtained from both the dry storage as well as the refrigerator. When asked to see the cooling log, she stated that they did not keep a cooling log. In a subsequent interview on 2/23/22 at 3:05 p.m., DSS stated that he had never tracked the cooling temperatures for egg and tuna salad. A review of the facility's policy titled, Cooling and reheating potentially hazardous foods (PHF) also called Time/Temperature Control for Safety (TCS), dated 2018, indicated, Potentially hazardous foods shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Use cool down log in section 7, for ambient temperature foods. According to the Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5 degrees C [41 degrees F] or less if prepared from ingredients at ambient temperature, such as .canned tuna. According to the FDA Food Code, (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature such as reconstituted foods and canned tuna. (2017 FDA Food Code, 3-501.14 Cooling). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 27 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure resident showers were documented for one of 20 sampled residents (Resident 18) as per the facility's skin care policy. Residents Affected - Few This failure resulted in Resident 18 developing buttocks pressure ulcers that were not identified and documented by the direct care nursing staff. Findings: According to Resident 18's admission Record, her most recent admission to the facility was over 3 years ago with multiple diagnoses which included abnormality of gait/mobility, generalized muscle weakness and stroke late last year. Resident 1's most recent quarterly Minimum Data Set (MDS, an assessment tool), dated 12/11/21, indicated she scored 15 out of 15 in a Brief Interview for Mental Status (a cognitive screening tool) which indicated she was cognitively intact. The MDS also indicated she was at risk for developing pressure ulcers and had unhealed pressure ulcers. During the Initial Pool on 2/22/22 at 9:57 a.m., Resident 18 was observed resting in bed fully awake. Resident 18 stated she had a pressure ulcer to the buttocks area. On 2/25/22, at 9:45 a.m., the facility's Wound Nurse (WN) was interviewed and she stated Resident 18 had not developed pressure ulcers in the recent months. The WN further stated the resident had a history of recurrent pressure ulcers and the Licensed Nurses (LNs) completes a weekly skin check and the Certified Nursing Assistants checked the resident's skin during showers twice a week. During a follow up interview with the WN on 2/25/22, at 11:39 a.m., the WN stated she had checked Resident 18's skin after speaking to the Department and noted the resident had developed in-house pressure ulcers to the buttocks. A review of Resident 18's Activities of Daily Living (ADL) documentation printed on 2/25/22 at 12:42 p.m., reflected one documented shower/bath on 2/3/22. There were no other documented showers or baths from 2/4/22 through 2/25/22. The undated Bath Schedule reviewed indicated Resident 18 was to receive showers/baths twice per week on Mondays and Thursdays. During an interview with the Director of Nursing (DON) on 2/25/22, at 12:10 p.m., the DON stated he expected the CNAs to document the skin observation during showers twice a week and report the changes to the LNs. The facility's undated 'Wound And Skin Management' policy guidelines was reviewed and indicated in part, CNAs will complete body checks on resident's daily with care and on shower days and report findings to charge nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 28 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 infection control practices were maintained for a census of 100 residents when: Residents Affected - Some 1. Proper hand hygiene practices and cleaning of devices were not followed during medication administration, and, 2. A Certified Nurse Assistant (CNA) did not wear gloves and perform hand hygiene between resident care tasks. These failures had the potential to spread infections among staff and residents. Findings: 1. During a Medication Administration Observation on 2/23/22, starting from 8:30 a.m., Licensed Nurse (LN) 3 was observed as he prepared and administered medications to Resident 34. LN 3 was observed as he took the medication cup after the resident used it, and dumped it into the trash bin. LN 3 did not perform hand hygiene after handling the used cup and he proceeded to the medication cart and prepared inhalation therapy (also known as nebulization treatments, they enhance lung function) medications for Resident 34. LN 3 was observed taking the hand held inhalation therapy accessory device from Resident 34's bed side table without wearing protective gloves and proceeded to the bathroom sink to clean the device which was also attached to the mouthpiece (the resident places it in between the lips to inhale the treatment in the form of mist). LN 3, without allowing the accessories to air dry, proceeded to pour one of the inhalation medication into the nebulizer cup and connected it to the nebulizer machine, switched it on and handed the inhalation device to Resident 34 who placed the mouthpiece in between his lips. In a concurrent interview conducted on 2/23/22, shortly after 8:30 a.m., with LN 3, he stated he should have sanitized his hands between tasks and worn protective gloves while cleaning and handling the inhalation equipments and its accessories. Review of another facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment' revised 7/2014 indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected . The following categories are used to distinguish the levels of . disinfection necessary for items used in resident care: Semi-critical items consist of items that may come in contact with mucous [e.g., the lining of the mouth ] membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms . Review of another facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer revised 10/2010 indicated, The purpose of this procedure is to safely and aseptically (clean, but not sterile) administer aerosolized [in the form of spray] particles of medications into the resident's airway. The policy directed staff to wash and dry hands between the tasks, obtain the baseline pulse, respirations and lung sounds prior to the treatment. The policy also directed staff to either rinse all the nebulization accessories with sterile water or wash them with warm soapy water and rinse with hot water and, soak them in rubbing alcohol for 5 minutes and allow them to air dry on a paper towel. 2. During an observation of Certified Nurse Assistant (CNA) 6 on 2/22/22, at 9:40 a.m., CNA 6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 29 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 picked up soiled linen from a resident's room with bare hands and dumped the linen in a hamper. CNA 6 left the resident's room without performing hand hygiene, walked over to a storage room and went inside. CNA 6 was observed walking into two other resident rooms without performing hand hygiene. In one of the rooms, she assisted a nurse to lift a resident up in their bed by the resident's bed sheet. CNA 6 performed the task with bare hands, then left the resident's room to the nursing station to grab an oxygen tank, and went to another storage room. CNA 6 was not observed performing hand hygiene before or after any of her tasks. During an interview with CNA 6 on 2/22/22, at 9:50 a.m., when asked why she did not wear gloves when handling soiled linens, CNA 6 stated she did not wear gloves because she was allergic to the gloves at the facility. CNA 6 pulled out a pair of gloves from her pocket and stated she had her own special gloves she could wear. When informed of her lack of hand hygiene after handling soiled linen and lifting a resident up in bed by their bed sheet, she stated she was allergic to the alcohol-based hand sanitizer at the facility and needed to use soap and water when performing hand hygiene. CNA 6 confirmed she did not perform hand hygiene immediately after touching residents' items without gloves and before touching door handles and other items around the unit. A review of the facility's 'Handwashing/Hand Hygiene' policy revised 8/2015 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy further directed staff to use hand sanitizer or wash hands with soap and water, Before and after direct contact with residents; Before preparing or handling medications; . After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . During an interview on 2/23/22, at 11:46 a.m., with the Director of Nursing (DON), the DON stated he expected the nursing staff to perform and maintain hand hygiene between residents and between tasks and clean the devices properly as per the facility's infection control policy and procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 30 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to protect 100 residents from COVID-19 (an infectious disease caused by a virus) when: Residents Affected - Many 1. The facility's COVID-19 staff vaccination policy and procedure did not include the minimum components; and 2. The Infection Preventionist (IP) was not tracking and securely documenting the COVID-19 vaccination status of all contracted staff. These failures increased the potential for unvaccinated and partially vaccinated staff to spread COVID-19 to vulnerable residents. Findings: Review of an undated facility policy and procedure titled Employee COVID-19 Vaccination Policy, indicated insufficient or no documented evidence of the following components: 1. A process for ensuring all staff (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements, or those staff for whom COVID-19 vaccination must be temporarily delayed, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents; 2. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; 3. A process for tracking and securely documenting the COVID-19 vaccination status of all staff; 4. A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC [Center for Disease Control]; 5. A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; 6. A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains: (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 31 of 32 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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 0888 contraindications; Level of Harm - Potential for minimal harm 7. A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements; Residents Affected - Many 8. A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and 9. Contingency plans for staff who are not fully vaccinated for COVID-19. During an interview and concurrent document review with the Infection Preventionist (IP) on 2/25/22, at 8:10 a.m., the IP reviewed the Employee COVID-19 Vaccination Policy and confirmed the missing components. When asked if the IP's tracking log of staff COVID-19 vaccinations included all contracted staff that provide care to residents, for example hospice providers, podiatrists, nursing students, the IP stated their COVID-19 vaccination status was tracked elsewhere in the facility. The IP stated he believed a log was maintained at the reception desk. When asked if his tracking log included the COVID-19 vaccination status of the facility's medical director, the IP stated it did not, and he did not seek out that information. During an interview and record review with the Administrator (ADM) on 2/25/22, at 2:30 p.m. at the reception desk of the facility, the ADM was asked how the COVID-19 vaccination status of contracted staff was tracked at the facility. The ADM stated copies of COVID-19 vaccination records for contracted staff were kept in the visitor COVID-19 vaccination binders located at the reception desk. The ADM flipped through two large binders labeled Visitor Vaccination, and stated he was unable to locate a contractor's COVID-19 vaccination record amoung the other records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055438 If continuation sheet Page 32 of 32