Health inspection·January 6, 2026

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review the facility failed to:Ensure uncertified Nurse's Aides (NA, in training not certified) did not provide direct resident care (hands on care) while unsupervised by a Certified Nursing Assistant (CNA, certified by state) or Licensed Nurse (LN).Ensure uncertified Nurse's Aide did not go beyond the time frame of four months between hiring, graduation, and certification. This had the potential to put all residents at risk of injury and not to meet their care needs. Refer to F839.Findings:A review of Facility 2's document titled FACILITY: NURSE ASSISTANT TRAINING PROGRAM NOTICE dated 5/8/25, indicated they had an approved Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification) from California Department of Public Health (CDPH).A record review of Facility 2's policy titled, Hiring and Employment Verification revised 12/26/202,) indicated The facility is committed to hiring qualified, ethical, and legally authorized individuals to maintain the safety and quality of care for residents. Hiring and employment verification processes will follow all applicable federal and state regulations, including compliance with California's Department of Public Health (CDPH) requirements for skilled nursing facilities. Under Purpose it stated, To ensure the employees of the facility meet the standards for safe and lawful employment within California. This applied to prospective and current employees of the facility, including clinical, non-clinical, temporary and contracted staff.A record review of Nursing Assistant Job Description, undated indicated states Nurse's Assistants provide each assigned resident with routine daily care and services in accordance with nursing care activities in which nursing assistants have received clinical instruction and demonstrate competency. NA job description states NAs cannot perform direct resident care until theory and clinical skills are accomplished.1. A record review of Facility 2's CNA/NA active employee list, daily assignments for October, November, December 2025, and the California Board Nurse's Aide Registry on 1/08/2025 at 1:35 pm indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/5/2025. On 10/18/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/9/2025 -11/11/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/13/2025-11/16/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/1/2025 - 12/4/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified as a nursing assistant on 12/20/2025. On 11/12/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am. On 12/1/2025- 12/3/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am On 12/6/2025 NA 2 was assigned to work independently providing direct resident care, Page 1 of 5 055516 055516 01/06/2026 Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unpaired with a CNA from 10:30 pm to 6:30 am.NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. On 10/13/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/17/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On10/19/2025 NA 3 was assigned 1:1 care (direct observation), unpaired with a CNA from 6:30 am to 2:30 pm. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025). On10/13/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 11/11/2025 -11/12/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 1/15/2025 -11/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/23/2025 NA 4 was assigned to accompany residents to appointments from 6:30 am to 2:30 pm. NA 5 was hired on 9/5/2025, graduated 10/27/2025, and became certified on 11/19/2025. On 11/10/2025 - 11/12/2025 NA 5 was assigned to work independently providing direct resident care, unpaired with a CNA from 2:30 pm to 10:30 pm.NA 6 was hired 9/5/2025, graduated 10/17/2025, and remained uncertified until terminated. On 10/18/2025 NA 6 was assigned to work independently providing direct resident care, unpaired with CNA from 2:30 pm to 10:30 pm.2. A review of CNA and NA employee list dated 9/1/2025 to 12/8/2025 indicated: NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025).NA 7 was hired on 2/5/2025 and was certified on 9/26/2025.NA 8 was hired on 3/12/2025 and was certified on 10/27/2025.NA 9 was hired on 4/2/2025, graduated from NATP on 5/29/25 and certified on 10/6/2025.During an interview with CNA 1 on 12/5/2025 at 2:28 pm, CNA 1 was hired on 5/29/25 and stated they have recently become a CNA and have worked at Facility 2 for six months on evening shift. CNA 1 stated they were trained through Facility 2's NATP. During an interview with Licensed Vocational Nurse (LVN 1) on 12/5/2025 at 2:35 pm, LVN 1 stated after being signed off NAs perform direct resident care and CNAs are standby's (guides) for the NA. LVN 1 stated the NATP was within Facility 2. During a telephone interview with NA 2 on 12/8/2025 at 8:40 am, NA 2 stated they have recently graduated from NATP at Facility 2 and are waiting to retake the state CNA test. NA 2 stated they have been working at Facility 2 for 2 months on night shift. NA 2 stated once the clinical skills were checked off by the Nurse's Aide Training Program Instructor (NATP-I) or the Director of Staff Development (DSD) they were able to provide direct resident care to assigned residents. NA 2 stated they can do everything a CNA can do, including changing, peri care, and ambulating residents. NA 2 stated they know they are not supposed to provide direct resident care independently but there are times when they have. NA 2 stated they are somewhat watched by CNAs mostly when they are uncomfortable providing certain direct resident care tasks independently.During a concurrent interview with NATP-I (Facility 2) and DSD (Facility 2) on 12/23/2025 at 2:00 pm, NATP-I stated the NATP provides 60 hours of theory off-campus and 100 hours of clinical training at Facility 2. NATP-I stated students apply for the NATP and are interviewed prior to their training for hiring at Facility 1, Facility 2, and Facility 3. NATP-I stated 15 NA students are chosen for NATP per training course and once interviewed Facility 1, Facility 2, and Facility 3 hire five NA students for each site. NATP-I stated NAs are not supposed to do provide direct resident care without the supervision of a CNA or licensed nurse until they are state certified. NATP-I stated the graduated NAs are hired as NAs in training until they receive their certification. Upon reviewing statements from NA 2 on 12/8/2025 regarding being somewhat watched and providing care independently on the night shift, DSD 055516 Page 2 of 5 055516 01/06/2026 Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the NAs have recently been moved to am and pm shifts for closer observation. DSD stated they recently updated their employee assignments to include who the NAs are paired with. DSD and NATP-I stated they were unaware that NA graduates are not permitted to go to Facility 1 and Facility 3 as uncertified NAs. DSD and NATP-I were aware that Facility 1 and Facility 3 did not have NATPs. NATP-I stated NAs hired at Facility 2 do not receive additional competency testing because they have already trained them as NA students and are confident in their abilities. During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, the NATP, Facility 2 and Facility 3. VPO stated Facility1 was the only approved NATP site. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 2 and 3 were not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO was unaware that Facility 2 had multiple NAs working beyond the four months without being certified by the state. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations. 055516 Page 3 of 5 055516 01/06/2026 Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on interview and record review the Governing Body failed to provide oversight for the Administrator to ensure nurse's aides were state certified and had the competencies required prior to providing care to residents independently and were certified within four months of graduating from a Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification). This had the potential to put all residents at risk of injury and harm and to not receive quality of care when nine Nurse's Assistants (NA, in training not certified by state) were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.Findings:A review of the Governing Body Agenda and Minutes dated 10/24/2025 indicated that policy development, establishment, and implementation were handled by Administrative Services. A record review of Facility 1's Operational Manual Administrative Policies (undated) indicated the Governing Body (GB) was responsible and accountable for Quality Assurance and has engaged Administrative Services to develop policies and procedures for the management and operations of the facility.A record review of Facility 2's policy titled, Hiring and Employment Verification (revised 12/26/2024) on 1/8/2025 at 3:43 pm stated, The facility is committed to hiring qualified, ethical, and legally authorized individuals to maintain the safety and quality of care for residents. Hiring and employment verification processes will follow all applicable federal and state regulations, including compliance with California's Department of Public Health (CDPH) requirements for skilled nursing facilities. Under Purpose it stated, To ensure the employees of the facility meet the standards for safe and lawful employment within California. This applied to prospective and current employees of the facility, including clinical, non-clinical, temporary and contracted staff.1. A record review of Facility 2's CNA/NA active employee list, daily assignments for October, November, December 2025, and the California Board Nurse's Aide Registry on 1/08/2025 at 1:35 pm indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/5/2025. On 10/18/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/9/2025 -11/11/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/13/2025-11/16/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/1/2025 - 12/4/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified as a nursing assistant on 12/20/2025. On 11/12/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am. On 12/1/2025- 12/3/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am On 12/6/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am.NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. On 10/13/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/17/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On10/19/2025 NA 3 was assigned 1:1 care (direct observation), unpaired with a CNA from 6:30 am to 2:30 pm. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025). On10/13/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/16/2025 NA 4 was assigned to work independently 055516 Page 4 of 5 055516 01/06/2026 Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 11/11/2025 -11/12/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 1/15/2025 -11/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/23/2025 NA 4 was assigned to accompany residents to appointments from 6:30 am to 2:30 pm. NA 5 was hired on 9/5/2025, graduated 10/27/2025, and became certified on 11/19/2025. On 11/10/2025 - 11/12/2025 NA 5 was assigned to work independently providing direct resident care, unpaired with a CNA from 2:30 pm to 10:30 pm.NA 6 was hired 9/5/2025, graduated 10/17/2025, and remained uncertified until terminated. On 10/18/2025 NA 6 was assigned to work independently providing direct resident care, unpaired with CNA from 2:30 pm to 10:30 pm. 2. A review of CNA and NA employee list dated 9/1/2025 to 12/8/2025 indicated: NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025).NA 7 was hired on 2/5/2025 and was certified on 9/26/2025.NA 8 was hired on 3/12/2025 and was certified on 10/27/2025.NA 9 was hired on 4/2/2025, graduated from NATP on 5/29/25 and certified on 10/6/2025.During a concurrent interview with NATP-I (Facility 2) and DSD (Facility 2) on 12/23/2025 at 2:00 pm, NATP-I stated the NATP provides 60 hours of theory off-campus and 100 hours of clinical training at Facility 2. NATP-I stated students apply for the NATP and are interviewed prior to their training for hiring at Facility 1, Facility 2, and Facility 3. NATP-I stated 15 NA students are chosen for NATP per training course and once interviewed Facility 1, Facility 2, and Facility 3 hire five NA students for each site. NATP-I stated NAs are not supposed to do provide direct resident care without the supervision of a CNA or licensed nurse until they are state certified. NATP-I stated the graduated NAs are hired as NAs in training until they receive their certification. Upon reviewing statements from NA 2 on 12/8/2025 regarding being somewhat watched and providing care independently on the night shift, DSD stated the NAs have recently been moved to am and pm shifts for closer observation. DSD stated they recently updated their employee assignments to include who the NAs are paired with. DSD and NATP-I stated they were unaware that NA graduates are not permitted to go to Facility 1 and Facility 3 as uncertified NAs. DSD and NATP-I were aware that Facility 1 and Facility 3 did not have NATPs. NATP-I stated NAs hired at Facility 2 do not receive additional competency testing because they have already trained them as NA students and are confident in their abilities. During an interview with the Governing Body, with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, the NATP, Facility 2 and Facility 3. VPO stated Facility1 was the only approved NATP site. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 2 and 3 were not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO was unaware that Facility 2 had multiple NAs working beyond the four months without being certified by the state. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations. 055516 Page 5 of 5