Health inspection·November 9, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm residents had a mental disorder, to document any psychotropic medications the resident may be taking and how to monitor the resident for behavioral changes. The MDSD confirmed PASRR Level II evaluations guided the plan of care for residents with mental disorders and identified which residents required referrals to mental health resources not available within the facility Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 2 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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** 4. Review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in October 2023, with multiple medical diagnoses that included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged). During an observation on 11/7/23, at 9:56 a.m., in Resident 16's room, Resident 16 was observed to be sitting at the edge of his bed and was noted with an indwelling urinary catheter. Review of Resident 16's care plan failed to show a urinary catheter care plan was developed upon admission. During an interview on 11/8/23, at 3:23 p.m., with LN 14, LN 14 confirmed Resident 16 did not have a urinary catheter care plan. During a concurrent interview and record review on 11/9/23, at 10:51 a.m., with the DON, the DON confirmed Resident 16 did not have a urinary catheter care plan. The DON stated there should be a care plan in place. The DON further stated if there was no care plan in place, interventions could be missed and could cause a urinary tract infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised August 2022, indicated, .Review the resident's care plan to assess for any special needs of the resident . Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan .includes the resident's stated goals upon admission and desired outcomes .reflects currently recognized standards of practice for problem areas and conditions .Based on interview, and record review, the facility failed to develop and implement a plan of care (or Care Plan- a strategy on how the staff will help a resident with its medical, physical, or emotional problems) for 4 out of 21 sampled residents (Resident 18, Resident 7, Resident 81, and Resident 16) when: 1. Resident 18's Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety) care plan was not developed and implemented and could have resulted in recurrent traumatization. 2. Resident 7's Buspar (or buspirone, a drug used to treat anxiety) was not care planned to include resident's medical, nursing care, assessment of resident's needs, and medication use monitoring. 3. Resident 81's olanzapine (or Zyprexa, a drug used to treat mental illness) was not care planned to include resident's medical, nursing care and assessment of resident's needs, and medication use monitoring; and, 4. Resident 16's indwelling urinary catheter (foley catheter- a tube inserted into the bladder to drain urine) was not care planned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 3 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 These failures had the potential for Resident 18, Resident 7, Resident 81 and Resident 16's care needs and goals not being addressed. Findings: 1. During a review of Resident 18's clinical record titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 18 was admitted with a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (mental illness that causes unusual shifts in mood), and PTSD. A review of Resident 18's clinical record titled, Progress Notes, dated 9/28/23, at 12 PM, by the Medical Director (MD), indicated, I [Resident 18] went through emotional abuse when I was [AGE] years old. A review of Resident 18's clinical record titled, Section I Active Diagnosis, (part of the Minimum Data Set [MDS]- a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 11/5/22, 12/5/22, 3/6/23, 6/2/23, and 8/25/23, indicated, Resident 18 had an active diagnosis of PTSD. A review of Resident 18's clinical record titled, Preadmission Screening and Resident Review (PASRR) INDIVIDUALIZED DETERMINATION REPORT, (responsible for determining if individuals with serious mental illness and/or intellectual/developmental disability require specialized services), dated 11/21/22, indicated, .Recommended Specialized Services: Services and supports that supplement nursing ability care to address mental health needs .Recommended .Supportive Services- Interactions with facility staff that encourage problem solving, socialization, reality orientation or focus on therapeutic goals . A review of Resident 18's clinical record on 11/7/23, indicated, there was not a PTSD care plan in place. During an interview on 11/8/23, at 11:44 AM, with Licensed Nurse (LN) 1, LN 1 stated she was unsure if the resident had any psychological diagnoses (including PTSD). LN 1 further stated, she did not know of any triggers that Resident 18 had related to PTSD and without knowing specific triggers, Resident 18 could have been unintentionally re-victimized by not receiving specific resident-centered care. During an interview on 11/8/23, at 3:02 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was unsure if Resident 18 required specialized nursing care related to PTSD. During an interview on 11/8/23, at 3:06 PM, with LN 2, LN 2 stated Registered Nurses (RNs) and LNs initiated and updated the resident's care plans. LN 2 further stated, Resident 18 should have had a care plan in place to identify her specific triggers related to PTSD. LN 2 stated, she was unaware of the specialized care Resident 18 required. During a review of the facility's document titled, Job Description Registered Nurse [RN] Department: Nursing, dated 3/1/14, indicated, .Assist the Charge Nurse as required which includes but is not limited to assessment of residents .care plans . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 4 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 A review of the facility's document titled, JOB DESCRPTION Licensed Vocational Nurse (LVN) DEPARTMENT: Nursing, dated 3/1/14, indicated, .Essential Job Functions: work collaboratively with the resident/family and interdisciplinary team members to develop an individualized plan of care for each resident . A review of the facility's document titled, JOB DESCRIPTION Certified Nurse Assistant (CNA) DEPARTMENT: Nursing, indicated, .The CNA provides nursing and nursing related services to residents consistent with each resident's comprehensive resident assessment and plan of care . During a concurrent interview and record review on 11/8/23, at 3:18 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, dated 3/22, was reviewed. The P &P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .2. A comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment, and no more than 21 days after admission .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan .(2) any specialized services to be provided as a result of PASARR recommendations . The DON stated, a PTSD care plan should have been completed on admission to identify Resident 18's triggers. The DON verified the P&P was not followed. 2. Review of Resident 7's medical record, titled Order Summary Report, (a list of all doctor orders and medical conditions) dated 11/8/23, the record indicated Resident 7 had mental depression, anxiety, and memory problems. Further review of the records indicated a medication order for Buspar as follows: Buspirone Tablet 5 MG (anxiety pill; MG is measure of unit); Give 3 tablet by mouth two times a day for anxiety m/b (manifested by) repetitive health complaints .Order date: 10/31/23 . Review of Resident 7's medical record, titled Plan of Care, with an admission date of 9/18/23, the record did not show any plan of care for use of anxiety medications and diagnosis. In an interview with the DON in her office, on 11/9/23, at 12:29 PM, the DON confirmed that the plan of care for use of Buspar and anxiety medication was not developed. 3. Review of Resident 81's medical record, titled Medication Administration Record, (or MAR, a document that listed all medications and care a resident receives), with date range of 11/1/23 to 11/30/23, the record indicated Resident 7 had memory and behavioral problems. Further review of the record indicated a medication order for olanzapine tablet 2.5 MG at bedtime for dementia with nighttime agitation and irritability. Review of Resident 81's medical record, titled Plan of Care, with an admission date of 10/10/23, the record indicated The resident is risk for falls r/t [related to] Confusion; Date Initiated: 10/10/23. Further review of the record did not show any plan of care for olanzapine medication use and dementia care. In an interview with the DON in her office, on 11/9/23, at 1:29 PM, the DON confirmed that the plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 5 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 of care for use of olanzapine medication was not developed. DON stated the nursing plan of care should be developed within 14 days and the comprehensive care plan should have addressed all of the problem list. Review of the facility's policy titled, Using the Care Plan, dated 8/06, the policy indicated The Care Plan shall be used in developing the resident's daily routine and will be available to staff personnel who have responsibility for providing care or service to the residents. Review of the facility's policy titled, Care Plan, Comprehensive Person-Centered, dated 3/22, the policy indicated The interdisciplinary team (IDT) .develop and implement a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan is developed within 7 days of the completion of the required .assessment .and no more than 21 days after admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 6 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 interview and record review the facility failed to ensure an accurate psychiatric (mental health) diagnosis was documented in the medical records for 1 out of 21 sampled residents (Resident 13) based on standards of practice. This failure could result in inaccurate treatment, care and monitoring of Resident 13's psychotropic medication (medications that affect mood or behavior). Residents Affected - Few Findings: Review of Resident 13's medical record, titled Order Summary Report, (a list of all doctor orders and medical conditions), dated 11/8/23, indicated Resident 13 was on multiple mind-altering medications including Depakote (or Divalproex, a medication used to treat seizure and regulate the mood) for bipolar disorder (a chronic mental illness that fluctuated between depression and anxiety) as follows: Depakote Oral Tablet .250 MG (MG means milligram, a unit of measure); Give 1 tablet by mouth three times a day for bipolar disorder m/b (manifested by) yelling and combative behavior . Review of Resident 13's medical record titled, History and Physical, (a summary of medical condition upon admission to nursing home and annually written by a medical doctor), dated 4/28/22, written by Medical Doctor (MD) 2, indicated, Patient has history of .bipolar disorder, tobacco abuse, diabetes (blood sugar disease), depression. Review of Resident 13's medical record, titled Minimum Dataset, (or MDS- a set of mandatory clinical assessment of nursing home residents reported to the federal government), dated 10/27/23, section I under Psychiatric/Mood disorder, indicated, Anxiety disorder: NO; Depression .Yes; Bipolar Disorder: Yes . Review of Resident 13's medical record titled, Plan of Care, (or Care Plan - a written plan that listed and addressed how the nursing home staff will help a resident with its medical, physical, or emotional problems), dated 7/20/23, indicated, The resident has a mood problem and uses Depakote for Disease Process- bipolar disorder m/b (manifested by) yelling and combative behavior. Review of Resident 13's medical record, from Hospital A, titled, Past Medical History, dated 4/25/22, did not include any diagnosis of bipolar disease for mental health issues. The document indicated depression as a mental health diagnosis for past medical history. Review of a communication record between Consultant Pharmacist (CP) 2 and the medical provider, dated 9/26/23, the record asked the medical provider to assess dosage reduction of Depakote for Resident 13 or provide a justification for its continued use. The medical provider responded to the communication note as follows: A GDR (Gradual Dose Reduction) is not clinically appropriate due to seizure (an enduring condition) . In a telephone call with Resident 13's Family Member (FM), on 11/8/23, at 3:12 PM, the FM stated he could not recall ever being told or signing a document that Resident 13 had a bipolar diagnosis. FM stated most recently the memory was an issue. In an interview with the Director of Nursing (DON), in her office, on 11/9/23, at 1 PM, the DON stated the multidisciplinary team of nursing, social services, medical doctor and pharmacist often (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 7 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed the mental health medication use and monitoring. The DON stated the diagnosis was a doctor's area of expertise and nursing staff mainly administered and monitored response to therapy and possible side effects. In a telephone interview with Medical Doctor (MD) 1, on 11/9/23, at 11:50 AM, MD 1 stated he took over the care of Resident 13 recently and could not comment on the diagnosis recorded in the medical record. MD 1 stated he did not give mental health diagnoses to any resident since he was not a mental health doctor and agreed it should have been verified for accuracy. In a telephone interview with the Mental Health Nurse Practitioner (M-NP), on 11/9/23, at 4:34 PM, the M-NP stated she took over the mental health care of Resident 13 in January of 2023 and carried over what was in the medical record for the mental health diagnosis. M-NP stated Resident 13 had mood swings and adjustment behavior but did not fit the criteria to be diagnosed as bipolar disease. M-NP stated she focused on talk therapy and generally would not push medication use as side effects could add additional problems. Review of the facility's policy titled Psychotropic Medication Use, dated July 2022, indicated Residents, families and/or the representatives are involved in the medication management process. Psychotropic medication management includes: a. indication for use . The policy in section 4 indicated, Residents who .the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. The policy in section 8 indicated, Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's sign and symptoms in order to identify underlying causes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 8 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 4) was assisted in gaining access to hearing services when Resident 4's physician order to be evaluated by an audiologist (a person with specialized training in the science and medicine of hearing and balance) was not acted upon. Residents Affected - Few This failure had the potential for Resident 4 to not effectively communicate and express her needs and negatively impact Resident 4's quality of life. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in May 2023. A review of Resident 4's MDS (minimum data set- a resident assessment tool) dated 8/14/23, indicated, a brief interview for mental status (BIMS) score of 14. A score of 13-15 indicated intact memory. During an interview on 11/6/23, at 2:38 p.m., with Resident 4, Resident 4 stated she was hard of hearing, and she had no hearing aids. During an interview on 11/6/23, at 2:47 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 confirmed Resident 4 had no hearing aids. CNA 5 also confirmed there was no communication board or other means of communication except a yellow note pad at Resident 4's bedside table tray. CNA 5 explained she talked loudly when she communicated to Resident 4. During an interview on 11/7/23, at 8:37 a.m., with Resident 4, Resident 4 stated, she wanted hearing aids, and it would be a blessing if she had those. Resident 4 further stated no one ever talked to her about hearing aids. During an interview on 11/8/23, at 3:43 p.m., with the Social Services Director (SSD), the SSD stated, the facility had ENT (ear, nose, and throat) services and she would reach out to them. A review of social services notes in Resident 4's clinical record, dated 6/5/23, indicated, .Social services emailed ENT Dr to schedule a visit for ENT to come to facility and see resident . There was no documented evidence in Resident 4's clinical record of a hearing assessment completed by an audiologist. During an interview on 11/8/23, at 5:51 p.m., with the Director of Nursing (DON), the DON stated Resident 4 was scheduled to be seen by an ENT audiologist on 9/15/23. The DON confirmed Resident 4 was not seen by the ENT audiologist. The DON stated Resident 4's missed appointment should have been followed up. The DON further stated the risk of not getting Resident 4 hearing aids was the resident could not communicate her needs. Review of the facility's policy and procedure titled, Hearing Impaired Resident, Care of, revised February 2018, indicated, .Staff will assist the resident (or representative) with locating available resources, scheduling appointments .to obtain needed services . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 9 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 provide preventative care and treatment consistent with professional standards of care for one of six sampled residents with pressure injuries (Resident 63) when Resident 63's pressure injury (PI- an injury to skin and underlying tissue resulting from prolonged pressure) plan of care of the right knee PI was not followed. Residents Affected - Few This failure had the potential for Resident 63's right knee pressure injury to worsen and develop complications. Findings: During a concurrent observation and interview on 11/7/23, at 9:49 a.m., in Resident 63's room, Resident 63 was observed laying on her right side in bed. Resident 63 had severe bilateral lower extremity contractures (the lack of full, passive range of motion (ROM) of limbs due to joint, muscle or soft tissue limitations). Resident 63 stated she did not get out of bed because she could not tolerate sitting up in a chair. During a concurrent observation and interview on 11/7/23, at 11:09 a.m., in Resident 63's room, Resident 63's right knee PI dressing change was observed. Licensed Nurse (LN) 12 repositioned Resident 63 onto her left side, providing full assistance with turning and repositioning to Resident 63. LN 12 removed the dry dressing from the right outer knee. A stage 1 pressure injury (an observable, pressure-related alteration of intact skin with non-blanchable redness (an area of skin redness that does not turn white when pressed) of a localized area), measuring approximately 1 inch (unit of length) long and 1.5 inch wide was observed on the right outer knee. The overlying skin of the PI was intact, no blisters or drainage was observed. During a concurrent observation and interview on 11/7/23, at 11:45 a.m., in Resident 63's room, Resident 63 was observed to be positioned on her right side in her bed. Resident 63 stated she was concerned that she was not being repositioned on a routine basis. Resident 63 further stated she was to be repositioned every two hours. She stated she needed to call nursing staff to remind them to reposition her. During an observation on 11/7/23, at 2:07 p.m., in Resident 63's room, Resident 63 was observed laying on her right side in bed. During a concurrent interview and record review on 11/8/23, at 9 a.m., with LN 12, LN 12 displayed photographs of Resident 63's right knee PI taken that morning during daily wound treatment. The photograph indicated the right knee wound had an open area, measurements were 0.4 inch long, 0.5 inch wide and 0.1 inch in depth, as calculated by a wound staging application on the camera. The center of the wound's open area was noted with bright red, shiny tissue. LN 12 confirmed Resident 63's PI had an open area that was not present the day before. During an interview on 11/8/23, at 9:15 a.m., with CNA 4 in the hallway outside Resident 63's room, CNA 4 confirmed it was within her assigned duties to reposition the residents every two hours. A review of Resident 63's care plan, dated 10/19/23, indicated Resident 63 had a PI to the right knee lateral side. Care instructions included, Reposition resident per facilities protocol. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 10 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 63's mobility plan of care response history (a documented record of resident repositioning), dated 10/10/23-11/8/23, indicated Resident 63 was only repositioned 16 times out of 84 opportunities over a seven day review period. During a concurrent interview and record review on 11/8/23, at 1:52 p.m., with the Director of Staff Development (DSD), the facility policy titled, Repositioning, dated May 2013, was reviewed with the DSD. The Repositioning policy indicated, .Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing .Evaluate the resident for an existing pressure ulcer. If present, positioning the resident on the existing ulcer should be avoided . During a concurrent interview and record review, in-service materials from a course titled, The Skin, facts Risks and Care, presented on 11/2/23, was reviewed with the DSD. The DSD pointed out highlighted portions of the in-service, which instructed staff to .be sure residents is not [sic] remain the position longer than two hours . and .some older adults can begin to experience harm from pressure within an hour. For this reason, every two-hour schedule may not be adequate for all residents . The DSD confirmed the facility repositioning program provided instruction to staff on recognizing residents at risk of a PI. The DSD stated residents who were bedbound, had limited mobility, were dependent on staff for activities of daily living (ADL), non- ambulatory residents, residents in a state of malnutrition, a history of a prior PI, and incontinence were vulnerable to develop a PI. The DSD further stated preventative care was for everybody, mainly for residents who were dependent on staff. The DSD confirmed their facility training materials instructed staff that residents were to be repositioned at least every two hours. Review of facility policy titled, Prevention of Pressure Ulcers, dated April 2020, section Mobility/Repositioning, indicated, Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 11 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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, record review, the facility failed to ensure 1 of 21 sampled residents (Resident 16) who was admitted to the facility with an indwelling urinary catheter (foley catheter, tube inserted into the bladder to drain urine) had a physician order for the catheter. This deficient practice had the potential for Resident 16 to have an increase in recurrent UTI's and could cause actual harm. Findings: Review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in October 2023 with multiple medical diagnoses that included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged) and urinary tract infection. Review of Minimum Data Set (MDS- an assessment tool used to guide care) dated 10/15/23, Section O of the MDS indicated, Resident 16 had an indwelling urinary catheter upon admission. During an observation on 11/7/23, at 9:56 a.m., in Resident 16's room, Resident 16 was observed to be sitting at the edge of his bed and was noted with an indwelling urinary catheter. During an interview on 11/8/23, at 3:23 p.m., with Licensed Nurse (LN) 14, LN 14 confirmed there was no physician order for Resident 16's indwelling urinary catheter upon admission. Review of Resident 16's Discharge Summary from [acute care hospital] dated 10/12/23, indicated one of the diagnoses for Resident 16 upon admission at the hospital was urinary tract infection. During a concurrent interview and record review on 11/9/23, at 10:51 a.m., with the Director of Nursing (DON), the DON confirmed a physician's order for Resident 16's indwelling urinary catheter was not obtained upon admission. Hospital History & Physical (H&P) dated 10/9/23, was reviewed with the DON. The DON stated the H&P indicated Resident 16 had a chronic indwelling urinary catheter. The DON explained the physician order for Resident 16's urinary indwelling catheter should include the size, indication, catheter care and how long the resident needed a urinary indwelling catheter. The DON stated if there was no physician order for the urinary catheter with instructions when to change and what to do, it could be missed by staff and could cause a urinary tract infection. Review of the facility's policy and procedure titled, Catheter Care, Urinary, revised August 2022, indicated, .Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter in place. Use a standardized tool for documenting clinical indications for use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 12 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 2 of 4 sampled residents with a peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments) line (Resident 79, and Resident 80) when: Residents Affected - Few 1.Resident 79's PICC line dressing was not changed at least weekly; and 2. Resident 80's PICC line dressing was not changed at least weekly. These failures had the potential to increase the risk of developing an infection for Resident 79 and Resident 80. Findings: 1. A review of Resident 79's admission Record indicated, Resident 79 was admitted in 2023, with diagnoses including pneumonia (a respiratory infection that affects lungs), sepsis (body's extreme response to an infection) and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a concurrent observation and interview on 11/7/23, at 9:07 a.m., with Licensed Nurse (LN) 13, LN 13 confirmed Resident 79 had a PICC line. LN 13 confirmed that date written on the Resident 79's PICC line dressing was 10/26/23 and the date written on the PICC line dressing indicated when the dressing was last changed. LN 13 stated Resident 79's PICC line dressing was to be changed every Wednesday. LN 13 confirmed Resident 79's PICC line dressing was not changed for more than a week. During a concurrent interview and record review on 11/7/23, at 9:14 a.m., Resident 79's Order Summary Report was reviewed with LN 13. LN 13 stated the PICC line dressing should be changed every 7 days and as needed. LN 13 reviewed the Progress notes of Resident 79 and confirmed there was no documentation that Resident 79's PICC line dressing had been changed once a week. During a concurrent interview and record review on 11/7/23, at 9:28 a.m., with the Director of Nursing (DON), the DON reviewed the progress notes of Resident 79 and confirmed Resident 79's PICC line dressing was documented as last changed on 10/28/23 (PICC line dressing was dated 10/26/23). The DON stated Resident 79's PICC line dressing should have been changed three days ago. The DON stated the PICC line dressings were to be changed once a week and as needed. The DON further stated there could be a risk of infection if the PICC line dressing was not changed at least weekly. 2. A review of Resident 80's admission Record indicated, Resident 80 was admitted in 2023, with diagnoses of acute (severe and sudden in onset) osteomyelitis (infection of bone) of left ankle and diabetes mellitus. During a concurrent observation and interview on 11/7/23, at 11:20 a.m., Resident 80 stated he was receiving antibiotics (medication to treat an infection) through the PICC line. Resident 80 showed the Department his PICC line located on his left upper arm. The PICC line insertion site was noted to be covered with a clear dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 13 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 11/7/23, at 11:25 a.m., with LN 13, LN 13 confirmed Resident 80 had a PICC line located on his left arm. LN 13 confirmed that date written on the PICC line dressing was 10/18/23 and that the date written on the PICC line dressing indicated when the dressing was last changed. LN 13 confirmed Resident 80's PICC line dressing was not changed at least weekly. During a concurrent interview and record review on 11/7/23, at 11:30 a.m., Resident 80's Order Summary Report was reviewed with LN 13. LN 13 stated Resident 80's PICC line dressing should be changed every 7 days and as needed. LN 13 reviewed the Progress notes of Resident 80 and confirmed Resident 80's PICC line dressing had not been changed for 19 days. During a concurrent interview and record review on 11/7/23, at 11:36 a.m., with the DON, the DON reviewed the progress notes of Resident 80 and confirmed the PICC line dressing was not changed for more than two weeks. The DON stated the PICC line dressings were to be changed once a week and as needed. The DON further stated there could be a risk for local (at the site where the PICC line was inserted) and systemic (an infection that is in the blood stream) infection, if it was not changed at least weekly. During a review of the facility's policy and procedure titled, Central Venous Catheter Care and Dressing Changes, revised March 2022, indicated, .The purpose .is to prevent complications .Change the dressing if it becomes damp, loosened or visibly soiled and .at least every 7 days . Review of an undated online document from the Agency of Healthcare Reseach and Quality (AHRQ) titled, INSTRUCTIONS Selected Best Practices and Suggestions for Improvement, in the section titled Recommended Practice: Daily Monitoring and Assessment, indicated, .For nontunneled catheters [for short term use, a PICC line is a nontunneled catheter], change the transparent dressing and perform site care .every 5 to 7 days or more frequently if the dressing is soiled, loose, or damp . (https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4a-crbsi-bestpractices.pdf) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 14 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure timely availability of medications for three of twenty-one sampled residents (Resident 29, Resident 40, and Resident 68) when: Residents Affected - Few 1. Resident 29's zonisamide (medication used to prevent and control seizures) 50 mg (milligram, unit of measure) dose was not available for administration on 11/6/23. 2. Resident 40's neomycin/polymyxin B/hydrocortisone otic solution (medication used to treat ear infections) was not available for administration on 11/6/23. 3. Resident 68's lorazepam (medication used to treat anxiety) was not available for administration on 11/6/23. These failures had the potential to cause Resident 29 an increased risk of seizures, Resident 40's infection to worsen and Resident 68 to experience symptoms of anxiety and distress. Findings: 1. Resident 29 was admitted to the facility in the fall of 2020 with diagnoses which included epileptic seizures (disease characterized by recurrent seizures). A review of Resident 29's medication administration record (MAR), dated November 2023, indicated, .zonisamide capsule 150 mg .give 50 mg capsule from bubble pack and 100 mg from [name brand] machine [medication automatic dispensing unit] 50 + 100 = 150 mg in total dose . During an observation on 11/6/23, at 4:39 PM, licensed nurse (LN) 4 prepared Resident 29's medications for administration. LN 4 removed a medication from a plastic packet labeled zonisamide capsule 100 mg. LN 4 opened the capsule, mixed the medication in applesauce, and administered it to Resident 29. During a concurrent interview and record review on 11/7/23, at 1:36 PM, LN 5 confirmed Resident 29 should have received 150 mg of zonisamide. LN 5 further confirmed that the 50 mg dose was unavailable in the medication cart. LN 5 stated Resident 29 was at risk for seizures if he did not receive the correct dose of his medication. During an interview on 11/8/23, at 3:25 PM, the consultant pharmacist (CP) 1 stated the blister packed 50 mg dose of zonisamide had last been delivered to the facility in July. The CP 1 was not sure why the correct dose of the 100 mg capsule and the 50 mg capsule were not packaged together. During an interview on 11/9/23, at 9:43 AM, the Director of Nurses (DON) confirmed the correct dose of zonisamide should have been available for Resident 29. The DON stated not receiving the correct dose of medication put Resident 29 at risk of seizures. 2. Resident 40 was admitted to the facility in the summer of 2023 with diagnoses which included sepsis (a life-threatening infection) of unspecified organism (unknown germ), and intraspinal abscess (an infection inside the spine) and granuloma (small area of swelling). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 15 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 40's, Progress Notes, dated 11/5/23, at 12:31 PM, indicated, .yellow fluid drain [sic] reported by the resident upon assessment yellow fluid is noted in pt's incisura [indentation or notch under the ear canal] along with yellow crust on pt's [patient's] ear lobe . A review of Resident 40's, Order Summary Report, dated 11/7/23, indicated . [neomycin/polymyxin B/hydrocortisone otic solution] .instill 4 drops in left ear three times per day for infection .order date 11/5/2023 . A review of Resident 40's MAR dated, November 2023, indicated, neomycin/polymyxin B/hydrocortisone otic solution was scheduled to be administered at 8 AM, 12 PM and 5 PM daily starting on 11/6/23. During an interview on 11/7/23, at 1:52 PM, LN 5 confirmed the neomycin/polymyxin B/hydrocortisone otic solution was ordered to start on 11/6/23 at 8 AM. LN 5 stated the medication was not available and had not been administered to Resident 40. LN 5 further stated not receiving his medication as prescribed put Resident 40 at risk of worsening infection. During a telephone interview on 11/8/23, at 4:05 PM, the Consultant Pharmacist (CP) 1 stated an antibiotic should be available for administration within 4 hours of being ordered. The CP 1 further stated the physician should have been informed if the medication was not available. During an interview on 11/9/23, at 9:43 AM, the DON stated it was her expectation that the LN would call the pharmacy and physician when ordered medications were unavailable. The DON further stated not treating the ear infection as ordered put Resident 40 at potential risk of worsening infection. 3. Resident 68 was admitted to the facility in the Spring of 2023 with diagnoses which included malignant neoplasm of the left breast (breast cancer) and anxiety disorder. A review of Resident 68's MAR, dated November 2023, indicated, .Lorazepam oral concentrate 2mg/ml [milliliter, unit of measurement] Give 0.5 ml every 4 hours for anxiety manifested by inability to relax . The MAR indicated missed doses on November sixth at 12 AM, 4 AM, 8 AM, 12 PM and 4 PM. During an interview on 11/6/23, at 11:55 AM, LN 3 stated Resident 68 should have received a 12 PM dose of lorazepam (medication used to treat anxiety) but the medication had been unavailable since yesterday. During an observation and interview on 11/6/23, at 12:13 PM, in Resident 68's room, Resident 68 stated she was feeling anxious and requested lorazepam from LN 3. LN 3 stated Resident 68 always had anxiety and appeared tense. During an interview on 11/7/23, at 1:14 PM, LN 3 stated it was not acceptable for Resident 68 to have waited two days for her lorazepam prescription to be refilled. During an interview on 11/9/23, at 9:43 AM, the DON confirmed the missed doses of lorazepam caused Resident 68 to experience restlessness and anxiety. The DON stated the facility had an Emergency medication Kit (or Ekit- an emergency supply of medication) available that could have been accessed to provide Resident 68 with the prescribed doses of lorazepam. A review of a facility policy and procedure (P&P) titled, Pharmacy Services Overview, dated April 2019, indicated, .Pharmacy services are available to residents 24 hours a day, seven days a week (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 16 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete .Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner .Nursing staff shall communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration . A review of a facility P&P titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame .medications are administered within one (1) hour of their prescribed time . Event ID: Facility ID: 055917 If continuation sheet Page 17 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure safe use and monitoring of blood thinner (medication with high risk of bleeding) and cardiac (heart) medications for 1 out of 21 sampled residents (Resident 49) based on standards of practice on safe use of high-risk (drugs with heightened risk of causing significant patient harm due to side effect profile) medications when: Residents Affected - Few 1. Resident 49 was on four different blood thinning medications without daily side effect monitoring; and, 2. Resident 49 was on duplicate cardiac medications known as beta blockers (beta blocker medications are a class of drugs that cause the same additive effect on the heart) for the same indication with additive effect on heartbeat and blood pressure. These failures could have resulted in an additive medication side effects including bleeding or excessive lowering of Resident 49's heartbeat and blood pressure. Findings: 1. Review of Resident 49's medical record, titled Order Summary Report, (a list of all doctor orders and medical conditions), dated 11/8/23, the record indicated Resident 49 was on four different blood thinner medications as follows: a. Apixaban Oral Tablet 2.5 MG (or Eliquis, a blood thinner pill; MG is milligram, a measure of unit); Give 1 tablet by mouth every 12 hours for ATHEROSCLEROTIC HEART DISEASE .(a type of heart disease); Start date: 3/24/23. b. Aspirin EC Oral Tablet Delayed Release 325 MG (Aspirin, a pill that make the blood thin); Give 1 tablet by mouth one time a day for Clot (means blood clot) prevention .Start date: 3/24/23. c. Cilostazol Tablet 100 MG; (a pill that makes blood thin); Give 1 tablet by mouth every 12 hours for symptoms of intermittent claudication (a blood circulation problem in the legs); Start date: 3/24/23. d. Clopidogrel .Oral Tablet 75 MG (or Plavix, pill used to thin the blood to prevent clot formation); Give 1 tablet by mouth one time a day for ATHEROSCLEROTIC HEART DISEASE .Start date: 3/24/23. Further review of the Order Summary Report did not show any side effect monitoring or documentation of monitoring for blood thinner's possible adverse effects. Review of Resident 49's medical record, titled Plan of Care, dated 3/24/23, the care plan indicated Potential for injury r/t (related to) anticoagulation therapy clot prevention and A-fib (or Atrial Fibrillation, a type of heart rhythm disease) .Body checks to be done while providing care .Hold medicine and notify MD if resident has any s/s (sign and symptoms) of active bleeding .The resident is at risk for falls r/t Gait/balance problems, Unaware of safety needs. Review of the resident 49's electronic medical record, titled Progress notes, dated 5/25/23, at 1:52 PM, the record indicated an episode of skin tear with bleeding Situation: The Change in Condition/s reported .Skin wound or ulcer; At the time of evaluation Resident/Patient is on anticoagulant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 18 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 other than warfarin: No. Level of Harm - Minimal harm or potential for actual harm The assessment inaccurately indicated the resident was not on blood thinning medication. Residents Affected - Few Review of Resident 49's transfer summary record from Hospital B, dated 4/5/21, the record indicated the main discharge diagnosis was left femoral (thigh bone) fracture after a fall at home. Review of Resident 49's electronic medical record, titled History and Physical, (or H&P, a summary of medical problems and care) written by Medical Doctor (MD) 1, dated 8/5/23, the H&P indicated, Patient was hospitalized for a fall leading to left humerus (the bone in upper arm) fracture .Frequent falls .Patient is participating in physical therapy .she has poor baseline functional status, continue to reiterate fall precautions. In an interview with Licensed Nurse (LN) 8, at East Station, on 11/8/23, at 2:59 PM, LN 8 stated for monitoring blood thinner's side effects, she would have looked at the MAR (Medication Administration Record, a document listed medications and its monitoring parameters) and documented the observed or listed side effects as needed. LN 8 stated MAR was a document that nurses used frequently to guide them in watching for bleeding, bruises, or any unusual signs during resident care. In an interview with the Director of Nursing (DON), in her office, on 11/9/23, at 1:12 PM, the DON stated the care plan should have triggered and listed the side effects to be monitored by licensed staff. DON stated the bleeding and fall risk could have consequences. In a telephone interview with MD 1 on 11/9/23, at 11:50 AM, MD 1 stated the four blood thinners were a recommendation from cardiologists (heart doctors). MD 1 added if there was risk of a fall, the use should be re-assessed for risk versus benefits in addition to close monitoring. Review of the facility's policy titled, Anticoagulation (means blood thinning)- Clinical Protocol, dated 11/2018, the policy indicated, As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated .Assess for any signs or symptoms related to adverse drug reactions due to medication alone or in combinations with other medications. The policy under Treatment/Management indicated, The physician will periodically identify individuals .and will document a rationale for continuing anticoagulation over time, including the medication and current dosage .The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. 2. Review of Resident 49's medical record, titled Order Summary Report, (a list of all doctor orders and medical conditions), dated 11/8/23, the record indicated Resident 49 was on two different beta blocker medications (beta blocker medications are a class of drugs that cause the same additive effect on the heart) for the same indication as follows: a. Metoprolol Succinate ER Tablet .25 MG (drug used to slow the heartbeat and treat high blood pressure; Long-acting drug; MG is milligram, a unit of measure); Give 1 tablet by mouth one time a day for HTN (hypertension or high blood pressure) .Start date: 3/24/23. b. Propranolol HCl Oral Tablet 20 MG (drug slows down the heart rate and lowers blood pressure); Give 1 tablet by mouth every 12 hours for Hypertension .Start Date: 5/10/23. Further review indicated the order for propranolol was given over the phone and the order was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 19 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 signed by MD 2 on 5/18/23. Level of Harm - Minimal harm or potential for actual harm Review of resident 49's medical record, titled Plan of Care, dated 3/24/23, the care plan indicated, The resident has altered cardiovascular status r/t (related to) CAD (type of heart disease) .Hypertension (high blood pressure), Hypotension (low blood pressure); Date Initiated: 03/24/23 .Monitor Vital signs per facility protocol. Notify MD of significant abnormalities. Date Initiated: 03/24/23. Residents Affected - Few The care plan was not updated when the second beta-blocker medication, called propranolol, was added to the medication regimen. Review of Resident 49's medical record, titled Progress Notes, with a time frame from 10/9/23 to 11/9/23, the notes indicated nursing staff held the betablocker medications and alerted the medical providers (Doctor or Nurse Practitioner, or NP) on drug-drug interactions in the following dates and times: 10/09/23, 20:41PM 10/10/23, 20:08 PM 10/12/23, 20:59 PM 10/13/23, 20:35 PM 10/16/23, 20:31 PM 10/17/23, 20:48 PM 10/22/23, 8:53 AM 10/24/23, 21:05 PM 10/26/23, 19:37 PM 10/27/23, 20:56 PM 10/28/23, 15:37 PM-Drug interaction alert to NP 10/28/29, 20:57 PM 10/29/23, 20:40 PM 10/30/23, 21:03 PM 11/2/23, 20:45 PM 11/4/23, 7:37 AM - Drug interaction alert to MD 11/5/23, 21:06 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 20 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 The Progress Notes to medical doctor or the Nurse Practitioner on 10/28/23 and 11/4/23 were as follows: Level of Harm - Minimal harm or potential for actual harm a. 11/4/2023 07:37 Health Status Note Text: received alert for possible drug to drug interaction between metoprolol succinate and propranolol. MD made aware; no new orders at this time. Residents Affected - Few b. 10/28/2023 15:37 Health Status Note Text: Received drug to drug interaction alert. reviewed and acknowledged by NP with no new orders noted. In a telephone interview with the facility's Consultant Pharmacist (CP) 1 on 11/8/23, at 3:48 PM, CP 1 stated he would need to look at the records to recall Resident 49's reviews. CP 1 added that he would have questioned the duplicate beta blocker use and would have asked for clinical justification. In an interview with the Director of Nursing (DON) in her office, on 11/9/23, at 1:12 PM, the DON stated the nursing staff followed the doctor's order with hold parameters in place for safe use of cardiac medications. In a telephone interview with Medical Doctor (MD) 1 on 11/9/23, at 11:50 AM, The MD 1 stated he was not aware of the duplicate beta blocker and would review the medical record to assess its use and effect on the resident. In an in-person interview with MD 1, on 11/9/23, at 5:45 PM, MD 1 stated he looked at Resident 49's medication profile and was making changes by contacting specialists. MD 1 stated he will be working with the pharmacist to help him optimize medication use and duplicate therapy. Review of the facility's policy titled, Medication Regimen Review, (or MRR, monthly review of medication uses by a pharmacist) dated 5/2019, the policy indicated the MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems . The policy further indicated, The attending physician documents in the medical record that the irregularity has been reviewed and what .action was taken to address it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 21 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than 5 percent (%, a number or ratio indicating parts per hundred) when 7 medication errors occurred out of 33 opportunities during medication administration observation for 4 out of 17 residents (Resident 23, Resident 29, Resident 40, and Resident 68). Residents Affected - Few As a result of these failures, the facility's medication administration error rate was 21% which could contribute to unsafe medication use and not following the doctor's orders. Findings: 1. During an observation on 11/6/23, at 8:07 AM, licensed nurse (LN) 5 prepared Resident 23's medications for administration. LN 5 administered Vitamin D3 (a vitamin essential for bone strength) 125 MCG (microgram, a unit of weight) to Resident 23 along with his other medications. A review of Resident 23's Medication Administration Record, (MAR) dated November 2023, indicated, .Vitamin D3 Oral Tablet 50 mcg .one time a day for supplement . During an interview on 11/7/23, at 1:52 PM, LN 5 confirmed that Resident 23 received the incorrect dose of Vitamin D3. LN 5 further stated Resident 23 should have received the dose the physician ordered. 2. During an observation on 11/6/23, at 4:39 PM, LN 4 prepared Resident 29's medications for administration. LN 4 removed a medication from a plastic packet labeled zonisamide capsule (a medication used to prevent and control seizures) 100 mg (milligram, unit of measure). LN 4 opened the zonisamide capsule with her bare hands and poured the contents into a small plastic cup. LN 4 mixed the zonasimade and another medication in applesauce and administered them to Resident 29. A review of Resident 29's MAR, dated November 2023, indicated, .zonisamide capsule 150 mg .give 50 mg capsule from bubble pack and 100 mg from [brand name] machine [medication automatic dispensing unit] 50 + 100 = 150mg in total dose .(DO NOT OPEN, CRUSH, OR CHEW, SWALLOW WHOLE CAPSULE) WEAR GLOVES WHILE HANDLING THE MEDICATION . During a concurrent interview and record review on 11/7/23, at 1:36 PM, LN 5 confirmed Resident 29 should have received 150 mg of zonisamide. LN 5 further confirmed that the 50 mg dose was unavailable in the medication cart. LN 5 stated Resident 29 was at risk for seizures if he did not receive the correct dose and correct administration of his medication. During an interview on 11/9/23, at 9:43 AM, the Director of Nurses (DON) confirmed the zonisamide capsule should not have been opened and Resident 29 should have received the correct dose of the medication to prevent seizure activity. 3. During an observation on 11/6/23, at 8:17 AM, LN 5 prepared Resident 40's medications for administration. LN 5 administered amlodipine (medication used to treat high blood pressure) 5mg, fluoxetine (medication used to treat mood disorders) 20 mg, furosemide (medication used to treat fluid overload) 20mg, and a multivitamin with minerals. A review of Resident 40's MAR dated November 2023, indicated, acidophilus (a probiotic used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 22 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few improve or restore gut health) one capsule, amlodipine 5mg, fluoxetine 20 mg, furosemide 20 mg, lisinopril (medication used to treat high blood pressure) 20 mg, a multivitamin and neomycin/polymyxin B/hydrocortisone otic solution (antibiotic medication used to treat ear infections) were scheduled to be administered at 8 AM. During an interview on 11/7/23, at 1:52 PM, LN 5 stated Resident 40's neomycin/polymyxin B/hydrocortisone otic solution was not administered because she did not have the medication available in her cart. LN 5 further stated the medication was ordered to start on 11/6/23 at 8 AM. LN 5 stated not receiving his medication as prescribed put Resident 40 at risk of his ear infection worsening. LN 5 further stated Resident 40 did not receive his acidophilus or lisinopril because she .overlooked it . LN 5 stated Resident 40 should have received all his medications as ordered by the physician. During an interview on 11/9/23, at 9:43 AM, the DON stated it was her expectation that the LN would call the pharmacy and physician when medications were unavailable. The DON further stated not treating the ear infection, per physician order, put Resident 40 at potential risk of worsening infection. 4. During a concurrent observation and interview on 11/6/23, at 11:55 AM, LN 3 prepared Resident 68's medications for administration. Resident 68 received hydrocodone-apap (medication used to relieve pain) 10-325 mg and hydromorphone (opioid medication used to relieve pain) 1 ml (milliliter, unit of measure). LN 3 stated Resident 68 should have received a dose of lorazepam (medication used to treat anxiety) at the same time, but the medication had been unavailable since yesterday. A review of Resident 68's MAR, dated November 2023, indicated, .Lorazepam oral concentrate 2mg/ml [milliliter, unit of measurement] Give 0.5 ml every 4 hours for anxiety . During an interview on 11/9/23, at 9:43 AM, the DON stated the missed doses of lorazepam caused Resident 68 to experience restlessness and anxiety. A review of a facility policy and procedure (P&P) titled, Administering Medications, revised April 2019, indicated, .Medications are administered in accordance with prescriber orders, including any required time frame .medications are administered within one (1) hour of their prescribed time .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right method (route) of administration before giving the medication . Review of the facility's policy titled, Hazardous Drugs, dated 4/2019, the policy indicated Any staff members who come in contact with hazardous drugs are trained and exhibit competency in handling these drugs. The policy on section 9 indicated Staff are trained on and required to wear personal protective equipments (PPE) specific to the risk of exposure and activities performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 23 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 80 when: 1. Unlabeled prescription medications were stored in the East Hall treatment cart, 2. An expired bottle of vitamin B6 (vitamin supplement) was stored in a [NAME] Hall medication cart, 3. Expired normal saline (saltwater solution) syringes were stored in the East Hall emergency supply cart and expired normal saline vials were stored in the [NAME] Hall intravenous (IV, administered in the vein) emergency supply cart; and, 4. Unpackaged, unlabeled IV fluid bags and IV fluid bags labeled with the names of discharged residents were stored in the [NAME] Hall emergency IV supply cart. These failures had the potential for the use of medications that were expired and the possibility for a medication to be used for the wrong resident. Findings: 1. During a concurrent observation and interview on [DATE], at 3:12 PM, licensed nurse (LN) 11 confirmed there were two unlabeled prescription medications located in the East Hall treatment cart, collagenase (an ointment used to remove damaged tissue from wounds) and nystatin powder (a medication used to treat fungal infections). LN 11 stated unlabeled prescription medications should not have been stored in the treatment cart. 2. During a concurrent observation and interview on [DATE], at 9:46 AM, on the [NAME] Hall, LN 10 confirmed a bottle of Vitamin B6 tablets, located in [NAME] Hall 2 medication cart had an expiration date of 8/2023. 3. During a concurrent observation and interview on [DATE], at 3:12 PM, in the East Hall nurse's station, LN 11 confirmed there were five 10 ml (milliliter, a unit of measure) normal saline syringes in the emergency supply cart with expiration dates of [DATE]. LN 11 stated the syringes should have been discarded. LN 11 further stated there was the potential for the outdated saline to cause an infection if used. During a concurrent observation and interview on [DATE], at 10:26 AM, in the [NAME] Hall medication room, LN 9 confirmed there were three 10 ml vials of normal saline with an expiration date of [DATE] located in the emergency IV supply cart. 4. During a concurrent observation and interview on [DATE], at 2:50 PM, in the [NAME] Hall medication room, the infection preventionist (IP) confirmed there were multiple 1000 ml bags of IV fluids, located in the emergency IV supply cart, labeled with the names of three different residents who had been discharged . The IP stated the IV fluids should have been moved to the discontinued medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 24 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 cabinet when the residents were discharged . The IP confirmed another bag of IV fluids located in the cart was unlabeled with its outer wrap removed. The IP stated the IV bag should not have been in the cart and should be disposed of. During an interview on [DATE], at 8:55 AM, the DON stated the IV supply cart in the [NAME] Hall medication room was used to store extra IV bag medications that did not fit in the automated dispensing unit. The DON further stated the IV supply cart did not have a list of items and was not sealed. The DON stated any unused or expired or discontinued medications or products should have been removed from the active storage areas. A review of a facility policy and procedure (P&P) titled, Storage of Medications, dated [DATE], indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Drugs .are stored in the packaging, containers .in which they are received .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . A review of a facility P&P titled, Pharmacy Services Overview, dated [DATE], indicated, .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 25 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe food production when: 1. Multiple food items were found undated and were not labeled with an open date and/or use by date in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), 2. Multiple expired food products were not removed from the kitchen and were available for use, 3. Cleaned, ready to use water pitchers with lids were placed on an unsanitary wooden shelf; and, 4. A clear pitcher containing orange colored liquid was leaking onto the shelf and the liquid was dripping onto the bottom shelf that contained a tray with food ready to be served. These failures had the potential to expose 78 residents of a census of 80 to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: 1.a. During a concurrent observation and interview on 11/6/23, at 8:46 a.m., with the Dietary Manager (DM) in the kitchen, the DM confirmed five bags of 5 lb (pound, a unit of weight) ground coffee were not labeled with a received date and a used by date. The DM stated there should have been a received date and a used by date labeled on the boxes. b. During a concurrent observation and interview on 11/6/23, at 9:34 a.m., with the DM in the walk-in refrigerator, the DM confirmed an opened 25 lb bag of chocolate chips was not labeled with an opened date and a used by date. The DM stated it should have been labeled. c. During a concurrent observation and interview on 11/6/23, at 9:56 a.m., with the DM in the walk-in refrigerator, the DM confirmed four opened bags of celery were not labeled with an opened date, and a used by date. The leaves in one of the celery bags were noted to be wilted and yellow. The DM stated the celery bags should have been labeled with an opened date and a used by date. d. During a concurrent observation and interview on 11/6/23, at 10:15 a.m., with the DM in the walk-in refrigerator, the DM confirmed a clear 5 lb bag of thawing ground beef, two white 10 lb bags of thawing beef, 11 bags of 1 lb thawing lunch meats, and two bags of 2.5 lb of thawing lunch meats were not labeled with the date and time when the thawing began. The DM stated it should have been labeled with the date and time when the thawing was started and also should be labeled with a used by date. e. During a concurrent observation and interview on 11/6/23, at 11 a.m., with the DM in the dry storage room, the DM confirmed an opened 12 qt (quart, a unit of measurement) bulk storage bin containing sugar was labeled with a date of 10/26/23 and had no used by date. The DM stated it should have been labeled with a used by date. f. During a concurrent observation and interview on 11/6/23, at 11:08 a.m., with the DM in the dry storage room, the DM confirmed an opened 8 qt bulk storage bin containing pearled barley had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 26 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 - Few opened date of 3/23/23 and had no used by date. The DM stated opened or unopened pearled barley was good for one year. The DM further stated it should have been labeled with a used by date. g. During a concurrent observation and interview on 11/6/23, at 11:15 a.m., with the DM in the reach-in freezer, the DM confirmed an opened 2 lb bag of diced chicken had a received date of 10/26/23 and had no used by date. The DM stated it should have been labeled with a used by date. h. During a concurrent observation and interview on 11/6/23, at 11:38 a.m., with the DM in the reach-in refrigerator, the DM confirmed an opened one- gallon (unit of measurement) container of mayonnaise was not labeled with an opened date and a used by date. The DM stated the container of mayonnaise should have been labeled with an opened date and a used by date. 2. a. During a concurrent observation and interview on 11/6/23, at 8:59 a.m., with the DM in the reach-in freezer, the DM confirmed an unopened box containing 18 packs of popsicles had an expired date of 7/24/23. The DM stated the box of popsicles was expired and should not be in the freezer. The DM further stated the risk is serving expired food to residents and health risk. b. During a concurrent observation and interview on 11/6/23, at 10 a.m., with the DM in the walk-in refrigerator, the DM confirmed an opened 5 lb bag containing shredded carrots had a received date of 10/16/23. The DM further confirmed the bag was not labeled with an opened date and a used by date. The DM stated the carrots were good for only two weeks once opened. The DM further stated serving expired food was a health risk for the residents. c. During a concurrent observation and interview on 11/6/23, at 10:05 a.m., with the DM in the walk-in refrigerator, the DM confirmed a metal tray containing eight cucumbers had a received date of 10/19/23 and no used by date labeled on the tray. The DM stated the cucumbers were expired and should not be in the refrigerator. 3. During a concurrent observation and interview on 11/6/23, at 8:36 a.m., with the DM in the kitchen, the DM confirmed there was visible dirt on the wooden shelf attached to the wall and there were 7 clean water pitchers and 7 clean lids on a tray on the bottom shelf. The DM further confirmed the clean water pitchers and lids were ready to use. The DM stated the dirt should not be on the shelf and the shelf should be always clean. The DM further stated the risk was infection. 4. During a concurrent observation and interview on 11/6/23, at 9:25 a.m., with the DM in the walk-in refrigerator, the DM confirmed a clear pitcher containing an orange colored liquid on the second shelf of the metal rack was leaking. The DM further confirmed the orange colored liquid was dripping on the bottom shelf of the rack which had a tray with food. The DM stated the tray had food that was ready to be served on 11/7/23 for the evening shift. The DM further stated the liquid should not be leaking and dripping on the ready to serve food. The DM also stated the risk of dripping liquid on the ready to serve food could cause cross contamination. During an interview on 11/08/23 at 1:50 p.m., with the Registered Dietitian (RD) in the kitchen, the RD stated the kitchen staff should label all food products and items with the received date and opened date. The RD further stated expired food should not be in the kitchen and should be thrown away. The RD stated residents could be exposed to food borne illnesses if served expired food. The RD explained the kitchen should be clean and sanitary, if it was not clean it could cause infection and food borne illnesses. The RD further explained food should not be leaking and dripping on the other food. The RD stated the leaking and dripping of food on other food placed on the bottom shelf could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 27 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 cause cross contamination. Level of Harm - Minimal harm or potential for actual harm During a review of the facility provided document titled, SECTION 8 SANITATION, dated 2023, indicated, .All utensils, counters, shelves .shall be kept clean . Residents Affected - Few During a review of the facility policy titled, LABELING AND DATING OF FOODS, dated 2023, indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated .Newly opened food items will need to be closed and labeled with an open date and used by the date . During a review of an undated facility provided document titled, DRY STORAGE GUIDELINES, indicated, .Do check expiration dates on boxes of foods to be sure the length of time is correct . During a review of the facility's policy and procedure titled, THAWING OF MEATS, dated 2023, indicated, .Label defrosting meat with pull and use by date . Review of a document created by the U.S. Food and Drug Administration titled, 2022 Food Code, dated 1/18/23, in the section 3-302 Preventing food and ingredient contamination, indicated, .Food shall be protected from cross contamination by .Arranging each type .so that cross contamination of one type with another is prevented . (https://www.fda.gov/media/164194/download) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 28 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on observation, interview, and record review, the facility failed to effectively coordinate nursing care with the hospice (specialized health care that focuses on the providing care to terminally ill residents) agency for 1 of 13 sampled residents (Resident 68) receiving hospice care when Resident 68 did not receive their scheduled anti-anxiety medicine. This failure resulted in Resident 68 not receiving five scheduled doses of Lorazepam (anti-anxiety medication) resulting in Resident 68 experiencing distress, agitation, and anxiety. Findings: During a review of the document titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 68 had an admitting diagnosis of Malignant Neoplasm (cancer) of the left breast, chronic pain, and palliative care (specialized medical care that focuses on providing relief from pain). A review of Resident 68's clinical record titled, [HOSPICE COMPANY NAME] Hospice Care Visit Notes, dated 3/13/23, indicated, Resident 68 was admitted to hospice with a diagnosis of breast cancer. During a concurrent observation and interview on 11/7/23, at 3:30 PM, with Resident 68 and the Director of Nursing (DON), Resident 68 was observed to be very upset (whimpering) that she did not have her Lorazepam medication. Resident 68 stated, she is crawling out of her skin. The DON stated the medication had not been delivered from the pharmacy. A review of Resident 68's clinical record titled, Care Plan, dated 3/17/23 (revised 11/6/23), indicated, Resident 68 used anti-anxiety medication (Lorazepam) related to an anxiety disorder. Interventions included, administer Lorazepam medications as ordered by the physician. During a concurrent interview and record review on 11/9/23, at 8:51 AM, with the DON, Resident 68's clinical record titled, MEDICATION ADMINISTRATION RECORD (MAR), dated 11/6/23 was reviewed. The MAR indicated, Resident 68 did not receive Lorazepam every four hours as ordered by the physician at 12 AM, 4 AM, 8 AM, 12 PM, and 4 PM. The DON stated it was the facility's responsibility to administer all medications to residents on hospice. The DON stated, if a resident's medication was about to run out, the facility nursing staff were supposed to notify the hospice agency, so the medication could be restocked. The DON stated, the facility had an automated dispensing machine that had emergency Lorazepam and other medications that could have been accessed until the pharmacy delivered the medication. The DON further stated, the facility staff could have called her sooner to inform her the medication had ran out, and the DON would have escalated the issue with the hospice agency. The DON verified Resident 68 missed five scheduled doses of Lorazepam on 11/6/2023. The DON stated on 11/6/23, Resident 68 appeared very restless without her anti-anxiety medication. During an interview on 11/09/23, at 9:15 AM, with Licensed Nurse (LN) 3, LN 3 stated before Resident 68 ran out of the scheduled Lorazepam, she could have called the hospice agency to find out what pharmacy was being used, and then call the pharmacist to ask them to refill the medication order. LN 3 further stated she should have escalated the situation sooner to the DON for further assistance. During an interview on 11/09/23, at 9:19 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 29 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 68 would get very anxious when she did not get her anti-anxiety medication right away. CNA 2 stated Resident 68 would get very upset if the medication was given late. During an interview on 11/09/23, at 9:22 AM, with Resident 68, Resident 68 stated when she did not have her anti-anxiety medication available on 11/6/23, she was very jittery. Resident 68 stated the facility staff kept extending the estimated time of arrival (ETA) of the medication. Resident 68 stated this made her very worried the medication would never come. During a phone interview on 11/09/23, at 10:33 AM, with the [HOSPICE COMPANY NAME] DON (DON) 2, the DON 2 stated, it was the shared responsibility of the hospice nurse and the facility nurse to ensure Resident 68's medications were always in stock. The DON 2 stated attempts were made to refill Resident 68's Lorazepam, and he was unsure where the breakdown occurred. The DON 2 verified missing scheduled doses of Lorazepam would have caused Resident 68 to have untreated anxiety. A review of the facility's document titled, JOB DESCRIPTION Registered Nurse DEPARTMENT: Nursing, dated 3/1/2014, indicated, .ESSENTIAL JOB FUNCTIONS .Ensure drug ordering and receiving policies and procedures are followed in accordance with the facility's policies and procedures . A review of the facility's document titled, JOB DESCRIPTION Licensed Vocational Nurse (LVN) DEPARTMENT: Nursing, dated 3/1/2014, indicated, .ESSENTIAL JOB FUNCTIONS .Proficiently and accurately monitor and report resident condition changes to the Registered Nurse, attending physician .and Director of Nursing .Follow through on resident care services needed to meet the individualized needs of each resident . During a concurrent interview and record review on 11/09/23, at 8:51 AM, with the DON, the Policy titled, Hospice Program, dated 7/2017, was reviewed. The policy indicated, Policy Statement: Hospice services are available to residents at the end of life .1 .In general, it is the responsibility of the facility the meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include .b. Administering prescribed therapies .d. Communication with the hospice provider .to ensure that the needs of the resident are addressed and met 24 hours per day . The DON verified the facility did not communicate with the hospice provider effectively to ensure Resident 68's needs were met 24 hours a day; and therefore, the policy was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 30 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 implement infection control practices with a census of 80 when: Residents Affected - Few 1. Resident 13 was on transmission based precautions (TBP, precautions implemented based upon means of transmission to prevent or control infections) and no TBP signage on the use of personal protective equipment (PPE), and an isolation cart (cart containing supplies such as gown, gloves, mask, and/or face shield) were not placed outside of Resident 13's room, 2. Facility failed to follow safe infection control practices for cleaning and disinfecting shared glucometers (a device used to measure blood sugar) in-between resident care for Resident 80 and Resident 50; and, 3. Facility failed to prevent contamination of multi-dose medication containers when oral syringes were returned to storage after resident use for Resident 41 and Resident 63. These deficient practices had the potential to result in the transmission and spread of infection in the facility, leading to negatively impact the residents' health and well-being. Findings: 1. During an observation on 11/6/23, at 11:46 a.m., Resident 13's room had no posted TBP signage on the use of PPE and there was no isolation cart placed outside of Resident 13's room. During an subsequent observation on 11/8/23, at 10:06 a.m., Resident 13's room had no posted TBP signage on the use of PPE and there was no isolation cart placed outside of Resident 13's room. A review of Resident 13's Order Summary Report, indicated, (ESP) Enhanced standard Precautions [infection control intervention to reduce transmission of resistant microorganisms through gown and glove use during high contact resident care activities] d/t [due to] history of MDRO [multidrug-resistant organisms, microorganisms that are resistant to one or more classes of antimicrobial agents] every shift .start date 6/7/23 .Foley catheter care every shift . During a concurrent observation and interview on 11/8/23, at 1:36 p.m., with Certified Nurse Assistant (CNA) 3 in Resident 13's room, CNA 3 stated staff had to wear gown and gloves all the time when they provided care for Resident 13. CNA 3 further stated there was no TBP signage outside of Resident 13's door and was unsure why there was none posted. During a concurrent observation and interview on 11/9/23, at 9:33 a.m., with Licensed Nurse (LN) 5 outside of Resident 13's room, LN 5 confirmed there was no posted TBP signage on the use of PPE and no isolation cart was placed outside of Resident 13's room. LN 5 stated there should be a TBP signage posted outside of Resident 13's room along with an isolation cart. LN 5 further stated the risk of not having these outside of Resident 13's room, a staff may not know and provide care to the resident without the proper PPE and can cause an outbreak. During an interview on 11/9/23, at 4:26 p.m., with the Infection Preventionist (IP), the IP stated the facility's process for a resident on TBP such as ESP should have TBP signage posted outside of the door along with an isolation cart. The IP further stated the risk of no TBP signage and isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 31 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 - Few cart outside of the door, staff may spread the disease if they provided care to the resident without proper PPE on. The IP further stated this would be a safety concern for residents and staff. During an interview on 11/9/23, at 5:40 p.m., with the Director of Nursing (DON), the DON stated if a resident had an MDRO then enhanced precautions were used. The DON further stated the facility followed the Centers for Disease Control and Prevention (CDC) guidelines. Review of a facility policy and procedure (P&P) titled, Isolation-Categories of Transmission-Based Precautions, dated September 2022, indicated, .Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door .so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room . Review of an online document published by the CDC titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), last reviewed dated 8/1/23, indicated, .Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) .For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .Make PPE, including gowns and gloves, available immediately outside of the resident room . (https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html) 2a. During a medication administration observation, with LN 6, on 11/6/23, at 9:11 AM, in the East station, LN 6 gathered the blood sugar measurement supplies plus a glucometer into the Resident 80's room. LN 6 then placed the supplies and glucometer on Resident 80's bed sheet, with gloved hands, LN 6 poked one finger for blood to test via a strip attached to the glucometer. Once out of the room, LN 6 used a single disposable wipe, from an orange color top container, to quickly clean the glucometer for less than 20 seconds and then placed the glucometer on top of the mediation cart. LN 6 then proceeded to administer insulin medication to Resident 80 as ordered. 2b. During a medication administration observation, with LN 9, on 11/6/23, at 11:42 AM, in the [NAME] station, LN 9 placed supplies and glucometer device on a tray into the Resident 50's room. LN 9 then placed the tray on bed side table. LN 9 with gloved hand poke the left index finger to get blood and then soaked the test strip attached to glucometer with blood for blood sugar measurement. LN 9 then exited the room and used one wipe to clean the glucometer for less than 20 seconds and then used the same wipe to wrap the glucometer before placing it on the top of the medication cart. In an interview with the DON in her office, on 11/9/23, at 12:32 PM, the DON stated the glucometer should be cleaned with bleach wipe and stay wet for a minimum of 4 minutes. The DON further stated each medication cart had two glucometer devices for nursing staff to alternate in-between resident care to allow for the wet time requirement. The DON stated the staff should follow the device and sanitizing wipe directions on the label for the two-step process of first cleaning with one wipe and then sanitizing with a bleach wipe to keep it wet for 4 minutes. The DON stated the facility's policy should have been followed and she may need to re-educate the front-line staff. Review of the facility's policy titled Blood Sampling .Finger Stick, dated 9/2014, the policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 32 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 indicated, The purpose of this procedure is to guide the safe handling of .blood sampling devices to prevent transmission of bloodborne disease to residents and employee. The policy on General Guidelines section indicated, Always ensure that blood glucose meters (Glucometer) intended for reuse are cleaned and disinfected between resident uses. The policy on steps in the Procedure section indicated, Following the manufacturer's instruction, clean and disinfect reusable equipment .after each use. Residents Affected - Few Review of the facility's approved disinfectant wipe, labeled as Sani-Cloth Bleach Germicidal Disposable Wipe, with an orange color top, the label indicated, cleaning procedure: All blood .must be thoroughly cleaned from surfaces before disinfection by the germicidal wipe. Open, unfold and use first germicidal wipe to remove heavy soil .Use second germicidal wipe to thoroughly wet surface. Allow to remain wet .Treated surface must remain visibly wet for full 4 minutes. Review of the glucometer manufacturer's, with brand name Assure Platinum Blood Glucose Monitoring System, with revision date of 9/2019, last accessed via https://medaval.ie/docs/manuals/Arkray-Assure-Platinum-Manual.pdf, the section on Cleaning and Disinfecting . indicated, The meter should be cleaned and disinfected after use on each patient .The cleaning procedure is needed to clean dirt, blood, and other body fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens (means germs in the blood). 3a. During a medication administration observation of Resident 41 with LN 7 on 11/6/23, at 4:56 PM, on the [NAME] Unit, LN 7 administered a liquid medication called gabapentin (or Neurontin, drug used to treat seizure or nerve pain). LN 7 used an oral syringe that was rubber banded (attached) to the brown bottle and drew up 2 ml (mL or milliliter, a measure of volume) of Neurontin. LN 7 then went into the room and asked the resident to open his mouth and with the syringe being way inside the mouth, LN 7 squeezed the content into the Resident 41's mouth. LN 7 then exited the room and attached the syringe to the rubber band around the bottle. 3b. During a medication administration observation of Resident 63 with LN 7 on 11/6/23, at 5:07 PM, on the [NAME] Unit, LN 7 administered a liquid medication called Morphine (an opioid pain medicine). LN 7 used a small oral syringe that was in a plastic pouch that was rubber banded to the morphine container. LN 7 measured the 0.25 mL volume of morphine then went into Resident 63's room and asked her to open her mouth and squeezed the content of the syringe inside the mouth under the tongue. LN 7 then exited Resident 63's room and returned the syringe inside the plastic pouch attached to the morphine container. In an interview with LN 7 on 11/7/23, at 4:44 PM, in the [NAME] unit, LN 7 acknowledged the re-use of the oral syringe that was attached to the medication bottle for Resident 41 and Resident 63. LN 7 stated she would have washed the syringe before putting it away. LN 7 acknowledged that by putting the syringe in the resident's mouth could contaminate the stock solution and contribute to spread of infection. LN 7 acknowledged that washing with water would not sanitize the re-usable syringe and using a new syringe or pouring the syringe content in a cup would have been another option. In a telephone interview with the Consultant Pharmacist (CP) 1 on 11/08/23, at 3:25 PM, the CP 1 stated liquid medication like gabapentin or morphine were delivered by the pharmacy provider with syringes. CP 1 further stated the syringe should stay with the bottle. The CP 1 added that use of a syringe was for accurate measuring of a liquid medication dose and the facility could request other syringes to have in stock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 33 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 - Few In an interview with the DON in her office, on 11/9/23, at 9:40 AM, the DON stated to re-use oral syringes the staff should wash the syringe thoroughly before the next use. DON agreed that once a disposable product went in the resident's room and inside their mouth, source of contamination was significant and washing with water would not eliminate the risk of contamination. DON stated they could order more syringes or for hospice (end of life care) residents could ask for prefilled one-time use syringes and for larger volume medications, the nurse could measure the drug via syringe and pour it into a medicine cup to administer. Review of the facility's policy, titled Infection Prevention and Control Program, dated 2018, the policy indicated An infection prevention and Control Program (IPCP) is established to provide a safe, sanitary .environment and to help prevent the development and transmission of .infections. The policy on section 11 indicated, Important facets of infection prevention include .Identifying possible infection or potential complications .educating staff and ensuring that they adhere to proper techniques and procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 34 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure appropriate use of an antibiotic medication (used to treat bacterial infections) within the antibiotic stewardship program, for one of seven residents (Resident 291) when Resident 291's antibiotic order did not have a stop date. Residents Affected - Few This failure increased Resident 291's risk for an infection with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) in the facility. Findings: Review of Resident 291's Order Summary Report, indicated Resident 291 had a physician order for Cephalexin [antibiotic medication used to treat bacterial infection] Oral Capsule 500 MG [milligram, a unit of measurement] .Give 1 capsule by mouth one time a day for UTI [urinary tract infection] prophylaxis [a treatment taken to prevent a disease] .Start Date .11/3/23 . There was no stop date listed. During a concurrent interview and record review on 11/8/23, at 3:44 p.m., with Licensed Nurse (LN) 11, Resident 291's physician orders, progress notes, and care plan were reviewed. LN 11 confirmed Resident 291 had a physician order for Cephalexin with no stop date and should have one. LN 11 also confirmed there was no documentation of nonpharmacologic interventions or education done for Resident 291 prior to the start of the antibiotic. LN 11 mentioned there was also no follow up labs ordered for Resident 291 to verify if the antibiotic medication worked for Resident 291. During a telephone interview on 11/8/23, at 4:18 p.m., with Consultant Pharmacist (CP) 1, CP 1 stated an antibiotic order should have a duration of use with a start and stop date. CP 1 further stated if there was no stop date the risk of continuing to give the resident the medication will lead to drug resistance and side effects. During a concurrent interview and record review on 11/9/23, at 4:26 p.m., with the Infection Preventionist (IP), Resident 291's physician orders were reviewed. The IP confirmed Resident 291 had a physician order for Cephalexin with no stop date and should have one. The IP further stated a physician order for an antibiotic should have the medication name, the dose, frequency, duration of start and stop date and the diagnosis. The IP mentioned the risk of no stop date would be antibiotic resistance. The IP also mentioned Resident 291 did not have any UTI symptoms prior to the start of the antibiotic order Cephalexin with no stop date. When asked if the IP had any evidence based practice, journals, or articles stating an antibiotic can be given indefinitely for a UTI prophylaxis, the IP was not able to provide any. During an interview on 11/9/23, at 5:29 p.m., with the Director of Nursing (DON), the DON stated she expected a physician order for an antibiotic to include the name of the medication, the indication, the dose, frequency, and a stop date. The DON further stated the risk of an antibiotic with no stop date would be a MDRO, and the resident could develop Clostridioides difficle (C. difficile, results from disruption of normal healthy bacteria in the colon that causes diarrhea). During a review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, the policy indicated, .Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .antibiotic orders including the following elements (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 35 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0881 Level of Harm - Minimal harm or potential for actual harm .Drug name .Dose .Frequency of administration .Duration of treatment .Start and stop date, or .Number of days of therapy .Route of administration; and .Indications for use .When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 36 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 68) had a functioning call light (visual cue that a resident needs assistance) at the bedside. Residents Affected - Few This failure had the potential for Resident 68's needs not being met in a timely manner and placed Resident 68 at risk for injury (falls) related to getting out of bed to find assistance. Findings: During a review of the document titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 68 had an admitting diagnosis of Malignant Neoplasm (cancer) of the left breast, chronic pain, and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 68's clinical record titled, [HOSPICE (specialized health care that focuses on the providing care to terminally ill residents) COMPANY NAME] Hospice Care Visit Notes, dated, 3/13/23, indicated, Resident 68 was admitted to hospice with a diagnosis of breast cancer. During an observation on 11/6/23, at 2:54 PM, Resident 68 was observed pressing her call light and a light illuminated above Resident 68's room door. The light above the door turned off (automatically) after approximately 10 seconds when the resident moved her wrist in a certain direction while holding the call light device system. During a concurrent observation and interview on 11/6/23, at 2:57 PM, with Licensed Nurse (LN) 8, LN 8 observed the call light stop functioning after a few seconds. LN 8 verified the call light was not in proper working order. LN 8 stated a functioning call light was important for Resident 68 to be able to alert staff of her needs. LN 8 further stated a non-functioning call light placed Resident 68 at risk for accidents. During an interview on 11/6/23, at 2:58 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was not aware Resident 68's call light was not working. CNA 1 stated a non-functioning call light was a safety concern because the call lights were used to alert staff when the resident needs help. During a concurrent observation and interview on 11/6/23, at 3:01 PM, with the Director of Nursing (DON), the DON observed the call light malfunctioning. The DON verified the call light was not in working order and stated, the non-functioning call light placed Resident 68 at risk for falls. During an interview on 11/6/23, at 3:09 PM, with Resident 68, Resident 68 stated she frequently got out of bed on her own because the call light was not in working order. Resident 68 stated, the call light has been 'cranky' since I got to the facility. Resident 68 further stated, she used a walker to ambulate (walk), was currently on pain and antianxiety medication, and often felt very weak. During an interview on 11/9/23, at 10:25 AM, with the Maintenance Director (Maintenance Dir), the Maintenance Dir stated his department checked the call lights monthly, and he was unaware Resident 68's call light was not working. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 37 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 68's Care Plan, dated 3/17/23, indicated, Resident 68 had a self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and pain. Interventions included: staff assistance for bathing, turning/repositioning in bed, dressing, and personal hygiene/oral care. A review of Resident 68's clinical record titled, Care Plan, dated 3/17/23, indicated, Resident 68 was at risk for falls related to balance problems, low blood pressure, and not being aware of safety needs. The interventions included, have the call light within reach and prompt response to all requests for assistance. The care plan further indicated, Resident 68 had an actual fall on 10/5/23. A review of the facility's document titled, JOB DESCRIPTION Maintenance Director DEPARTMENT: Maintenance, indicated, POSITION: The Maintenance Director is responsible to maintain the facility in good repair at all times .ESSENTIAL JOB FUNCTIONS: Ensure that all interior fixtures in good repair including .nurses call system . A review of the facility's Policy and Procedure (P&P) titled, Call System, Resident, dated September 2021, indicated, Policy Heading - Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation - 1. Each resident is provided with a means to call staff directly for assistance from his/her bed .3. The resident call system remains functional at all times .If visual communication is used, the lights remain functional . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 38 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide behavior health training consistent with the requirements and as determined by a facility assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide recent education to their staff regarding Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety) to ensure quality of care was delivered for one resident with a diagnosis of PTSD (Resident 18), with a census of 80 residents. This failure resulted in Resident 18 not receiving specialized nursing care that recognized the signs of trauma and incorporated a system of responding to trauma, which had the potential to result in re-traumatization for Resident 18. Findings: During a review of Resident 18's clinical record titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 18 was admitted with a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (mental illness that causes unusual shifts in mood), and PTSD. A review of Resident 18's clinical record titled, Progress Notes, dated 9/28/2023, at 12 PM, by the Medical Director (MD), indicated, I [Resident 18] went through emotional abuse when I was [AGE] years old. A review of Resident 18's clinical record titled, Section I Active Diagnosis, (part of the Minimum Data Set [MDS] - a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 11/5/22, 12/5/22, 3/6/23, 6/2/23, and 8/25/23, indicated, Resident 18 had an active diagnosis of PTSD. A review of Resident 18's clinical record titled, Preadmission Screening and Resident Review (PASRR) INDIVIDUALIZED DETERMINATION REPORT, (responsible for determining if individuals with serious mental illness and/or intellectual/developmental disability require nursing facility services and/or specialized services) dated 11/21/22, indicated, .Recommended Specialized Services: Services and supports that supplement nursing ability care to address mental health needs .Recommended .Supportive ServicesInteractions with facility staff that encourage problem solving, socialization, reality orientation or focus on therapeutic goals . A review of the facility's document titled, FACILITY ASSESSMENT, (a written plan of the availability of health facility services and the capacities of facilities to provide services at required standards of quality) dated, 10/31/23, indicated, .TRAINING PLAN (Nursing skills checks, Education, In-services) a. CNA monthly Inservice/education and yearly competency skills check. B. Nursing education as needed/yearly competency skills check . During an interview on 11/8/23, at 11:44 AM, with Licensed Nurse (LN) 1, LN 1 stated, she was unsure if Resident 18 had any psychological diagnoses (including PTSD). LN 1 further stated she was unaware of any triggers that Resident 18 had related to PTSD and without knowing specific triggers, Resident 18 could have been unintentionally re-victimized by not receiving specific resident-centered care. LN 1 stated she was unsure when she was last educated on PTSD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 39 of 40 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/8/23, at 3:02 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was unsure if Resident 18 required specialized nursing care related to a psychological diagnosis. CNA 1 further stated she did not know the meaning of PTSD and was unsure when she last received education on PTSD. During an interview on 11/8/23, at 3:06 PM, with LN 2, LN 2 stated she was unaware of the specialized care Resident 18 required or when LN 2 had last received education on PTSD. During a concurrent interview and record review on 11/8/23, at 4:30 PM, with the Director of Nursing (DON), the facility's document titled, Program: In-Services Class: Post Trauma Care, was reviewed. The document indicated, the last in-services classes related to trauma was held on 11/2021. The DON stated, Post Trauma Care education should have been completed at least annually and included with the new employee hire education. A review of the facility's document titled, JOB DESCRIPTION Director of Nursing [DON] DEPARTMENT: Nursing, dated 3/1/14, indicated, .Essential Job functions: supervise development of in-service education programs designed to equip nursing staff with sufficient knowledge and skills to provide nursing and nursing related services to each resident to attain or maintain the highest practicable physical, mental and psycho social well-being and to perform the essential functions of their jobs satisfactorily . During a concurrent interview and record review on 11/9/23, at 8:48 AM, with the DON, the facility's policy and procedure [P&P] titled, Trauma-Informed and Culturally Competent Care, dated 8/22, was reviewed. The P&P indicated, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with processional stands of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization .Definitions: 'Trauma-informed care' is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of traumas .'Trigger' is a psychological stimulus that prompts recall of a previous traumatic event .Preparation: 1. All staff are provided in-service training about trauma and trauma-informed care in the context of the healthcare setting . The DON stated, it was not acceptable that the last Trauma-Informed education was provided two years ago and should have been completed at least annually and with all newly hired staff. The DON verified the P&P was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 40 of 40