Health inspection·April 8, 2022

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the care plans. The MDSC confirmed there was no evidence the SCSA was completed when Resident 17 was discharged from hospice and there was no evidence Resident 17's care plans were reviewed and revised. A review of the facility's policy Care Plan, Comprehensive, dated [DATE], indicated It is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life. It is reviewed and revised by the Interdisciplinary Team quarterly, following completion of the MDS assessment, and following assessment for significant change. A review of the CMS RAI manual, dated October 2019, indicated that a significant change in status assessment must be completed .when the resident comes off the hospice benefit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 2 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 residents (Resident 20) received necessary and proper care and services when Resident 20's psychological evaluation (used to determine a resident's mental state and guide recommendations for the best treatment) was not done as requested by the physician.These failures had the potential to affect the residents' care, health and well-being. Residents Affected - Few Findings: Review of Resident 20's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). Review of Resident 20's physician order indicated he had orders for divalproex (used to treat the manic phase of bipolar disorder) 2000 mg every day for bipolar disorder, started on 3/19/21, quetiapine (used to treat bipolar disorder) 200 mg two times a day for bipolar disorder, started on 3/26/21, and trazodone (used to treat sleep disorder) 100 mg at bedtime for insomnia (trouble falling asleep, staying asleep, or both), started on 11/19/2020. Review of Resident 20's Consultation Report, dated 9/10/21, indicated the consultant pharmacist noted Resident 20 had received antipsychotic (a class of medication used to manage a range of psychotic disorders) and Resident 20 was due for medication evaluation. The physician accepted the consultant pharmacist's recommendation and requested a psychological evaluation to be implemented. There was no psychological evaluation done for Resident 20. During an interview on 4/8/22 at 12:53 p.m., the director of nursing (DON) reviewed Resident 20's clinical record and confirmed Resident 20 did not have a psychological evaluation as requested. Review of the California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 3 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview, on 4/4/22 at 12:13 p.m., with Resident 192, he took one open pack of cigarettes and a lighter out of his pocket and stated that he kept the cigarettes and lighter on his own. Resident 192 stated he smoked in the parking area without facility staff supervising him. During an observation, on 4/4/22 at 2:30 p.m., Resident 192 was smoking at the designated smoking area by himself without facility staff supervision. An open pack of cigarettes and a lighter were placed on the side of his wheelchair. During an observation on 4/5/22 at 8:15 a.m., Resident 192 was smoking at the designated smoking area by himself without facility staff supervision, with an open pack of cigarettes and a lighter on the side of his wheelchair. During a concurrent observation and interview with Resident 192, on 4/5/22, at 8:30 a.m., he was smoking at the designated smoking area without facility staff supervision, carrying an open pack of cigarettes and a lighter on the side of his wheelchair. Resident 192 stated he kept the cigarettes and lighter on his own. Review of Resident 192's clinical record indicated he was admitted on [DATE] with diagnoses including alcohol dependence, pain in the left hip, left ankle and joints of left foot. The admission nursing assessment, dated 3/28/22, indicated Resident 192 had short and long-term memory problems. During a concurrent interview and record review, on 4/6/22 at 10:21 a.m., the DON reviewed Resident 192's clinical records and confirmed the admission nursing assessment, dated 3/28/22, indicated Resident 192 was a smoker. The DON confirmed the facility did not complete a smoking safety screening and care plan upon admission. She stated the smoking screening assessment and care plan should have been done upon admission. During an interview on 4/6/22 at 10:36 a.m., with the DON, she stated that per the facility's policy and procedure, facility staff should have kept the cigarettes and lighter locked in the medication cart, or for independent smokers, the facility should have provided a locked drawer or container at bedside. 3. During a concurrent observation and interview on 4/4/22 at 9:03 a.m., Resident 193 stated he kept his own cigarettes and lighter inside his pocket when he smoked in the designated smoking area, and he kept the cigarettes and lighter in his bedside table drawer at night. Resident 193 stated there was no staff supervising him while he smoked. During a concurrent interview and record review, on 4/6/22 at 11:08 a.m., the DON reviewed Resident 193's clinical record and confirmed the admission nursing assessment, dated 3/16/22, indicated Resident 193 was a smoker. The DON confirmed Resident 193's smoking safety was screened and smoking care plans were not initiated upon admission. Review of the facility's policy, Smoking Policy, revised 2/2018, indicated licensed nurses, certified nursing assistants and interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) are responsible to monitor and evaluate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 4 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 - Some residents for safety related to smoking .The IDT is responsible for evaluating safety risk and providing a safe designated smoking location, facility have specific smoking rules that are provided to residents and families at the time of admission. The IDT is responsible for evaluating safety risks and providing a safe designated smoking location .Staff will control the distribution of smoking material (cigarettes, cigars, tobacco, lighters) and for independent smokers that was assessed by the IDT, smoking materials should be locked in a drawer or container. Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards and receive adequate supervision during smoking sessions to prevent accidents for three of five sampled residents (Residents 92, 192, and 193). When: 1. Resident 92 was not assessed for smoking safety upon admission, was not provided adequate supervision during smoking sessions, and the facility did not initiate smoking care plan timely; and, 2. For Residents 192 and 193, the residents had no smoking assessment and smoking related care plans upon admission and facility staff did not provide supervision during the scheduled smoking time. This failure had potential to cause smoking related accidents/harm of these residents Findings: 1. Review of Resident 92's clinical record indicated he was admitted on [DATE] with infection of left hip joint, chronic kidney disease (a gradual loss of kidney function), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). There was no smoking safety assessment done and care plans related to smoking were not initiated. During a concurrent observation and interview on 4/4/22, at 8:35 a.m., in Resident 92's room, an unopened pack of cigarettes was observed on the bedside table. Resident 92 stated he kept the cigarettes and lighter on his own. During an observation on 4/4/22 at 10:20 a.m., Resident 92 was smoking outside with another resident at the designated smoking area without supervision. During an observation on 4/5/22, at 10:15 a.m., Resident 92 was smoking at the designated smoking area without supervision. During a concurrent interview and record review, on 4/6/22 at 10:31 a.m., with the director of nursing (DON) regarding smoking safety assessment, she stated that licensed nurses were responsible for completing the smoking safety assessment upon admission and facility staff should keep both the cigarettes and lighter. The DON further stated that staff should provide smoking supervision even if the resident is independent. During a concurrent interview and record review, on 4/6/22 at 1:18 p.m., the DON reviewed Resident 92's clinical record and confirmed there was no smoking safety assessment done upon admission and smoking related care plans were not initiated timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 5 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act on reports from the pharmacist for two of five residents (Residents 11 and 24) when: 1. For Resident 11, the physician did not document patient-specific rationales describing the reason for gradual dose reductions (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) are clinically contraindicated for the use of quetiapine (antipsychotic medication used to treat mental or mood disorders) and sertraline (medication used to treat depression) and the facility did not act on the pharmacist's Medication Regimen Review (MRR) recommendation to perform an Abnormal Involuntary Movement Scale (AIMS) assessment; and, 2. For Resident 24, the physician did not document patient-specific rationales describing the reason GDRs are clinically contraindicated for the use of quetiapine and bupropion (medication for the treatment of depression). These failures had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects. Findings: 1.a. Review of Resident 11's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting daily function) and psychosis (a mental disorder that may include deletions and hallucinations). Review of Resident 11's physician orders indicated he had an order, dated 1/7/21 for quetiapine 25 milligrams (mg, unit of measurement) at bedtime for depression, visual hallucinations, paranoid delusions, and agitation. A GDR was attempted when Resident 11 had a physician order, dated 2/2/21 quetiapine 25 mg 0.5 tablet (12.5 mg) for visual hallucinations, paranoid delusions, agitation. There was no documentation that indicated another GDR of quetiapine was attempted in the first year of Resident 11's admission. Review of Resident 11's Consultation Report, dated 2/10/22 indicated that Resident 11 was due for assessment for GDR and to consider reducing the dose of quetiapine. The report indicated the physician could accept or decline the recommendation. Review of the above report indicated the physician responded to the recommendation on 2/18/22. The box to decline the recommendation was checked. Checking that box indicated, I decline the recommendation(s) above because GDR is CLINICALLY CONTRAINDICATED for this individual as indicated below. (NOTE: Please check option #1 or #2 AND provide patient-specific rationale on the lines below. The physician checked option #2. Checking that box indicated, The resident's target symptoms returned or worsened after the most recent GDR attempt . Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual: The space provided for the physician to document a rationale was left blank. During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) acknowledged the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 6 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0756 physician did not document a rationale describing why a GDR attempt was clinically contraindicated. Level of Harm - Minimal harm or potential for actual harm b. Review of Resident 11's physician orders indicated he had an order dated 1/8/21 for sertraline 50 mg every day for depression, sadness, and angry outbursts. A GDR was attempted when Resident 11 had a physician order, dated 7/17/21 sertraline 25 mg every day for depression. There was no documentation that indicated another GDR of sertraline was attempted in the first year of Resident 11's admission. Residents Affected - Some Review of Resident 11's Consultation Report, dated 10/25/21 indicated the resident receives quetipine 25 mg at bedtime, sertaline 25 mg once daily for depression, and PRN Haldol (antipsychotic medication). The pharmacist recommended, If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual . The report indicated the physician could accept or decline the recommendation. Review of the above report indicated the physician responded to the recommendation on 11/1/21. The box to decline the recommendation was checked. Checking that box indicated, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The space provided for the physician to document a rationale was left blank. During an interview on 4/7/22 at 1:36 p.m., the DON acknowledged the physician did not document a rationale describing he declined the recommendation. Review of the facility's policy, Psychotropic Medication Management, dated 11/2017 indicated GDR should be attempted twice in the first year of admit or use (within two quarters separated by one month in between) unless clinically contraindicated. c. Review of Resident 11's Consultation Report (MRR), dated 2/8/21, indicated the pharmacist recommended, Please monitor for involuntary movements now and at least every [six] months or per facility protocol. Review of Resident 11's Consultation Report, dated 3/2/21 indicated that the nurse noted (acknowledged) the recommendation to perform AIMS but it could not be located under assessments. Review of Resident 11's Assessments indicated he had an AIMS assessment completed on 3/2/21. During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) acknowledged that the February 2021 pharmacy recommendation was missed. Review of the facility's policy, Medication Regimen Review, dated 11/2016 indicated the facility should encourage the director of nursing to act upon the recommendations contained in the MRR. 2. Review of Resident 24's Consultation Report, dated 3/1/22 through 3/8/22, indicated the resident had received quetiapine 200 milligrams (mg, unit of dose measurement) every 12 hours for bipolar disorder since 5/2021, Bupropion 100 mg every 12 hours since 3/2021, and clonazepam (used to control anxiety) 1 mg twice a day since 2021 for anxiety. The pharmacist (PH) recommended, If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 7 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the above report indicated on 3/11/22, the physician responded to the recommendation with his initials.The consultation report did not indicate a detailed rationale for the continuation of the medication. Rationale: The space provided for the physician to document a rationale was left blank. During a concurrent interview and record review on 4/8/22 at 12:26 p.m., with the PH, she reviewed Resident 24's clinical record and stated the report indicated the physician could accept or decline the recommendation, and the report indicated the physician responded to the recommendation on 3/11/22. The box to decline the recommendation was not checked and if checking that box indicated, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. During an interview on 4/7/22 at 2:10 p.m., the DON acknowledged the physician did not document a rationale describing he declined the recommendation, and the physician should have documented rationales on the space provided. Review of the facility's policy, Psychotropic Medication Management, dated 11/2017, indicated GDR should be attempted twice in the first year of admit or use (within two quarters separated by one month in between) unless clinically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 8 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of five residents (Residents 11, 34, and 242) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications. 1. For Resident 11, there was no documented clinical rationale by the physician to extend an as-needed (PRN) Ativan (medication used to treat anxiety) order beyond 14 days, there was no documented evaluation by the physician to renew a PRN Ativan order, and the Abnormal Involuntary Movement Scale (AIMS) assessment was not completed timely; 2. For Resident 34, there was no side effect monitoring and behavior monitoring for the use of citalopram (medication used to treat depression) and nortriptyline (medication used to treat depression); and 3. For Resident 242, there was no side effect monitoring for the use of nortriptyline. These failures had the potential to result in lack of adequate monitoring and for the residents to receive unnecessary medications. Findings: 1. a. Review of Resident 11's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting daily function) and psychosis (a mental disorder that may include delusions and hallucinations). Review of Resident 11's physician orders indicated he had the following Ativan orders: 1) Ativan 0.5 mg every six hours PRN for agitation, dated 2/12/22 until 3/6/22; 2) Ativan 0.5 mg every six hours PRN for agitation, dated 3/6/22 until 3/20/22; and 3) Ativan 0.5 mg every six hours PRN for agitation, screaming, and hitting others, dated 3/28/22 until 4/11/22. Review of Resident 11's progress notes indicated there was no documented clinical rationale by the physician to extend his PRN Ativan order beyond 14 days and there was no documented evaluation by the physician to renew his PRN Ativan orders During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) confirmed there was no documented rationale each time Resident 11's PRN Ativan order was renewed. During an interview on 4/8/22 at 12:43 p.m., the pharmacist (PH) stated the doctor should have a documented rationale if a PRN psychotropic order is extended beyond 14 days and the doctor should have a documented reason to write a new PRN psychotropic order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 9 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 Review of the facility's policy, Psychotropic Medication Management, dated 11/2017, indicated clinically necessary PRN psychotropic drug orders are limited to 14 days. If the prescribing practitioner determines a need for continued PRN use beyond the original 14 days, it is accompanied by supporting documentation in the electronic health record including rationale for continued use and duration. Residents Affected - Some b. Review of Resident 11's physician orders indicated the following: 1) Resident 11 was admitted with an order for quetiapine 25 milligrams (mg, unit of measurement) at bedtime on 1/7/21; 2) Resident 11's quetiapine order was reduced to 12.5 mg at bedtime on 2/2/21; and 3) Resident 11's quetiapine order was increased to 25 mg at bedtime on 8/7/21. Review of Resident 11's care plan for psychosis, revised 4/6/22, indicated to complete AIMS assessment every six months and with each increase in dose of antipsychotics. Review of Resident 11's Assessments indicated he had an AIMS assessment completed on 3/2/21, 10/15/21, and 3/9/22. During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) stated there was no AIMS assessment done for Resident 11 upon admission. The DON also stated the AIMS assessment should be completed every 6 months and with increase in the dose of antipsychotic. The DON acknowledged the 10/15/21 AIMS assessment was one month late. The DON also acknowledged there was no AIMS done when Resident 11's quetiapine order was increased. Review of the facility's policy, Psychotropic Medication Management, dated 11/2017 indicated if antipsychotic medications are used, an AIMS assessment will be completed upon admission, at the onset of a new order, every six months, and if medication dose is increased. 2. Review of Resident 34's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (feeling nervous, restless or tense). Review of Resident 34's physician order indicated Citalopram 10 milligrams (mg, a metric unit of mass) every day for depression/anxiety, with the start date of 3/5/22, and Notriptyline 25 mg at bedtime for depression/anxiety, with the start date of 3/4/22. There were no evidence the resident was monitored for the manifested behaviors and the side effects of two medications. During an interview with the director of nursing (DON) on 4/8/22 at 12:42 p.m., she reviewed Resident 34's clinical record and confirmed there were no evidence the resident was monitored for the manifested behaviors of depression/anxiety and the side effects of citalopram and notriptyline. 3. Review of Resident 242's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depression. Review of Resident 242's physician order, dated 4/2/22, indicated an order of Notriptyline 10 mg at bedtime for depression. There was no documented evidence the resident was monitored for the side effects of Notriptyline. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 10 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the DON on 4/8/22 at 12:38 p.m., she reviewed Resident 242's clinical record and confirmed there were no monitoring for the side effects of notriptyline. DON stated Resident 242 should be monitored for the notriptyline side effects. Review of the facility's policy, Psychotropic Medication Management, dated 11/2017, indicated the facility observe, report the behaviors and monitor the medication side effects and document them in the Electronic Health Record (EHR). Event ID: Facility ID: 055646 If continuation sheet Page 11 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store medications appropriately when the following were observed: 1. Two of three medication carts were left unlocked and unattended; and, 2. For Residents 295, 193, and 24, medications were left at their bedside. These failures had the potential to result in the access of medications by unauthorized personnel or residents. Findings: 1. During an observation on 4/4/22 at 11:28 a.m., the medication cart at Station 2 was unlocked and unattended. During an observation on 4/4/22 at 11:31 a.m., two visitors passed by the unlocked medication cart. During an interview on 4/4/22 at 11:33 a.m., registered nurse C (RN C) confirmed she forgot to lock the medication cart and stated the medication cart should be locked. RN C stated if the medication cart was left unlocked and unattended, anybody can get to the medications inside. During a medication pass observation on 4/5/22 at 8:20 a.m., registered nurse D (RN D) prepared medications for Resident 3. During concurrent observation and interview on 4/5/22 at 8:31 a.m., RN D stated she need to get an item from her medication cart. After opening the medication cart and removing an item, RN D left the medication cart unlocked. RN D left the medication cart unattended as she administered medication to Resident 3. During an interview on 4/5/22 at 8:42 a.m., RN D stated the medication cart was supposed to be locked. 2. a. During a medication pass observation on 4/5/22 at 8:26 a.m., RN C prepared medications, including MiraLAX (medication to treat constipation), for Resident 295. RN C mixed MiraLAX in a cup of water. During an observation on 4/5/22 at 8:48 a.m., RN C administered the medications to Resident 295. Resident 295 took sips of the MiraLAX, did not finish the MiraLAX and Resident 295 placed the cup on his bedside table. RN C did not instruct Resident 295 to finish the MiraLAX. During an observation on 4/5/22 at 9:18 a.m., the cup of MiraLAX was on Resident 295's bedside table as RN C continued to prepare medications for other residents. During a concurrent interview, RN C stated she did not check if Resident 295 finished all of the MiraLAX. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 12 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy, Medication Administration Operating Standard Guideline, dated 12/2012, indicated medication carts and rooms should be kept locked unless within eyesight of a licensed nurse and make sure the resident swallows the medication and observe that the resident is not having difficulty swallowing, and that they consume all the medication. b. During an initial tour on 4/4/22 at 9:00 a.m., a bottle of diluted Dakin's solution (a skin disinfectant to cleanse wounds in order to prevent infection), containing 473 milligrams (mg, unit of dose) per milliliter (ml, a unit of volume), was placed on Resident 193's bedside table with a glass of water next to it. Resident 193 stated he obtained the solution from an acute care hospital and had been using it daily to clean his right leg wound, since his admission to the facility on 3/16/22. Resident 193 stated he kept the solution on his bedside table. Review of Resident 193's clinical record indicated the resident had diagnoses including an unspecified open wound on the right lower leg and foot ulcer. During an observation and interview on 4/4/22 at 9:04 a.m., RN C stated Resident 193's bottle of diluted Dakin's solution should have been kept in the treatment cart instead of on the resident's bedside table. c. During an observation and concurrent interview with RN C, on 4/4/22 at 9:50 a.m., in Resident 24's room, one tube of Neosporin ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) was placed on the bedside table, and unattended. RN C stated the resident's Neosporin ointment should have been kept inside the treatment cart and locked. During an interview on 4/4/22 at 10:00 a.m., licensed vocational nurse I (LVN I) stated all medications, treatment items, and biologicals are securely stored in a locked cart. During an interview on 4/5/22 at 11:00 a.m., Resident 24 stated she kept Neosporin ointment in her stand drawer and used it for her forearm, daily and as needed. Review of the facility's policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and needles, dated 1/3/2017, indicated the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors Bedside Medication Storage: Facility should store bedside medications or biologicals in a locked compartment within the resident's room Facility should ensure that only facility representatives and the appropriate resident maintains the keys, access cards, electronic codes or combinations which open the locked compartment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 13 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: Residents Affected - Some 1. Undated food, over used by date food, expired food, and dented cans were found in the freezer and on the shelves in the kitchen; 2. [NAME] F (CK F) used his bare hand to pick up a lid which dropped inside the sliced peach can; and, 3. [NAME] G (CK G) and the dietary manager (DM) did not sanitize the thermometer before checking the temperature of the sliced peach and sugar free lemonade. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 40 residents eating at the facility. Findings: 1. On 4/4/22 at 8:50 a.m., during an observation of the freezer, in the dry food storage room, with the registered dietician (RD), one bag of frozen french fries, with the use-by date (the last date recommended for the use of the product) of 3/11/22, and one bag of undated frozen tortillas were found. On 4/4/22 at 9 a.m., during an observation in the dry food storage room and in the cooking area, with the RD and the dietary manager (DM), the following were observed: a. One dented can of mushroom pieces and stems, one dented can sliced peaches and two dented cans of coconut milk were on the shelves b. Six (6) caramel sauces with a use-by date of 3/21/22 c. One basic cheddar cheese sauce with a use-by date of 3/16/22 d. Five (5) cans of olives cans with a use-by date of 8/31/21 e. One can pizza sauce with basil with a use-by date of 2/3/22 f. One cornbread mix with an expiration date of 9/30/21 g. One box of 280 bags containing 1.2 oz coffee without a use-by date and/or an expiration date h. One brown rice bin with a use-by date of 3/28/22 i. Ten (10) coffee bags without a use-by date and/or an expiration date j. One brown sugar container with a use-by date of 4/3/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 14 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 k. One container of tarragon leaves with a use-by date of 3/19/22 Level of Harm - Minimal harm or potential for actual harm l. One bottle of mushroom flavored dark soy sauce with a expiration date of 12/25/21 m. One ground nutmeg container with a use-by date of 3/12/22 Residents Affected - Some n. One bottle of blended sesame oil with a use-by date of 1/23/22 During an interview with the DM on 04/06/22 at 3:15 p.m., she stated dented cans, undated food, over use-by date food, and expired food should have not been on the shelves and should have been discarded. Review of the facility's policy, Food Safety in Receiving and Storage, dated 2/2009, indicated Food will be inspected when it is delivered to the facility and prior to storage for signs of contamination. Examples of signs of contamination include the following: a. Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks . Expiration dates and use-by dates will be checked to assure the dates are within acceptable parameters. 2. During an observation on 4/06/22 at 11:05 a.m., CK F opened a can of sliced peaches, the lid was dropped down into the can and with his bare hands, CK F picked up the lid in the can. During a concurrent interview with CK F, he stated he should have not picked up the lid with his bare hand. Review of the facility's policy, Safe Food Handling, dated 9/2017, indicated Use utensils to handle food or wear disposable gloves when it is necessary to handle food directly with your hands. 3. During an observation on 4/06/22 at 11:10 a.m., CK G calibrated the thermometer in ice water and without sanitizing the thermometer, poked the thermometer into the canned peaches to check the temperature. During a concurrent interview with CK G, she stated she should have sanitized the thermometer before checking the temperature of the canned peaches. During an observation on 4/6/22 at 11:50 a.m., the DM removed thermometer cap, and dipped it into the cup of sugar free lemonade to check its temperature without sanitizing the thermometer. During a concurrent interview with the DM, she stated she should sanitize the thermometer before checking the temperature of the sugar free lemonade. Review of the facility's policy, Safe Food Handling, dated 9/2017, indicated Each new operation shall begin with food contact surfaces and utensils that are clean and have been sanitized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 15 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 26's admission Record indicated she was admitted to the facility on [DATE]. Residents Affected - Some During an observation, on 4/4/22 at 11 a.m., Resident 26 had a PICC line on her left upper arm. The dressing covering the PICC line was dated 3/24/22. During an observation and interview with registered nurse C (RN C) on 4/4/22 at 11:38 a.m., RN C confirmed Resident 26's PICC dressing was changed on 3/24/22 and it should had been changed weekly on 3/31/22. During an interview on 4/8/22 at 12:34 p.m., the director of nursing (DON) stated PICC dressing should have been changed every week. Review of the facility's policy, Peripherally Inserted Central Catheter (PICC) Dressing Change, dated 8/15/08, indicated Dressing changes using transparent dressings are performed at least weekly . 4. During an observation on 4/4/22 at 11:29 a.m., certified nursing assistant H (CNA H) was making the bed for Resident 242. CNA H carried dirty linen from Resident 242's bed, walked out of Resident 242's room, walked through the hallway to place the dirty linen into the dirty linen storage room. During a concurrent interview with CNA H, she stated she should have a linen hamper in front of Resident 242's room so she could throw the dirty linen in the hamper. CNA H stated she should not carry Resident 242's dirty linen out of the resident's room. During an interview with the infection preventionist (IP), on 4/8/22 at 1:05 p.m., she stated CNA H should have not carried dirty linen out of the resident's room and in the hallway. Review of the facility's undated Lesson Plan, Infection Control - Linen Handling, indicated Soiled linen should be immediately placed in a linen hamper . 5. During an observation, on 4/5/22 at 10:10 a.m., the dietary manager (DM) entered Resident 296's room without eye protection, N95 mask, or gown. Signs outside the door indicated Resident 296 was on precautions. During an interview on 4/5/22, at 10:30 a.m., the DM confirmed she should wear appropriate PPE upon entering the room for residents with precautions. During an observation on 4/6/22, at 9:16 a.m., the DON entered Resident 296's room with a gown and N95 mask, but no eye protection. Registered nurse E (RN E) entered the room with a gown, but with a surgical mask and no eye protection. During an interview on 4/5/22 at 10:03 a.m., registered nurse C (RN C) stated Resident 296 was admitted on [DATE] and was on precaution. She confimed everyone entering a room with precaution signs needed to wear appropriate PPE until it is cleared by infection control. During an interview on 4/6/22, at 1:18 p.m., with the DON regarding a policy for new admission quarantine, she confirmed Resident 296 a new admission who was not fully vaccinated against COVID-19, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 16 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 should be put on precautions. The DON stated all personnel entering the room should wear appropriate PPE. During an interview and record review on 4/7/22 at 1:34 p.m., the director of staff development (DSD) and back-up infection preventionist (IP) confirmed new admissions who were not fully vaccinated against COVID-19 should be quarantined, all staff were provided in-services regarding quarantine policy, and staff should use the full PPE when entering these residents' rooms. Review of facility policy, COVID-19 Management & Mitigation Policy, updated 2/25/2022, indicated, New admissions that are not up to date with all recommended COVID-19 vaccine doses (including booster, if eligible) should be tested and quarantined (in single rooms or a separate observation area i.e., yellow-zone) for at least 7 days from the date of admission until results of testing sample obtained between days 5 and 7. Those testing negative can be released from quarantine . Staff caring for them should use full PPE includes gowns, gloves, eye protection, and N95 or higher-level respirator. 2. During an initial tour of the facility on 4/4/22 at 9:58 a.m., there were five medication cups and one Opti foam dressing were placed together in the basket with a blood pressure cuff of a blood pressure machine stand. During a concurrent observation and interview on 4/4/22 at 9:59 a.m., Registered Nurse A (RN A) confirmed the above observation and stated it should not be there due to infection control issue and contamination. Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility stored clean pillows and residents' clothing next to the dirty laundry; 2. Blood pressure stand machine had five medication cups and one Opti foam dressing together with a blood pressure cuff; 3. The dressing of Resident 26's peripherally inserted central catheter (PICC, a long, flexible thin tube that is put into a vein in the upper arm) was not changed weekly; 4. Certified nursing assistant H (CNA H) carried dirty linen in the hallway out of a resident's room; and, 5. Facility staff did not wear full personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering a resident's room who was on COVID-19 quarantine. These failures had the potential to result in the spread of infection throughout the facility. Findings: 1. During a concurrent observation and interview on 4/7/22 at 12:50 p.m. with laundry services staff (LS) and central supply staff (CS), in the facility's laundry room, the bin marked dirty containing the facility's dirty laundry, was next to the clean laundry bin containing residents' clean clothing, and both bins were uncovered. In the corner, multiple pillows for residents were observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 17 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 uncovered. LS stated she was not sure if they should be stored like that. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/8/22 at 1:30 p.m., the DON and IP stated clean and dirty laundry should not be next to each other. Residents Affected - Some During a review of the facility's policy Laundry Services dated 2012, it indicated Separating clean from dirty in the laundry: Dirty linen should be clearly separated from areas where clean linen is handled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 18 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive. Findings: The room measurement indicated multiple rooms were less than 80 square feet per resident. Room Number Number of Beds Square Feet Per Resident 1 3 72.8 5 2 71.37 7 2 71.95 9 2 75 12 3 73.2 14 3 73.2 15 3 73.2 16 3 74 17 3 74 18 2 75 19 2 73.2 20 2 74.4 23 3 73.2 24 3 73.6 25 3 73.6 27 3 73.6 29 3 73.2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 19 of 20 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 055646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Alto Post-Acute 911 Bryant Street Palo Alto, CA 94301 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 0912 Level of Harm - Minimal harm or potential for actual harm During the survey, residents and staff were observed and interviewed to determine if there were any concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy affecting residents' care. Recommend to continue room waivers. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055646 If continuation sheet Page 20 of 20