Health inspection·November 18, 2022

F 0557 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/22 at 9:48 a.m., the Director of Nursing (DON) stated the facility policy was to ensure nail care was done weekly every Sunday. She stated the expectation was residents nails were cut as needed and weekly. She stated if the residents nails were long, the facility policy was not followed. The DON stated bacteria could be concealed under long fingernails and could result to skin breakdown and infection. Residents Affected - Few During an interview on 11/16/22 at 10:23 a.m., MDS Coordinator stated he expected residents to have short fingernails. He stated having long fingernails can affect residents psychosocially since fingernails that were long could be dirty. He stated having long fingernails nails could result to accidental self harm, wound and infection. During an interview on 11/17/22 at 1:38 p.m., the Infection Preventionist (IP) verified Resident 8's long fingernails suggested it was not cut for more than 3 weeks. IP stated the facility policy was to provide nail care weekly. She stated Sunday was nail care day. She stated it was expected for staff to cut residents nails every Sunday. IP stated If residents nails were long and dirty, the facility policy was not followed. IP verified that residents having long nails are at risk for skin infection and self inflicted injury. During a review of facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL's), Supporting, undated, the P&P indicated appropriate care and services will be provided for residents who were unable to carry out ADL's independently such as personal hygiene and grooming. During a review of facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, undated, the P&P indicated it's purpose was to ensure nail bed are clean, nails are trimmed to prevent infections. It stated nail care includes daily cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 2 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on interviews and record reviews, the facility failed to follow its policy and procedure on disclosure and release of information, when a request for records of one resident (Resident 1) by her legal representative on 9/6/22, was not processed and released within two days. This failure did not ensure resident rights and had the potential to adversely affect Resident 1's health, safety, and best interests. Findings: During a review of Resident 1's admission Record, dated 9/23/22, the admission record indicated Resident 1 had Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During a review of Resident 1's completed Physician Orders for Life Sustaining Treatment, (POLST) form, dated 6/27/22, at 2:20 p.m., the POLST form indicated, Resident 1's son was designated as her legally recognized decision-maker. During a concurrent record review and interview on 9/23/22, at 11:30 a.m., with Management Staff K, she stated she receives request for records via phone call or fax. Management Staff K stated the facility process was to fulfill a request for records within 48 hours. Management Staff K stated that on 9/6/22, she did not receive a request via fax or U.S. Mail from Resident 1's legal representative. Management Staff K stated that on 9/20/22, she received a phone call from Resident 1's legal representative, in follow-up to a request sent on 9/6/22, on behalf of Resident 1. Management Staff K stated that after the phone call, she started working to get the requested records right away. Management Staff K presented a document, indicating Resident 1's legal representative sent the facility a request for Resident 1's records via fax on 9/6/22, at 10:31 a.m. Management Staff K stated that she did not know if any staff received a fax or mail regarding the request for Resident 1's records that day. Management Staff K stated that during the call on 9/20/22, she informed Resident 1's legal representative the facility could provide the requested records in a couple of days. During an observation on 9/23/22, at 1:40 p.m., Management Staff K provided a test fax, sent by the Department to the facility's fax number on 9/23/22, at 1:33 p.m., which indicated no fax transmission issues. During an interview on 11/3/22, at 10:30 a.m.,Management Staff K stated the facility had no process to ensure the faxes received by the facility reach their intended recipient. Management Staff K stated the facility Administrator was not aware of the phone call on 9/20/22, with Resident 1's legal representative. Management Staff K stated she sent the requested medical records to Resident 1's legal representative on 9/27/22, and the billing records were sent on 10/19/2022. During an interview on 11/3/22, at 10:35 a.m., the Administrator stated that he was not aware of the call regarding a renewed request for records that Management Staff K received on 9/20/22. During a review of a facility policy and procedure (P&P) titled, Health Information Record Manual, Chapter IV 4020 Disclosure/Release of Information/Authorization, dated 2/16/19, the P&P indicated, The facility will keep all information in the resident's records confidential, except when release is to the resident or the resident representative where permitted by applicable law, required by law (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 3 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (i.e. subpoena or regulatory reason) or for treatment, payment, or healthcare operations permitted and in compliance with HIPAA .The Health Information Department will be responsible for: Making electronic and manual medical records, protected health information, under the supervision of the Administrator and in consultation with the Health Information Consultant. When the information is in electronic format, the resident may direct the facility to transmit such copy directly to any entity or person designated by the [resident], provided that such choice is clear, conspicuous, and specific. Event ID: Facility ID: 055919 If continuation sheet Page 4 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to ensure a comfortable environment for eight of 74 residents (Residents 19, 23, 31, 43, 47, 55, 60 and 182) when the ambient temperature at the facility was too cold for these residents. This failure resulted in Residents 19, 23, 31, 43, 47, 55, 60 and 182 reporting feeling cold and uncomfortable in their rooms. Findings: During an interview on 11/14/22, at 10:34 a.m., Resident 60 stated the temperature in his room was uncomfortably cold. During an interview on 11/14/22, at 10:36 a.m., Resident 182 stated the temperature in his room had been uncomfortably cold for the past two or three days. Resident 182 reported it was freezing in his room. During an interview on 11/15/22, at 9:30 a.m., Resident 55 stated the temperature in her room was uncomfortably cold. Resident 55 stated her room felt like an icebox. During observations on 11/16/22, starting at 8:30 a.m., with the Director of Maintenance (DM), the DM measured the ambient temperature of 32 of 34 resident rooms (room numbers 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 34, 35 and 36). During concurrent resident interviews, five residents, Residents 19, 23, 31, 43 and 47, reported the temperature in their rooms was uncomfortably cold. The DM measured the temperature in the rooms of these residents and, during a concurrent interview, stated it was 67° Fahrenheit (F) in Residents 19 and 43's room, 68° F in Resident 31's room and 69.5° F in Residents 23 and 47's room. The DM stated he set the facility's thermostats for 72° F throughout the facility. A review of facility policy titled Room Temperature, undated, indicated: It is the policy of this facility to provide a comfortable and safe temperature levels and that Facility shall maintain a safe a comfortable temperature levels or room temperature range of 71° - 81° F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 5 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1) Ensure of one of one resident (Resident 280) was protected from potential abuse, when it discharged Resident 280 home with the suspected abuser on 10/22/22 without notifying Adult Protective Services (APS, a state-funded program that promote safety, independence, and quality-of-life of vulnerable adults). 2) Report the result of its abuse investigation for two of two residents (Residents 280 and 38) to the State Survey Agency (SSA), within 5 working days of the incident. These failures did not ensure residents' right to be protected from abuse, and did not comply with facility policy and procedure. Findings: 1) During a review of Resident 280's face sheet (demographics), it indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. During an interview on 11/16/22 at 11:08 a.m., IP stated that yelling, name calling, calling a person lazy was considered an abusive behavior. She stated name calling can be considered an emotional abuse if there was an emotional outcome. IP stated abuse between a family member and resident should be reported to APS. During a concurrent interview and nursing and social services note record review on 11/16/22 at 3:08 p.m., the Social Services Director (SSD) verified there was an incident reported by a nursing student teacher on 10/20/22 , a concern that Resident 280 might be being emotionally abused by her daughter. SSD stated a day after the report was made, Resident 280 requested to be discharged to home to her daughter that was allegedly abusing her. SSD stated that APS should had been contacted per facility policy. SSD verified that APS was not contacted when Resident 280 was discharged to home. SSD stated since this incident was not reported to APS, this could put Resident 280 at risk for further abuse at home. During an interview on 11/16/22 at 4:14 p.m., the Director of Nursing (DON) stated that this incident should have been reported to APS per facility policy. She verified that SSD/facility did not call APS about this incident. She stated that the facility policy was not followed when this incident was not reported to APS. She stated this placed Resident 280 at risk for further abuse at home. The DON also verified there was no 5 day investigative report completed and submitted to State Survey Agency (SSA) for Resident 280 During an interview on 11/17/22 at 11:40 p.m., the Administrator verified that on 10/20/20 Resident 280's daughter spoke to him and was really upset that the DON and the SSD felt she was abusing Resident 280. He stated Resident 280's daughter gives her tough love to get her better and that Resident 280's daughter even admitted she tells her mom like it is. Administrator stated Resident 280's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 6 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daughter even recommended that he speaks with Resident 280 because she wants to sue the facility for accusing her daughter of abuse. The administrator verified APS was not notified of Resident 280's possible abuse from her daughter. The Administrator stated the facility should have contacted APS when Resident 280 was discharged to home with her daughter, the day after the facility reported the abuse. He stated APS notification was important to ensure Resident 280's safety. He stated that failure to report to APS could result to further abuse at home. He stated that APS could investigate further and follow up on the abuse allegation since Resident 280 was discharged to home with her daughter. During a review of facility's policy and procedure (P&P) titled, Elder/Dependent Abuse, revised 5/21/19, the P&P indicated the facility should control visits by family pending investigation by allowing only visits in presence of staff or denying access to the facility. During an interview on 11/17/22 at 11:40 a.m., the Administrator verified he did not complete nor submitted Resident 280's 5 day investigative report to SSA. The administrator stated he did not complete nor submitted to SSA the 5 day investigative report for Resident 280 because he was not aware it was needed. 2. During a review of Resident 38's face sheet (demographics), it indicated he was [AGE] years old and was admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Paraplegia (a partial or complete paralysis of both legs) and Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). During a review of Resident 280's face sheet (demographics), it indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. During an interview on 11/16/22 at 4:14 p.m., the DON stated the facility did not complete or submit a 5-day investigative report to the State Survey Agency (SSA) regarding abuse allegedly suffered by Resident 280 and Resident 38. During an interview on 11/17/22 at 11:40 a.m., the Administrator verified the facility neither completed nor submitted 5-day investigative reports regarding the reports of abuse concerning Resident 280 and Resident 38 to SSA. The administrator stated he did not complete or submit reports because he was not aware it was needed. During a review of facility's policy and procedure (P&P) titled, Elder/Dependent Abuse, revised 5/21/19, the P&P indicated the facility will have evidence that all alleged violations were thoroughly investigated .that results of all investigations were submitted to the SSA within 5 working days of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 7 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet the activities' interests of one of 18 sampled residents (Resident 183) when Resident 183 enjoyed watching TV but was provided the remote control of another resident's TV. This failure did not support the well-being of Resident 183, which required the resident to watch TV looking sideways and caused the resident discomfort and neck pain. Residents Affected - Few Findings: A review of Resident 183's facesheet indicated Resident 183 was admitted to the facility on [DATE] with diagnoses including depression and muscle weakness. During an observation on 11/14/22, at 10:10 a.m., Resident 183 was in his room. The room had two beds: one close to the door (Bed A) and one close to the window (Bed B). Each bed had a TV located in front of the bed. Resident 183 was lying in Bed A, but his head was turned to the left, and he was watching the TV placed in front Bed B. The TV placed in front of Resident 183's bed was turned off. During a concurrent interview, Resident 183 stated his TV was broken and for this reason he was watching the TV in front of the other bed, to his left. Resident 183 stated it was uncomfortable for him to turn his head to the left to watch TV and it caused him neck pain. A review of Resident 183's activities care plan, initiated on 11/09/22, and revised on 11/12/22, indicated Resident 183 enjoyed watching TV. During an interview an interview on 11/14/22, at 3:31 p.m., Resident 183 stated his favorite activities were sleeping and watching TV. During an observation on 11/15/22, at 1:45 p.m., Resident 183 was in his room lying in Bed A. During a concurrent interview, Certified Nursing Assistant (CNA) L was asked to turn on the TV in front of Resident 183's bed. CNA L removed a remote control from Resident 183's bedside table, pointed it towards the TV in front of his bed, and pressed the power button. The TV in front Bed A remained off but the TV in front of Bed B, to the left of Resident 183, turned on. During a concurrent interview, the Director of Maintenance (DM) explained both TVs were operational, but the remote controls had been inadvertently switched, so that Resident 183, who was on Bed A, had the remote control of the TV for Bed B and vice-versa. The DM stated this was a problem and happened often because the TV remote controls were identical and were not marked to which TV they belonged to. A review of facility policy titled Activities and Social Services, revised December 2006, indicated: Residents shall have the right to choose the types of activities and social events in which they wish to participate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 8 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure quality healthcare services for one of 18 sampled residents (Resident 76), when facility staff did not: Residents Affected - Few 1. Utilize an accurate medication administration record (MAR, a clinical record indicating medications used by an individual, including the medication names, dosages, and administration times) that reflected the resident's current opioid regimen. Resident 76 received opioid medication orally and by intrathecal pump (e.g., continuous delivery of medication directly into the spinal cord) for pain management. 2. Administer the opioid-reversal agent Narcan, as ordered, when the resident appeared pale and sleepy on [DATE]. 3. Provide coordinated, safe physician services for pain management involving more than one physician-prescriber. These failures resulted in Resident 76 receiving higher, more frequent doses of opioid medication than expected by Physicians H and A, and a higher dose of intrathecal opioid medication than indicated by the MAR, and caused two emergent hospital transfers for opioid overdoses, which caused the resident's death on [DATE]. Findings: 1. On [DATE] the Department received a complaint that indicated Resident 76 had been sent to the emergency department multiple times related to opioid overdoses, and on one of these occasions he died in the ambulance on his way to a hospital's emergency department. Review of Resident 76's medical record revealed the resident was admitted to the facility on [DATE]. Resident 76's medical diagnoses included chronic ulcers of both legs, Type-2 Diabetes Mellitus (a disease in which the body cannot regulate blood sugar levels effectively) with Diabetic Neuropathy (damage to nerves caused by high blood sugar, often resulting in pain in hands and feet), peripheral vascular disease (reduced blood flow to the limbs), chronic pain syndrome, and accidental poisoning by opioids (dated [DATE]), among others. During an interview on [DATE], at 2:25 p.m., Licensed Nurse F stated he was not aware the dose of opioid infused by Resident 76's intrathecal pain pump had been increased on [DATE]. Licensed Nurse F stated he did not know the method to communicate a dose change among facility staff when a provider changed the dose while on-site in the facility. During an interview on [DATE], at 10:31 a.m., Physician A stated she had been Resident 76's physician for several years. Physician A stated Resident 76 preferred pain relief that placed him on the edge of unconsciousness. Physician A stated she was unaware Resident 76's dose of intrathecal opioid was increased on [DATE] by the resident's pain specialist physician (Physician H). During an interview on [DATE] at 9:44 a.m., Licensed Nurse C stated she was unaware Resident 76's dose of pump-infused opioid increased on [DATE]. Licensed Nurse C stated nurses should communicate dose increases during verbal report at change-of-shift. Licensed Nurse C stated nursing would not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 9 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 document the information anywhere in the patient's record. Level of Harm - Actual harm During an interview on [DATE] at 9:18 a.m., Physician H stated Resident 76 was a new patient to him. Physician H stated Resident 76's primary pain specialist was unavailable and Physician H was asked to refill Resident 76's pump with medication on [DATE]. Physician H verified that 3.0 mg/day was the amount of opioid the pump infused each day, continuously. Regarding communication of dose adjustments, Physician H stated sometimes he would tell the patient's attending physician, but in the case of Resident 76, Physician H told Resident 76's nurse that he had adjusted the dose and then later faxed a visit note, too. Physician H stated he was not aware Resident 76 was getting 4 mg of opioids orally, twice daily. Physician H stated he would not have ordered Resident 76 to be administered oral opioids twice daily, but rather for administration as needed. Physician H stated he never spoke with Physician A, Resident 1's attending physician at the facility. Residents Affected - Few During an interview on [DATE], at 11:00 a.m., Medical Director stated if a resident care requires two different physicians to prescribe opioid medication for pain management, then the resident's attending physician and the pain specialist should coordinate with each other about their orders for opioid medication. Medical Director stated Resident 76's situation sounded like a communication breakdown. During a record review and concurrent interview on [DATE] at 2:00 p.m., the DON stated the nurse caring for a resident requiring an intrathecal pump was responsible for updating the MAR if the dosage of medication changed. The DON reviewed Resident 76's MAR from [DATE] MAR. The DON reviewed Resident 76's visit note from Physician H dated [DATE]. The DON stated facility staff did not update Resident 76's MAR after Resident 76's dose of intrathecal opioid increased on [DATE]. When informed that the dose of intrathecal opioid after [DATE] was 3.0 mg/day, twice as much as the MAR indicated, DON stated she would have to ask the medical records staff about it. The DON stated the facility leadership did not perform a root cause analysis after Resident 76's overdose on [DATE], or after his overdose and death on [DATE]. Resident 76's pain specialist's (Physician H) visit note, dated [DATE], indicated Resident 76's intrathecal pump was refilled on [DATE] with opioid medication. The visit note indicated that before refill, the pump was administering of 2.8 mg/day of opioid medication. The visit note further indicated, After reprogramming, the infusion rate was increased to administer 3.0 mg/day of opioid medication. Under section Medication List at End of Visit the visit note indicated the following direction for oral opioid medication: As of [DATE] . Hydromorphone (Dilaudid) 2 mg tablet, take 2 mg by mouth daily as needed for pain. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive oral opioid medication (Dilaudid, a pain medication stronger than morphine but with shorter duration and greater sedation) administered twice daily, for a total of 8 milligrams (mg, a unit of measure) daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive oral opioid medication (Dilaudid) administered twice daily, for a total of 8 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 10 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 1.5 mg daily. Level of Harm - Actual harm Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Residents Affected - Few Resident 76's MAR for [DATE] indicated facility staff administered oral opioid, 4 mg per administration, to Resident 76 from [DATE] through [DATE], at noon and in the evening each day (8 mg total, daily). From [DATE] through [DATE], doses were held related to Resident 1's hospital admission for opioid overdose. On Resident 76's return to the facility, facility staff continued administering oral opioid, 4 mg per administration, to the resident on [DATE] and [DATE], at noon and in the evening (8 mg total, daily). The MAR for [DATE] reflected no change in the dose of oral opioid administered to Resident 76. Resident 76's MAR for [DATE] indicated facility staff administered oral opioid, 4 mg per administration, to Resident 76 on [DATE], at noon and in the evening (8 mg total, daily). On [DATE], the MAR indicated facility staff held each administration of oral opioid for Resident 76. The noon dose was held due to Resident 76's diminished respiratory rate, and the evening dose could not be administered because Resident 76 was at the hospital when the dose was due. The MAR for [DATE] reflected no effective change in the dose of oral opioid administered to Resident 76. Resident 76's MARs for August and [DATE] indicated the resident received 1.5 mg of opioid pain medication daily though an intrathecal pump. Despite that Resident 76's dose increased to 3.0 mg per day on [DATE], on [DATE] and days subsequent, the facility's MARs for August and [DATE] still indicated the resident was administered only 1.5 mg daily through the intrathecal pump. 2. During an interview on [DATE] at 10:31 a.m., Physician A stated she was Residenbt 76's attending physician at the facility and had been the resident's physician for several years. Physician A stated no nurse administered Narcan on [DATE], when Resident 76 was sent to the ED by ambulance for opioid overdose and died enroute. Physician A stated Resident 76 should have been given Narcan. Physician A stated Resident 76's cause of death was cardiopulmonary arrest secondary to opiate overdose. During an interview on [DATE], at 9:40 a.m., Licensed Nurse J stated she was Resident 76's nurse on [DATE], when the resident required emergency transfer to an acute care hospital. Licensed Nurse J stated she called 911 for Resident 76 because the resident appeared sleepy and not himself, despite being arousable. Licensed Nurse J stated she did not believe Resident 76 had overdosed on opioid medication because his vital signs were stable, and she did not administer Narcan for the same reason. Licensed Nurse J stated the signs and symptoms of opioid overdose were respiratory depression and unresponsive[ness]. When asked if there were any other signs or symptoms, Licensed Staff J stated No, that's all. During record review and concurrent interview beginning on [DATE] at 2:00 p.m., the DON stated that she spoke with Licensed Nurse J about her nursing care on [DATE]. The DON stated Licensed Nurse J told her that she did not administer Narcan to Resident 76 Narcan on [DATE] because Resident 76's vital signs were within normal limits. DON stated it was her expectation that the nurses follow the Narcan physician's order and call 911 as soon as the first dose was given. During a review of Resident 76's medical record, the resident's Polypharamcy care plan, initiated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 11 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few [DATE], indicated a Black Box Warning for the oral opioid medication (Dilaudid) administered to Resident 76 twice daily. The Black Box Warning indicated [s]erious, life-threatening, or fatal respiratory depression may occur with use of [Dilaudid]. The care plan further indicated for facility staff to observe for respiratory depression, especially . following a dose increase. The care plan did not indicate guidance on managing polypharamcy risks associated with opioids administered via Resident 76's intrathecal pump. Review of Resident 76's physician orders, dated [DATE], indicated a provider ordered Narcan (e.g., a reversal agent for opioids, which blocks opioid receptors in the body) for Resident 76, to administer as needed for [signs or symptoms] of opiate overdose, and to [u]se 1 spray in one nostril and seek immediate emergency medical assistance. The physician order did not direct staff to not administer, or hold Narcan if a resident's vital signs are stable. Resident 76's progress note written by Licensed Nurse C dated [DATE], at 5:56 p.m., indicated information about Resident 76's first opioid overdose following the [DATE] dosage increase. The record indicated: Resident unresponsive at beginning of this shift and low O2 sats (blood oxygen saturation, normal percentage is 92 to 100%) of 80 [percent] on [room air] . MD called by this [nurse] and reported above [change in condition]. Licensed Nurse C wrote that she gave Resident 76 three doses of Narcan and called the physician between each dose, with no sustained improvement. The progress note further indicated, MD called for the fourth time and ordered to send resident out to ED for further eval[uation]. Resident 76's MAR for [DATE] indicated facility nurses administered Narcan to Resident 76 three times on [DATE], at 9:05 a.m., 12:32 p.m., and 1:03 p.m. Resident 76's hospital record included a document titled Hospitalist History and Physical, dated [DATE], which indicated Resident 76's dose of [opioid medication] in his pump was just increased which is likely contributing towards his current presentation [for emergency services. H]e was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. Review of Resident 76's physician orders, dated [DATE], indicated a provider ordered Narcan for Resident 76, to administer as needed for [signs or symptoms] of opiate overdose, and to [u]se 1 spray in one nostril and seek immediate emergency medical assistance. The physician order did not direct staff to not administer, or hold Narcan if a resident's vital signs are stable. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 5:51 p.m., indicated information about Resident 76's second overdose after the increase in opioid dosages. The record indicated: [At] 5pm resident found to be arousable, but lethargic. Resident found to be clammy and pale . 911 was called; MD aware. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 6:34 p.m., indicated, [Local hospital] ED called to inform that [Resident 76] passed away on route to ED. Resident 76's MAR for [DATE] indicated facility nurses did not administer Narcan to Resident 76 on [DATE], the second time Resident 76 was transferred for higher level services for overdose. Resident 76's hospital record included an ED physician note, dated [DATE], which indicated that EMS (emergency medical services) reports that they were coming from a nursing facility and on the way here in the ambulance he lost his pulse. The patient has a DNR and DNI (do not resuscitate or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 12 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 intubate) form completed and with him so they did not perform any resuscitation. Per EMS, call was initially for 'lethargy'. On exam, the patient is pulseless, apneic (not breathing), and unresponsive . Level of Harm - Actual harm Residents Affected - Few The package insert (e.g., a document included in the package of a medication that provides information about that drug and its use) for Resident 76's oral opioid medication (Dilaudid), revised 5/2022, indicated the medication could cause: Life-Threatening Respiratory Depression: Serious, life-threatening, or fatal respiratory depression may occur with use of DILAUDID Oral Solution and DILAUDID Tablets. Monitor for respiratory depression (slow, shallow breaths), especially during initiation of . or DILAUDID Tablets or following a dose increase. The section of the insert titled OVERDOSAGE indicated: Acute overdosage with . DILAUDID Tablets can be manifested by respiratory depression, somnolence (drowsiness) progressing to stupor or coma, . cold and clammy skin, . and, in some cases, . [low heart rate], [low blood pressure], . and death. According to the Centers for Disease Control and Prevention, updated [DATE], signs and symptoms of an opioid overdose include: Falling asleep or loss of consciousness, as well as pale, blue, or cold skin. From: https://www.cdc.gov/opioids/overdoseprevention/index.html (accessed [DATE]). 3. On [DATE] the Department received a complaint that indicated Resident 76 had been sent to the emergency department multiple times related to opioid overdose, and he had died in the ambulance on his way to the emergency department. Review of Resident 76's medical record revealed an admission date of [DATE]. Resident 76's medical diagnoses included chronic ulcers of both legs, Type-2 Diabetes Mellitus (a disease in which the body's blood sugar levels are too high) with Diabetic Neuropathy (damage to nerves caused by high blood sugar, often resulting in pain in hands and feet), peripheral vascular disease (reduced blood flow to the limbs), chronic pain syndrome, and accidental poisoning by opioids (dated [DATE]), among others. Care of Resident 76's chronic pain syndrome required pain management though oral opioid medication as well as continuously infused opioid medication via intrathecal pump (e.g., continuous delivery of medication directly into the spinal cord). During an interview on [DATE] at 10:31 a.m., Physician A stated she had been Resident 76's physician for several years. Physician A stated Resident 76 wanted to be right on the edge of unconsciousness with his pain medication dose. Physician A stated a pain-specialist physician recommended the dose of oral opioid medication for Resident 76 and she would modify the resident's orders to reflect the recommendation. When asked if she knew Resident 76 had a dose increase on his intrathecal pump on [DATE], Physician A first stated she was not aware, then stated she was not sure and would have to check. Physician A stated she did not expect the nurses to call 911, as per the physician order, when administering an initial dose of Narcan (e.g., the reversal agent for opioid medication). Physician A stated she preferred that the nurses call her. Physician A stated the nurse caring for Resident 76 on [DATE] did not administer Narcan when Resident 76 was sent to the ED by ambulance and died. Physician A stated Resident 76 should have been given Narcan. Physician A stated Resident 76's cause of death was cardiopulmonary arrest (heart and breathing stopped) secondary to opiate overdose. During an interview on [DATE] at 9:18 a.m., Physician H, the pain-specialist physician, stated Resident 76 was a new patient to him. Physician H stated Resident 76's previous pain-specialist physician had left, and Physician H was asked to refill Resident 76's pump with medication on [DATE]. Physician H verified that 3.0 mg/day is the amount of opioid the pump infused each day, continuously. Physician H stated the 3.0 mg dose was a 5% increase from Resident 76's previous opioid dose. Physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 13 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few H stated sometimes he told the a patient's attending physician about dose changes on the pump. Physician H stated in Resident 76's case, the physician told the resident's nurse of the dose adjustment and also faxed a visit note to the facility later that day. Physician H stated he was not aware Resident 76 continued to receive a scheduled, 4 mg dose oral opioid medication by mouth, twice daily. Physician H stated he would not have ordered the oral opioid for administration twice daily, but for administration as needed. Physician H stated he had never spoken with Physician A. During an interview on [DATE] at 11:00 a.m., Medical Director stated he did not have much knowledge of the circumstances of Resident 76's overdose or death. Medical Director stated he did not interfere with residents' medical management, but only reviewed whether physician followed policy in regard to ordering Narcan. Medical Director stated Physician A followed policy in ordering Narcan. When two different doctors order opiates for a resident, Medical Director stated the resident's attending physician and the pain-specialist physician should coordinate care by reaching-out to each other to communicate about opioid orders. Medical Director stated Resident 76's situation sounded like a communication breakdown. During a record review and concurrent interview on [DATE] at 2 p.m., DON stated the facility leadership did not perform a root cause analysis after Resident 76's overdose on [DATE] or after his death on [DATE]. DON stated the only action she took in response to these events was to inform Physician A and discuss with her Resident 76's pain medication regimen. When asked the reason these events did not trigger a root cause analysis, DON stated it was because Resident 76 was no longer here and we don't do them after the fact. Review of Resident 76's physician orders, initiated [DATE], indicated Resident 76 was prescribed to receive oral opioid medication (Dilaudid, a pain medication stronger than morphine but with shorter duration and greater sedation) administered twice daily, for a total of 8 milligrams (mg, a unit of measure) daily. Review of Resident 76's physician orders, initiated [DATE], indicated Resident 76 continued to receive oral opioid medication (Dilaudid) administered twice daily, for a total of 8 mg daily. Resident 76's physician order dated [DATE] indicated, FYI (for your information): Patient has pain pump LUQ (left upper quadrant of abdomen) managed by [clinic named] Sterile water [solution] by intrathecal route continuous Drug/Concentration: Hydromorphone [(e.g., an opioid)] 6 mg/ml [(milliliters, a unit of volumetric measure)], Baclofen [(muscle relaxant)] 1000 mcg/ml and Bupivacaine [(numbing medication)] 8 mg/ml Infusion . 1.5 mg/day . Resident 76's pain-specialist physician visit note, dated [DATE], indicated Resident 76's intrathecal pump was refilled with opioid medication. The visit note indicated that before the procedure, the pump was interrogated and revealed a rate of 2.8 mg/day. The visit note further indicated, After reprogramming, the following settings were noted: . Infusion mode/rate: 3.0 mg/day. Under section Medication List at End of Visit the visit note indicated, As of [DATE] . Hydromorphone (Dilaudid) 2 mg tablet, take 2 mg by mouth daily as needed for pain. Resident 76's progress note written by Licensed Nurse C dated [DATE] at 5:56 p.m., indicated, Resident unresponsive at beginning of this shift and low O2 sats (blood oxygen saturation, normal percentage is 92 to 100%) of 80 [percent] on [room air] . MD called by this [nurse] and reported above [change in condition]. Licensed Nurse C wrote that she gave Resident 76 three doses of Narcan, calling the physician between each dose, with no sustained improvement. The progress note further indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 14 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 MD called for the fourth time and ordered to send resident out to ED for further eval[uation]. Level of Harm - Actual harm Resident 76's medication administration record (MAR) for [DATE] indicated that on [DATE] Resident 76 received Dilaudid 4 mg by mouth, at 12:00 p.m. and 6:00 p.m. The MAR further indicated Narcan was administered to Resident 76 on [DATE] at 9:05 a.m., 12:32 p.m., and 1:03 p.m. Residents Affected - Few Resident 76's document Hospitalist History and Physical, dated [DATE], indicated, Patient has known history of opiate induced narcosis and oversedation. It seems his dose of Dilaudid in his pump was just increased which is likely contributing towards his current presentation he was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. His risk of opiate induced sedation is much higher. We will have to be somewhat firm with him so that he does not go through this again. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 5:51 p.m., indicated, [at] 5pm resident found to be arousable, but lethargic. Resident found to be clammy and pale . 911 was called; MD aware. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 6:34 p.m., indicated, [Local hospital] ED called to inform that [Resident 76] passed away on route to ED. Resident 76's ED physician note dated [DATE] indicated, EMS (emergency medical services) reports that they were coming from a nursing facility and on the way here in the ambulance he lost his pulse. The patient has a DNR and DNI (do not resuscitate or intubate) form completed and with him so they did not perform any resuscitation. Per EMS, call was initially for 'lethargy'. On exam, the patient is pulseless, apneic (not breathing), and unresponsive . Review of facility policy Physician Services, last revised [DATE], indicated, It is the attending physician's responsibility to supervise the resident's medical care and services . Surveyor: Famularcano, [NAME] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 15 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. During record review the admission Record for Resident 41 was reviewed. Resident 41 was admitted on [DATE] and had the following diagnoses: Left hip fracture, Dementia, Heart failure, and osteoarthritis. During an interview on 11/16/22, at 3:00 p.m., the DON stated she was present at the facility whe Resident 41 fell on [DATE]. The DON stated Resident 1 was alert and oriented at the time of the fall. The DON stated at the time of the fall she helped the bedside nurse by initiating the fall risk assessment for Resident 41. DON stated, I started the fall risk evaluation. I answered it as to how the resident was at the time of the fall. DON stated she started the form, but did not review the resident's medical records when answering the questions. DON stated the document was closed by other nursing staff. During record review of Resident 41's medical records, a SBAR Communication Form and Progress note dated 10/4/22 was reviewed. The SBAR documented that Resident 41 was found on the floor next to her bed on the morning of 10/4/22. It was documented that Resident 41 may have rolled out of bed, potential due to increased confusion. Resident 41's Fall Risk assessment dated [DATE] (day of admission) had a total score of 14, and was categorized as a high risk of falls. Question 7 indicated categories of medications. Resident 41 scored a 2, because she was on two categories of medication, a diuretic (water pill) and anti-hypertensive (for lowering blood pressure). Question 8 indicated twelve predisposing diseases including Arthritis, Osteoporosis (e.g., bone deterioration), fractures (broken bones), and dementia. Resident 41 scored a 2 for this question, as the resident had a history of fracture and dementia. Resident 41's Fall Risk Assessment, dated 10/4/22 had a total score of 9, categorized as a low risk for falls. Question 7 had a score of 0 to indicate resident was not on medications listed with the question. Question 8 was scored at 0 for no Predisposing diseases. Resident 41's Fall Risk assessment dated [DATE] had a total score of 20, categorized as High Risk for falls. Question 7 scored at a 4 due to three to four of the medication types listed were being given to Resident 41. These were diuretic, antihypertensive and narcotics. Question 8 was scored at a 4 due to three or more predisposing diseases were present, Arthritis, Fracture and Dementia. 3. A review of Resident 2's Facesheet indicated she was admitted to the facility on [DATE] for rehabilitation following a fracture and surgical repair of the left femur (the thigh bone). Resident 2's Facesheet indicated additional diagnoses of Alzheimer's (dementia), muscle weakness, abnormalities of gait and mobility, unsteadiness of feet, need for assistance with personal care and heart failure. During an observation and interview on 11/14/22, at 4:37 p.m., Resident 2 stated she was recovering from a fall where she broke her leg. Speaking about the fall, Resident 2 stated: It definitely hurt and It hurt really good. During an interview on 11/17/22, at 2:25 p.m., the Director of Nursing (DON) stated Resident 2 was originally admitted to the facility on [DATE], but was discharged to the hospital on [DATE] because of fall with injury. The DON stated Resident 2 returned to the facility on [DATE], for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 16 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 rehabilitation following surgical repair of a leg fracture sustained because of the fall. Level of Harm - Minimal harm or potential for actual harm During the same interview on 11/17/22, at 2:25 p.m., the DON stated Resident 2 fell a total of three times since her original admission to the facility, 7/22/20. The DON stated Resident 2 fell on 1/11/22 while transferring from the bathroom to the bed, fell a second time on 2/17/22 also during a transfer from the bathroom to the bed and fell a third time on 10/25/22 while transferring from the bed to the bathroom. The DON stated Resident 2 had intermittent confusion because of a diagnosis of dementia. Residents Affected - Some First Fall: 1/11/22 A review of Resident 2's Fall Risk assessment dated [DATE], the latest fall risk assessment completed prior to the first fall on 1/11/22, indicated Resident 2 was at low risk of falls. During a concurrent interview and record review on 11/17/22, at 2:25 p.m., the DON was present. The DON reviewed Resident 2's fall prevention care plan, created 6/7/21 and titled: Resident is at risk for falls r/t Deconditioning, Gait/balance problems, incontinence, poor communication/comprehension, psychoactive and opioid drug use, unaware of safety needs . The care plan indicated the following fall prevention interventions: (1) anticipate and meet the resident's needs; (2) ensure call light is within reach and encourage the resident to use it for assistance as needed; (3) encourage resident to participate in activities; (4) follow facility fall protocol; and (5) physical therapy to evaluate and treat as ordered. The care plan indicated these interventions were implemented starting 7/30/20. The DON confirmed this was the active care plan to manage Resident 2's risk of falls on 1/11/22, prior to the first fall. The DON stated these interventions were put in place on Resident 2's initial admission, or 7/22/20, and predated the creation of the fall care plan dated 6/7/21. During a review of Resident 2's record the report titled Interdisciplinary Team [(IDT)] Incident Review indicated a description of Resident 2's first fall on 1/11/22. The IDT Report indicated the fall occurred in the early morning of 1/11/22, at 3:00 a.m., and described the fall as follows: Resident called for assistance, when staff/LN [Licensed Nurse] arrived resident was found sitting in the bathroom floor and was trying to stand up on her own. Resident stated she hit her head and knees. Upon assessment found with some blood on forehead and claimed with pain on both knees. RP[Responsible Party] / MD [Medical Doctor] contacted. Resident was sent out to ER for eval[uation]. The IDT Report indicated the following contributing factors to the fall: (1) diagnoses of dementia and chronic pain; (2) impaired mobility; (3) cognitive impairment; and (4) use of assistive devices/equipment. Under the section, Impaired mobility comments, the IDT Report indicated the following: Weakness, uses [Front-Wheeled Walker] for stability but [due to] cog[nition] res[ident] forgets to [use Front-Wheeled Walker]. Under Cognitive Impairment the IDT Report indicated Alzheimer's Dementia and under Comments indicated Forgetful, needs reminding and under Interventions/Recommendations indicated Remind resident to call for assistance as needed, use well-fitting shoes or non-skid socks with ambulation, and under Additional Comments the IDT Report indicated De clutter bed space. A review of Resident 2's fall care plans indicated the facility updated the resident's fall care plan after the first fall on 1/11/22, with title Fall on 1/11/22 with minor scratch to forehead and the interventions of De clutter bedroom space . The fall care plan did not contain the intervention, recommended in the IDT Report dated 1/11/22, of ensuring resident wore well fitting shoes or non/skid socks with ambulation. During an interview on 11/17/22, at 2:25 p.m., the DON confirmed the IDT Report recommended that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 17 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2 wear shoes or non-skid socks to prevent slipping on the floor and decluttering the room to prevent tripping over objects. The DON further stated that Resident 2 was evaluated and treated by Occupational Therapy after the first fall to improve mobility and that Resident 2 was discharged with an assessment that Resident 2 was able to ambulate and transfer independently, without staff assistance. During interviews on 11/17/22, at 4:40 p.m. and on 11/18/22, at 9:20 a.m., the Occupational Therapist and Director of Rehabilitations (OT/DH) stated she evaluated and treated Resident 2 after the first fall. The OT/DH stated Resident 2 received occupational therapy from 1/24/22 to 2/4/22 and was discharged with a functional level of Modified Independence, which the OT/DH described as meaning Resident 2 was able to safely transfer and ambulate with the assistance of mobility devices, such as a walker, but without the need for staff assistance. The OT/DH stated Resident 2 was not further evaluated or treated by the rehabilitation department after being discharged on 2/4/22, until she returned from the hospital on [DATE]. Second Fall: 2/17/22 A review of Resident 2's Fall Risk assessment dated [DATE], the latest fall risk assessment completed prior to the second fall on 2/17/22, indicated Resident 2 was at a high risk of falls. The Fall Risk Assessment indicated fall risk factors such as history of falls, decreased muscular coordination, jerking or unstable when making turns, use of assistive devices, use of medications and predisposing diseases. A review of progress note dated 2/17/22, at 10:32 p.m., titled Post Fall, written by Licensed Nurse M, indicated: Resident was found by LN on the floor of her bathroom, sitting on her buttocks with legs underneath her. She reported [NAME] slipped while trying to get up from the toilet. Resident reports was not wearing any footwear at the time . A review of the facility's Interdisciplinary Team Incident Review (IDT Report) for Resident 2's second fall, dated 2/17/22, indicated the fall occurred on 2/17/22, at 9:00 p.m. The second IDT Report described the fall as follows: Resident was found in the bathroom floor with her legs underneath her facing the sink. Resident claimed that her legs slipped and she ended up on the floor on her bottom. Resident denies hitting her head and denies pain. Upon assessment observed with quarter size purplish discoloration to left knee. Resident mechanically transferred to bed. Reminded to call for assistance as needed. The second IDT Report indicated the following contributing factors: (1) diagnoses of dementia and chronic pain; (2) impaired mobility; (3) cognitive impairment; (4) use of assistive devices/equipment and (5) history of falls. The second IDT Report further indicated under Impaired mobility comments the following: Weakness and with poor safety awareness. Under Cognitive Impairment and With Dementia . Does not always call for assistance . and under Comments indicated Resident does not call for assistance as needed, reality oriented as needed under Interventions/Recommendations indicated Reality orientation provided regarding safety reminded to call for assistance at all times if needed refer to therapy for eval post fall and Under Additional Comments indicated Monitor and check q2 hours [(every 2 hours)] for needs and comfort . A review of the Resident 2's clinical record indicated note titled Rehab Post Fall Assessment dated 2/18/22, indicating: OT [Occupational Therapy] completed fall risk assessment, recommended environmental modifications. Specifically, removing current shower chair over toilet and replacing with raised commode seat appropriately modified with correct height for patient to minimize patient risk for falls. Additionally, recommending 2-hour toileting program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 18 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interviews on 11/17/22, at 4:40 p.m. and on 11/18/22, at 9:20 a.m., the Occupational Therapist and Director of Rehabilitations (OT/DH) stated she wrote Resident 2's Rehab Post Fall Assessment note, dated 2/18/22. The OT/DH stated Resident 2 fell on 2/17/22 because the shower chair over the toilet in her bathroom which she was using on 2/17/22 was too high for her. OT/DH stated the shower chair was not of an appropriate height and size for Resident 2 and stated Resident 2 required a toilet seat of lower height. The OT/DH stated the shower chair used by Resident 2 over the toilet on 2/17/22 belonged to another resident that was using the same bathroom. The OT/DH was asked if the shower chair contributed to the fall on 2/17/22. The OT/DH stated no, it caused of the fall of Resident 2. The OT/DH stated Resident 2 fell because the shower chair was not safe due to being the wrong size. During the same interviews on 11/17/22, at 4:40 p.m., and on 11/18/22, at 9:20 a.m., the OT/DH was asked why she recommended the 2-hour toileting program (e.g., an intervention where staff check on the resident every two hours to see if the resident needs toileting). The OT/DH stated it was for added staff supervision of Resident 2 while ambulating, to have an extra set of eyes on her. A review of progress note dated 2/18/22, at 2:37 p.m., titled Post Fall, written by Licensed Nurse N, indicated: Prior to this fall resident always non-compliant in using her walker and independently goes to the bathroom by herself without assistance. A review of Resident 2's fall care plans indicate it was updated after the second fall on 2/18/22, with the following fall prevention interventions: (1) Attend to resident promptly; (2) Call light within reach; (3) Encourage call for help; (4) Notify family / MD of any fall/injury; (5) Observe for potential adverse effects from medications . (6) Observe for signs/symptoms of Hypo/Hyperglycemia; (7) Offer/Assist with toileting before meals, before bedtime and PRN [as needed]; (8) OT [occupational Therapy] / PT [Physical Therapy] evaluation and treatment per MD order to improve functional mobility and safety; (9) Post fall assessment PRN; and (10) Provide clean, clutter free environment. Third Fall: 10/25/22 During a review of Resident 2's Fall Risk assessment dated [DATE], the latest fall risk assessment completed prior to the third fall on 10/25/22, indicated Resident 2 was a low risk of falls. The Fall Risk Assessment indicated Resident 2 had no balance or gait problems, though did indicate Resident 2's use of medications that increased the potential for falling. During a review of Resident 2's Order Review History Report, for the inclusive period of 10/1/22-10/31/22, the orders indicated Resident 2 received Fentanyl (a synthetic opioid for pain management that is 50-100 times stronger than morphine) dosed at 50 MCG/HR [Micrograms/Hour] every 72 hours (order dated 7/24/20) via patch, Duloxetine (a medication for depression) dosed at 30 MG [Milligrams] twice a day (order dated 10/23/22), and Donepezil (a medication to treat dementia) dosed at 10 MG (order dated 11/1/22). All medications could cause somnolence, dizziness and tremors, and increase the risk of falls. A review of Resident 2's Minimum Data Set (MDS - a comprehensive assessment of the resident), dated 10/18/22, indicated it was the most recent MDS assessment completed prior to the third fall. Section G of the MDS, Functional Status, indicated Resident 2 could not safely transfer independantly to and from the bed, walk in the room, toilet use or personal hygiene. The MDS indicated, for all those actions, Resident 2 needed Supervision - oversight, encouragement or cueing as well as One person [staff] physical assist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 19 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's Interdisciplinary Team Incident Review (IDT Report) for the third fall, dated 10/25/22, indicated the fall occurred on 10/25/22 at 8:40 a.m. The third IDT Report described the fall as follows: Resident had unwitnessed fall this morning in room. Found sitting up, bearing weight to left wrist and leaning on left hip. No bleeding or bruising noted. Severe pain noted to left hip. Unable to straighten left leg due to pain. Per son request, patient to go to hospital for further eval. MD notified . The third IDT report indicated the following were factors that contributed to Resident 2's fall: (1) behaviors (2) impaired mobility; (3) cognitive impairment; (4) use of assistive devices/equipment and (5) history of falls. The third IDT report indicated under Behaviors the following: Resident collects unnecessary things and brings more stuff from home brought in by son, cluttered area adjacent to bed which makes not enough space for resident to freely navigate area with FWW. Reality orientation provided to RP and Resident but not quite understanding safety and hazard, under Impaired mobility comments the following: unsteadiness to gait and balance, under Cognitive Impairment indicated dementia, forgetfulness ., and under Comments indicated, Resident is deemed independent in the room by therapy for toileting and ambulation. A review of progress note dated 10/25/22, at 10:48 a.m., titled Post Fall, written by Licensed Nurse O, indicated: Staff notified this LN that the patient was on the floor. Upon LN arrival, patient found sitting on floor on left side of bed. Patient was holding herself up with left wrist and leaning on left hip. States she was trying to ambulate to bathroom. Verbalized that she fell on her ass . Patient complaining of severe pain 9.5/10 [(e.g, zero to scale where zero mean no pain and 10 worst pain)] .911 called at 0845 [(8:45 a.m.)]. During an interview on 11/17/22, at 2:25 p.m., the DON stated a clinical nursing instructor supervising student nurses at the facility had found Resident 2 on 10/25/22, and alerted staff of her fall. The DON stated Resident 2 fell because of clutter around her bed. The DON stated Resident 2 filled the area around her bed with personal belongings leaving no space to move around with the walker. The DON stated Resident 2 attempted to transfer out of the bed using the walker but tripped on the clutter around her bed. The DON stated Resident 2 had a history of collecting personal objects and placing them around the bed which posed a safety hazard. The DON stated the clutter around her bed caused the fall. During the same interview on 11/17/22, at 2:25 p.m., the DON stated Resident 2 had been cleared by physical therapy to ambulate unassisted after being evaluated and treated following the first fall on 1/11/22. However, because Resident was at risk for falls, she had been placed on a Q2 [every two] hours toileting program. The DON explained a toileting program required certified nursing assistants (CNAs) to visually check and ask Resident 2, every two hours, if Resident 2 needed to use the toilet, and if the answer was positive, then CNAs assisted or supervised Resident 2 to the toilet. The DON stated the toileting program was a safety measure to prevent accidents such as falls. The DON stated every instance CNAs checked on residents who were on a toileting program they documented they did so on the resident's chart. During an interview on 11/18/22, at 1:21 p.m., the DON provided copies of the section of Resident 2's chart where CNAs documented the toileting program checks, titled Documentation Survey Report v2 . Intervention/Task - Scheduled toileting to minimize patient risk for falls. for October 2022. A review of this report for 10/25/22, the date of Resident 2's fall, indicated staff checked and offered toileting to Resident 2 on 10/25/22 only twice, at 11:32 a.m., and at 9:26 p.m. The DON stated staff should have checked on Resident 2 every two hours and documented the checks on the chart. A review of facility policy titled Falls and Fall Risk, Managing, revised 3/2018, indicated: Based (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 20 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated: Fall Risk Factors . Environmental risk factors that contribute to the risk of falls include . footwear that is unsafe or absent .obstacles in the footpath . The policy additional indicated Resident conditions that may contribute to the risk of falls include: .delirium and other cognitive impairment . lower extremity weakness .medication side effects .functional impairments . and [m]edical factors that contribute to the risk of falls include: .heart failure .balance and gait disorders . Furthermore, the policy indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Moreover, the policy indicated Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear . Based on observation, interview, and record review, the facility failed to minimize accident hazards for three of 24 sampled residents (Residents 41, 279, and 2), when facility staff did not: 1. For Resident 41, accurately indicate the resident's fall history, past medical history, and medication history when assessing the resident's risk of falling. 2. For Resident 279, plan the resident's bowel and blader care to include interventions to mitigate falls associated with the resident's toileting pattern. 3. For Resident 2, implement fall prevention interventions to mitigate the resident's fall risk. The failure associated with Resident 41 resulted in the facility not collecting sufficient data to plan for the resident's fall risk and safety, and had the potential to not prevent future falls. The failure associated with Resident 279 contributed to the resident's fall 1/10/22 that caused a right ankle fracture. The failures associated with Resident 2 resulted in the resident experiencing two falls on 2/17/22 and 10/25/22, the second causing a leg fracture. Findings: 2. A review of Resident 279's demographics indicated she was [AGE] years old, admitted to the facility on [DATE],with diagnoses of Muscle Weakness, Difficulty in Walking, Sciatica (aggravation of the sciatic nerve, which travels from butt to foot, causing pain along the nerve's pathway) and Spinal Stenosis (narrowing of space between spinal vertebrae) of the Cervical (neck) region. Resident 279 had an additional diagnosis of right ankle fracture on 1/14/22. Review of Resident 279's Minimum Data Set (MDS, an assessment tool), dated 12/14/22, indicated a Brief Interview of Mental Status (BIMS, a brief interview assessment for mental status) score of 11, indicating moderately impaired cognition. The MDS assessment also indicated Resident 279 required extensive assistance of 1 person when toileting and transferring. During a concurrent interview and skilled assessment charting review on 11/16/22 at 11:28 a.m., the Infection Preventionist (IP) verified facility staff completed a initial fall assessment for Resident 279 on 12/7/21. The Fall assessment indicated Resident 279 scored a total of 8, meaning the resident was a low risk for fall. IP stated the facility's protocol for managing residents with high fall risks included resident monitoring every 2 hours, low bed, fall mattress, room assignment (near nursing station). IP reviewed Resident 279's medical record including several fall incidents indicated therein. IP stated that based on these information from the record, the facility should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 21 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some initiated scheduled toileting as an intervention for Resident 279. IP verified Resident 279 was not on scheduled toileting or a bladder and bowel (B/B) training program (e.g., a program aimed to minimize episodes of incontinence or urgency, and promote controlled bowel and bladder elimination) when she fell on 1/10/22. During a concurrent interview and record review on 11/17/22, at 10:13 a.m., the Director of Nursing (DON) stated Resident 279 was alert and oriented, but very impulsive. The DON verified Resident 279 fell while transferring commode unassisted, on 1/10/22. The DON also verified Resident 279 had three other falls between admission and readmission: [DATE], 12/30/21, and 3/16/22. The DON stated three of four falls occurred when the resident transferred to the commode unassisted to meet her toileting needs. The DON reviewed Resident 279's care plan that concerned the resident's risk of falling, dated 12/31/21. The DON stated the care plan indicated Resident 279 should have been on a B/B training program. Continuing the concurrent interview and record review, initiated on 11/17/22 at 10:13 a.m., the DON reviewed Resident 279's IDT- Incident Review for Fall, dated 12/30/22, which indicated a recommendation to enroll Resident 279 in the facility's B/B training program and for staff to verbally prompt with the resident every 2 hours about the resident's need to toilet. The DON stated that Resident 279's fall incident on 1/10/22 could have been prevented had Resident 279 called for help before self-transferrring to a commode without staff assistance. When asked what interventions were put in place to ensure Resident 279's risk of falling decreased prior to 1/10/22, DON was silent. DON stated Resident 279's fall care plans did not directly address the root cause of the resident's falls. The DON stated she expected the staff to assist Resident 279 during toileting based on her care plan and MDS assessment. The DON stated Resident 279's risk of falling on 1/10/22 would have decreased had the facility placed Resident 279 on a B/B program beforehand. During a concurrent interview and record review on 11/18/22, at 8:24 a.m., the OT / Assistant Rehabilitation Director (OT) stated Resident 279 consistently used the commode without asking staff for assistance. She stated her expectation was that clinical staff would assist Resident 279 when toileting, for safety. The OT verified that Resident 279's participation in the facility B/B training program began on 5/4/22. OT verified facility staff did not institute a toileting program prior to Resident 279's fall on 1/10/22, and after IDT's 12/30/22 recommendation to place the resident on B/B training program. During a review of facility's policy and procedure (P/P) titled Fall and Fall Risk- Managing revised 3/2018, the P&P indicated staff will identify residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .staff will try to minimize the serious consequences of falling .if resident continues to fall, staff will re-evaluate the situation and whether it was appropriate to continue or change the interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 22 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on interview and record review, the facility failed to keep record of visits from the attending physician for one of three sampled residents, Resident 76. This failure resulted in Resident 76's caregivers and practitioners having no written record of his physician's examination, plan of care, or clinical decision-making for a six-month period of time. Findings: During a record review on 11/8/22 at 1:30 p.m., Resident 76's facesheet revealed an admit date of 2/18/22 and discharge date of 9/2/22. Review of Resident 76's paper and electronic medical records revealed there were no progress notes written by Resident 76's attending physician after 2/24/22. During a record review and concurrent interview on 11/8/22 at 2:55 p.m., Director of Nursing (DON) reviewed Resident 76's paper and electronic medical records with medical records staff and verified Resident 76's attending physician had not entered any progress notes since 2/24/22. DON stated the residents' physicians should write a progress note every 45 to 60 days. During an interview on 11/9/22 at 10:55 a.m., Physician A stated the facility had made her aware that Resident 76's medical record did not have any progress notes from her since February. Physician A stated she was trying to find any notes she may have written but had not faxed to the facility. Physician A stated Resident 76 would often approach her at the nurses' station and they would discuss his care. Physician A stated she did not always document those interactions. She stated, I should have. During an interview on 11/15/22 at 8:56 a.m., Medical Director stated it was his expectation that the residents' attending physicians write a progress note in the medical record once per month. Review of facility policy Physician Services, last revised 5/16/19, indicated, At each visit, the physician must: i. Review the resident's total program of care, including medications and treatments; ii. Write, sign and date progress notes . The facility will routinely review for ongoing physician compliance by means of a monitoring/auditing system that includes review for physician services/documentation upon: . Conducting required routine visits . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 23 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staff to maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 18 sampled residents (Residents 44, 66, and 8), when nursing staff did not: 1. Timely respond to residents who triggered a call light 2. Follow the Facility Assessment's recommendation for nurse staffing. The call-light-response failure resulted in nurses taking between 12 and 38 minutes to respond to call lights, and caused Residents 44 and 66 to feel humiliated, as well as angry, helpless, and frustrated due to being left wet for an extended time. The failure to follow the Facility Assessment's staffing recommendation resulted in Resident 8 feeling bothered due to having untrimmed, long, dirty fingernails, and it did not allow the facility to meet the recommended total of nursing staff on multiple days. Findings: 1. A review of Resident 44's face sheet (demographics) indicated she was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus ( DM - a condition that happens when the body can't use glucose (a type of sugar) normally), Pyonephrosis ( pus in the renal pelvis, the area at the center of the kidney) and Hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 44's MDS dated [DATE] indicated a BIMS score of 14 indicating intact cognition. A review of Residents 66 face sheet (demographics), indicated he was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Hypertension (a condition in which the blood vessels have persistently raised pressure), Acute Respiratory Failure (a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can ' t get enough oxygen into the blood) and Chronic Obstructive Pulmonary Disease (COPD - A type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe). A review of Resident 66's MDS dated [DATE] indicated a BIMS score of 12 indicating moderately impaired cognition. During an observation on 11/15/22 at 10:50 a.m., the call light in room [ROOM NUMBER] was on. Multiple staff (Licensed Nurse at 10:44 a.m., housekeeping at 10:58 a.m., administrator was at the hallway at 11:03 a.m., Certified Nursing Assistant M (CNA M) was at the nursing station 5 at 11:15 a.m., Treatment Nurse was sitting at nursing station 5 at 11:19 a.m.) passsed by the call light without responding to it. At 11: 28 a.m., staff responded to room [ROOM NUMBER]'s call light. The total wait time for staff to answer room [ROOM NUMBER]'s call light was 38 mins. No CNAs were observed in the Station 5 hallway between 10:50 a.m. and 11:14 a.m. During an observation on 11/15/22, at 10:57 a.m., room [ROOM NUMBER]'s call light was on. Multiple staff (Housekeeping at 10:58 a.m., administrator was at the hallway at 11:03 a.m., nursing station 5 charge nurse passing medications at 11:01 a.m.) were noted to pass by room [ROOM NUMBER], but no one answered the call light. The total wait time for staff to answer room [ROOM NUMBER]'s call light was 18 mins. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 24 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0725 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/17/22, at 11:00 a.m., the Director of Nursing (DON) stated the facility expected staff to answer call lights timely and promptly. DON stated timely meant staff should respond within 3 to 5 minutes. She stated a response beyond 5 minutes was unacceptable and meant the facility policy was not being followed. She stated not answering call light timely and promptly could lead to resident accidents and falls, and residents could hurt themselves. Residents Affected - Some During an interview on 11/17/22 at 11:30 a.m., the Administrator stated the facility policy was to answer call light timely, or between 3 to 5 minutes. He stated call lights could be answered by any staff, but the type of help given would depend on the staff's scope of practice. The Administrator stated not answering call lights timely or promptly could result to resident falls and accidents. During an interview on 11/17/22 at 3:25 p.m., the Director of Staff Development (DSD) stated the facility expects staff to answer call light timely, between 7 to 10 minutes. DSD stated that anytime after a 10 minutes response time was not acceptable and meant that the facility policy was not followed. DSD stated answering a call light was the responsibility of everyone. She stated it was important for staff to answer call light timely to prevent falls, accidents or even death. During an observation on 11/18/22 at 11:05 a.m., the call light in room [ROOM NUMBER] was on, the Occupational Therapist Assistant (COTA) was noted documenting a few feet away from room [ROOM NUMBER] but did not answer the call light. During an observation on 11/18/22 at 11:10 a.m., the Physical Therapist (PT) presented to meet with a resident in room [ROOM NUMBER], but did not answer the call light in room [ROOM NUMBER]. During an observation on 11/18/22, at 11:10 a.m., room [ROOM NUMBER]'s call light was on. The Infection Preventionist (IP) passed by but did not answer the call light. The Administrator passed by a few seconds later but did not answer the call light either. During an observation on 11/18/22, at 11:17 a.m., room [ROOM NUMBER]'s call light was responded to by staff, total wait time was 12 minutes. During an observation on 11/18/22, at 11:18 a.m., Licensed Nurse N passed by room [ROOM NUMBER], but did not answer the call light. During an observation on 11/18/22 at 11:22 a.m., call light in room [ROOM NUMBER] was responded to by staff, total wait time was 12 mins. During an interview on 11/14/22 at 10:04 a.m., Resident 44 stated the facility did not have enough staff. Resident 44 stated yesterday, before lunch, she had to wait for over an hour for staff to answer her call light. Resident 44 stated I was left in bed, soaking wet in my urine. Resident 44 stated she felt the burning and stinging sensation on her buttocks and the back of her legs. Resident 44 stated she had to call an outside friend to call the facility to ask for help. Resident 44 stated she felt humiliated sitting in her urine. During an interview on 11/17/22 at 11:30 a.m., the Administrator stated Resident 44's friend had complaint about slow call light response time in the past. When asked what the administrator did with this complaint, Administrator stated the facility did what they could to answer the call lights timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 25 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and assignment sheet review dated 11/13/22 on 11/18/22 at 9:02 a.m., the Staffing Coordinator verified that the morning shift CNA caring for Resident 44 had 11 residents under her care. When asked if she felt this was a lot for a CNA to care for, staffing coordinator was silent. During an interview on 11/15/22 at 1:45 p.m., Resident 66 verified he did have to wait for over 30 minutes before lunch time today when he was waiting for a staff to answer his call light. Resident 66 stated he pressed his call light so staff can come and empty his catheter. Resident 66 stated that this long wait for staff to answer his call light was ridiculous. He stated this long response time to call light also happened early in the morning today. Resident 66 stated he had to wait for over 30 minutes for someone to help him empty his catheter. Resident 66 stated it was frustrating and annoying. He stated at around 2:00 a.m. today, he had to wait for more than 30 minutes before someone came to help empty his catheter. He stated he ended up getting soaked in urine and staff having to change his clothing and his beddings. He stated he had a disrupted sleep because of this incident. He stated feeling frustrated, angry and helpless. During an interview on 11/16/22 at 12:20 p.m., Resident 66 stated that by the time staff answered his call light yesterday early morning, his urinary bag was so full, it has back flowed hence the soaking wet with the urine situation. He stated he was really angry when this occurred, he was humiliated and felt really helpless. He stated he also worries that in case a real emergency occurs, like a fall or accident, that staff could not come to help him timely. During a concurrent interview and daily staffing review on 11/18/22 08:54 a.m., the Staffing Coordinator verified that on 11/15/22, the night shift CNA taking care of Resident 66 had 18 residents under her care. During a review of facility's policy and procedure (P&P) titled, Answering the Call Light, revised 3/2021, the P&P indicated it's purpose was to ensure timely responses to the resident's requests and needs. 2. A review of Resident 8's face sheet indicated he was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Hemiplegia (a symptom that involves one-sided paralysis)/ Hemiparesis (a weakness or the inability to move one side of the body), Diabetes Mellitus (DM, a condition that causes uncontrolled blood sugars) and Gout ( a common form of inflammatory arthritis that was very painful). A review of Resident 8's Minimum Data Set assessment (MDS, an assessment tool), dated 9/1/22, indicated a Brief Interview for Mental Status (BIMS, a quick assessment of cognitive status) score of 15, indicating intact cognition. During a concurrent observation and interview on 11/15/22 at 10:37 a.m., Resident 8 showed me his fingernails. The fingernails on both hands were long, both of the thumb fingernails were about 1.5 centimeters (cm, a unit of measure) long. Resident 8 stated he requested facility nurses multiple times to cut his fingernails, but the nails were still not cut. Resident 8 stated he had made this request weeks ago. Resident 8 stated his long fingernails nails were bothering him. Resident 8 stated there were times he accidentally scratched his arms at night that resulted in scrapes/scratches. Resident 8 stated he felt there were not enough nurses or staff to help the residents at the facility. Resident 8 stated that nurses always said they were busy and could not accomodate residents' requests. During a concurrent observation and interview on 11/16/22, at 8:59 a.m. Resident 8's both fingernails remained untrimmed. Resident 8 repeated his frustration that he asked staff to cut his nails (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 26 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 0725 Level of Harm - Minimal harm or potential for actual harm weeks ago. He stated it's very frustrating. I don't think they have enough people to help us here. Everyone says I'm busy. During an interview on 11/16/22, at 9:17 a.m., Licensed Nurse O stated she was not able to cut Resident 8's fingernails because she was busy. Residents Affected - Some During a concurrent observation and interview on 11/16/22, at 10:33 a.m., the Director of Nursing (DON) verified Resident 8's fingernails were long. The DON verified it was probably more than two weeks ago when she had cut Resident 8's fingernails. DON stated she was not sure on why staff did not cut Resident 8's fingernails per his request. A review of daily staffing schedule indicated the facility was not meeting the staffing needs based on the Facility Assessment. During an interview on 11/17/22 at 3:44 p.m., the Staffing Coordinator reviewed the Facility Assessment staffing plan. The Staffing Coordinator stated, per the Facility Assessment, the facility did not schedule enough staff to be able to provide support and care for residents. Under guidance of the Facility Assessment, the Staffing Coordinator stated during the month of November 2022 the facility did not provide enough Certified Nursing Assistant (CNA) staff on 15 of 16 days, from 11/2/22 to 11/16/22. The Staffing Coordinator also stated the staffing needs for licensed nurses was not met from 11/1/22 to 11/16/22. During an interview on 11/17/22, at 3:52 p.m., DON was reviewed the Facility Assessment as it concerned staffing needs. The DON stated she was not aware that their Facility Assessment indicated the facility should staff 16 licensed nurses and 25 CNAs daily. The DON verified the Interdisciplinary Team reviewed the Facility Assessment in April 2022. The DON stated the Facility Assessment was accurate. The DON stated that based on the Facility Assessment, the facility needed to schedule 16 licensed nurses and 25 CNAs each day to provide care to their residents. During a concurrent interview and record review of daily staffing information on 11/18/22, at 8:54 a.m., the Staffing Coordinator verified that for the month of September, CNA staffing needs were not met on 21 out of 30 days--all days from 8/1/22 to 8/19/22, as well as 8/24/22 and 8/25/22. The Staffing Coordinator stated the facility did not staff sufficient licensed nurses to match the needs indicated for September in the Facility Assessment. The Staffing Coordinator stated that for the month of October, CNA staffing needs were not met on 12 out of 31 days--from 10/2/22 to 10/7/22, as well as 10/9/22, 10/16/22, 10/23/22, 10/28/22, 10/29/22 and 10/30/22. The staffing coordinator stated the facility did not staff sufficient licensed nurses in October on 25 of 31 days--from 10/1/22 to 10/7/22, 10/8/22, 10/9/22 to 10/14/22, 10/16/22, 10/21/22 to 10/23/22, and 10/25/22 to 10/31/22. During a review of facility's policy and procedure (P&P), titled, Activities of Daily Living (ADL's), Supporting, the P&P indicated residents who were unable to carry out activities of daily living independently will receive the services to maintain good grooming and personal hygiene. During a review of facility's policy and procedure (P&P), titled, Facility Assessment dated 4/27/22, the P&P indicated that on a daily basis, the facility needed 16 licensed nurses providing direct care and 25 nurse aides to provide competent support and care for their resident population. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 27 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sufficient licensed nurses competent to manage one resident's (Resident 76) opioid-overdoses and intrathecal (e.g., continuous delivery of medication directly into the spinal cord via a pump system) opioid-delivery system, and manage another resident's (Resident 78) chest pain, when the facility's licensed nurses: 1. Could not consistently demonstrate the process for accessing and administering the opioid-reversal agent Narcan; 2. Were not trained how to safely care for residents using an intrathecal pump to deliver medication for pain management; 3. Did not appropriately respond to Resident 78's complaints of chest pain. Resident 76 required use of oral opioid medication as well as opioid medication administered via an intrathecal pump. Twice, on 8/26/22 and 9/2/22, Resident 76 was found unconscious and transferred to an acute care hospital for emergency services. On 9/2/22, Resident 76 was pronounced dead at the hospital, secondary to opioid overdose. The facility's failures regarding Resident 76 resulted in facility staff not timely identifying or responding to an opioid overdose concern, and contributed to the Resident 76's demise and ultimate death. The facility's failure in managing Resident 78's chest pain resulted in unresolved chest pain and transfer to the hospital for emergency services. Findings: 1. Review of Resident 76's medical record indicated the resident as admitted on [DATE]. Resident 76's medical diagnoses included chronic ulcers of both legs, Type-2 Diabetes Mellitus (a disease in which the body's blood sugar levels are too high) with Diabetic Neuropathy (damage to nerves caused by high blood sugar, often resulting in pain in hands and feet), peripheral vascular disease (reduced blood flow to the limbs), chronic pain syndrome, and an accidental poisoning by opioids (dated 8/29/22), among other diagnoses. During an observation and concurrent interview on 10/31/22 at 12:57 p.m., Licensed Nurse A stated that if a resident became sedated after taking an opiate pain medication, she would call the doctor and let them determine the next actions to take. Licensed Nurse A stated the Narcan protocol was at the nurses' station. Licensed Nurse A was observed entering the nurses' station. She pulled out two binders, though stated she could not locate the protocol. When asked where the facility kept its emergency supply of Narcan, Licensed Nurse A stated it was in the Cubex (e.g., an automated drug dispenser), and she could not remove it without entering a resident's name and the specific order. During an observation and concurrent interview on 10/31/22 at 1:16 p.m., Licensed Nurse B stated the emergency supply of Narcan was kept on the medication carts and in the medication room. Licensed Nurse B was observed entering the medication room where Director of Nursing (DON) was showing Licensed Nurse A the location where Narcan was kept-a shelf above the Cubex. The DON stated the store in the medication room was a house supply of Narcan available for emergencies. DON pointed to a row of boxes of Narcan that sat on a shelf above the Cubex. Licensed Nurse A stated she did not know the Narcan was there. Licensed Nurse B exited the medication room, then proceeded to her medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 28 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Actual harm Licensed Nurse B opened the bottom drawer and pulled out a box of intranasal (e.g., administered via nostrils) Narcan. Licensed Nurse B stated the protocol for Narcan was contained in the medication administration record (MAR) for residents whose physician ordered Narcan. Licensed Nurse B opened a resident's MAR that contained an order for Narcan, which described the steps to take when giving Narcan. Residents Affected - Few During an interview on 10/31/22 at 1:38 p.m., Licensed Nurse C stated that the steps for giving Narcan were to give one dose if the resident had an order, then wait two minutes, and give again if needed. When asked if there were any other steps to giving Narcan, Licensed Nurse C stated, No. During an observation and concurrent interview on 10/31/22 at 3:50 p.m., when asked where the Narcan was kept, Licensed Nurse D stated it was not on the cart, it was in the medication room. Licensed Nurse D entered to the medication room and stated, I don't know where the eKit is (kit containing emergency supply of medications). Licensed Nurse D stated he would look in the refrigerator for it, then unlocked the refrigerator. At that point, Licensed Nurse A entered the medication room and educated Licensed Nurse D that the Narcan was kept on the shelf above the Cubex. Licensed Nurse D stated, I learned something new. Licensed Nurse D stated he did not know the protocol for giving Narcan, and stated he would follow the instructions on the package. During an interview on 11/8/22 at 2:15 p.m., Licensed Nurse E stated she had not received training on Narcan for a few years. During an interview on 11/8/22 at 2:55 p.m., DON stated she gave an in-service to the nurses on Narcan when they started using Narcan about two years ago. DON stated after that in-service, if the nurses had any questions about Narcan they were expected to ask her or the pharmacist. During an interview on 11/9/22 at 10:31 a.m., Physician A stated that with Resident 76, she did not expect the nurses to call 911 after administering the first dose of Narcan, as directed by physician order. Instead, Physician A stated she preferred the nurses call her. Physician A verified no nurse administered Narcan on 9/2/22, when Resident 76 was sent to the ED by ambulance and died enroute. Physician A stated Resident 76 should have been given Narcan. Physician A stated Resident 76's cause of death was cardiopulmonary arrest secondary to opiate overdose. During an interview on 11/18/22, at 9:40 a.m., Licensed Nurse J stated she was Resident 76's nurse on 9/2/22, when the resident required emergency transfer to an acute care hospital. Licensed Nurse J stated she called 911 for Resident 76 because the resident appeared sleepy and not himself, despite being arousable. Licensed Nurse J stated she did not believe Resident 76 had overdosed on opioid medication because his vital signs were stable, and she did not administer Narcan for the same reason. During a record review and concurrent interview on 11/15/22 at 2:00 p.m., the DON reviewed her in-services binder and verified the facility had not trained licensed nurses on Narcan administration between the initial training and 10/31/22. Also, DON stated that she spoke with Licensed Nurse J about her nursing care on 9/2/22. The DON stated Licensed Nurse J told her that she did not administer Narcan to Resident 76 Narcan on 9/2/22 because Resident 76's vital signs were within normal limits. DON stated it was her expectation that the nurses follow the physician's order for Narcan and call 911 as soon as the first dose was given. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active 6/6/22 through 8/29/22, to receive oral opioid medication (Dilaudid, a pain medication stronger than (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 29 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 morphine but with shorter duration and greater sedation) administered twice daily, for a total of 8 milligrams (mg, a unit of measure) daily. Level of Harm - Actual harm Residents Affected - Few Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active 8/30/22 through 9/4/22, to receive oral opioid medication (Dilaudid) administered twice daily, for a total of 8 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active 2/18/22 through 8/29/22, to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active 8/29/22 through 9/4/2022, to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders, dated 2/18/22, indicated a provider ordered Narcan for Resident 76, for signs or symptoms of opiate overdose, and to [u]se 1 spray in one nostril and seek immediate emergency medical assistance. Resident 76's MAR for August 2022 indicated facility nurses administered Narcan to Resident 76 three times on 8/26/22, at 9:05 a.m., 12:32 p.m., and 1:03 p.m. Resident 76's progress note written by Licensed Nurse C dated 8/26/22, at 5:56 p.m., indicated information about Resident 76's first opioid overdose. The record indicated: Resident unresponsive at beginning of this shift and low O2 sats (blood oxygen saturation, normal percentage is 92 to 100%) of 80 [percent] on [room air] . MD called by this [nurse] and reported above [change in condition]. Licensed Nurse C wrote that she gave Resident 76 three doses of Narcan and called the physician between each dose, with no sustained improvement. The progress note further indicated, MD called for the fourth time and ordered to send resident out to ED for further eval[uation]. Resident 76's hospital record included a document titled Hospitalist History and Physical, dated 8/26/22, which indicated Resident 76's dose of [opioid medication] in his pump was just increased which is likely contributing towards his current presentation [for emergency services. H]e was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. Resident 76's MAR for September 2022 indicated facility nurses did not administer Narcan to Resident 76 on 9/2/22, the second time Resident 76 was transferred-out for higher level services for overdose. Resident 76's progress note written by Licensed Nurse J, dated 9/2/22 at 5:51 p.m., indicated information about Resident 76's second overdose. The record indicated: [At] 5pm resident found to be arousable, but lethargic. Resident found to be clammy and pale . 911 was called; MD aware. Resident 76's progress note written by Licensed Nurse J, dated 9/2/22 at 6:34 p.m., indicated, [Local hospital] ED called to inform that [Resident 76] passed away on route to ED. Resident 76's MAR for September 2022 indicated an order for Narcan, dated 8/29/22, directing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 30 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Actual harm licensed nurses to administer 1 spray in nostril as needed for [signs and symptoms] of opiate overdose *Use 1 spray in one nostril and seek emergency medical assistance. If the desired response is not obtained after 2-3 minutes, administer second dose using a new device in the other nostril until emergency medical assistance arrives. Residents Affected - Few Resident 76's hospital record included an ED physician note, dated 9/2/22, which indicated that EMS (emergency medical services) reports that they were coming from a nursing facility and on the way here in the ambulance he lost his pulse. The patient has a DNR and DNI (do not resuscitate or intubate) form completed and with him so they did not perform any resuscitation. Per EMS, call was initially for 'lethargy'. On exam, the patient is pulseless, apneic (not breathing), and unresponsive . According to the Centers for Disease Control and Prevention, updated 10/6/21, signs and symptoms of an opioid overdose include: Falling asleep or loss of consciousness, as well as pale, blue, or cold skin. From: https://www.cdc.gov/opioids/overdoseprevention/index.html (accessed 11/21/22) 2. During an interview on 11/8/22 at 2:25 p.m., Licensed Nurse F stated that when a resident has pain pump, the only care a licensed nurse must render is to assess the resident's skin. Licensed Nurse F stated he was not aware the dose of opioid infused by Resident 76's pain pump increased on 8/18/22. Licensed Nurse F stated he did not know the method to communicate a dose change among facility staff when a provider changed the dose here in the facility. During an interview on 11/14/22 at 9:44 a.m., Licensed Nurse C stated Resident 76 had a pain pump and oral pain medications for pain management. When queried, Licensed Nurse C stated she did not know what kind pump Resident 76 used. Licensed Nurse C stated she was not trained on managing Resident 76's pump, and the pump was managed entirely by another provider. Licensed Nurse C stated the resident's assigned nurse was only required to assess the resident's skin after the pump was refilled. Licensed Nurse C stated she was unaware Resident 76's dose of pump-infused opioid increased on 8/18/22. Licensed Nurse C stated nurses should communicate dose increases during verbal report at change-of-shift. Licensed Nurse C stated nursing would not document the information anywhere in the patient's record. During an interview on 11/15/22 at 11:00 a.m., Medical Director stated the nurses caring for residents with intrathecal pain pumps should be able to assess pain level, ensure vital signs were within normal limits, watch for change in level of consciousness, and recognize overdose symptoms. Medical Director verified a resident with a Do Not Resuscitate order should be given Narcan if they have an opiate overdose. During an interview on 11/18/22, at 9:40 a.m., Licensed Nurse J stated no nursing care was required when managing Resident 76's pump. During a record review and concurrent interview on 11/15/22 at 2:00 p.m., the DON stated nurses caring for residents with intrathecal pain pumps should know the side effects of the medications being administered through the pump, the risk for overdose, how to assess for overdose, documenting their monitoring on the MAR, and be aware that Narcan was available. DON stated the nurses were responsible for updating the MAR to reflect a dose increase on the pump. DON reviewed Resident 76's August 2022 MAR and verified she did not see that licensed nurses had updated the MAR to reflect the pump's dose increase on 8/18/22. DON stated that when she asked Licensed Nurse J the reason she did not give Resident 76 Narcan on 9/2/22, Licensed Nurse J told her it was because Resident 76's vital signs were within normal limits. DON stated it was her expectation that the nurses follow the Narcan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 31 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Actual harm physician's order and call 911 as soon as the first dose was given. DON stated that if the resident's doctor did not agree with calling 911, the nurse should question the doctor, or call the medical director. DON reviewed her in-services binder and verified she did not do any training on Narcan administration prior to 10/31/22. DON also stated she did not do any training with the nurses on intrathecal pumps. Residents Affected - Few Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active 2/18/22 through 8/29/22, to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active 8/29/22 through 9/4/2022, to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's pain specialist visit note, dated 8/18/22, indicated Resident 76's intrathecal pump was refilled with opioid medication. The visit note also indicated the pump had been running at a rate of 2.8 mg/day, and further indicated the pain specialist increased the dose rate to, 3.0 mg/day. Resident 76's hospital record included a document titled Hospitalist History and Physical, dated 8/26/22, which indicated Resident 76's dose of [opioid medication] in his pump was just increased which is likely contributing towards his current presentation [for emergency services. H]e was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. 3. A review of Resident 78 face sheet (demographics) indicated he was [AGE] years old with a diagnoses of Atherosclerotic Heart Disease (AHD, a common condition that develops when a sticky substance called plaque builds up inside your arteries ( a blood vessel that carries blood from the heart to tissues and organs in the body). Disease linked to atherosclerosis is the leading cause of death in the United States) and Hyperlipidemia (also known as dyslipidemia or high cholesterol, means you have too many lipids (fats) in your blood) During a review of the nursing note dated 8/18/22 at 3:44 a.m. on 11/16/22 4:26 p.m., the nursing note indicated that on 8/18/22 at 3:00 a.m., Resident 78 had a chest pain radiating to his left arm. The nursing note indicated Resident 78 received Tylenol (a medication that could treat minor musculoskeletal aches and pains, and reduces fever) to address the chest pain. It indicated that 15 minutes after the nurse administered Tylenol, the nurse checked Resident 78 who continued to complain of chest pain. Resident 78 was then transferred to the hospital on 8/18/22 at 3:30 a.m. The nursing note did not indicate whether the physician was notified of Resident 78's complaint of chest pain, or whether the physician was notified of Resident 78's transfer to the hospital. During an interview on 11/17/22 at 8:48 a.m., Minimum Data Set coordinator ( MDS - part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) stated that whenever a resident was complaining of chest pain, the nurse would have to contact the doctor right away. He stated it was not the facility's practice for residents complaining of chest pain to be receiving Tylenol. He stated that chest pain radiating to left arm could be cardiac in nature and if inappropriate treatment was given to the resident, a negative outcome (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 32 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 could occur. Level of Harm - Actual harm During a concurrent interview and nursing note record review on 11/17/22 at 9:33 a.m., the Director of Nursing (DON) stated that per facility policy, staff should have called the physician when Resident 78 complained of chest pain radiating to left arm. DON stated that the nurse should have requested the physician for an order of Nitroglycerin (a medication that can treat and prevent chest pain) per facility policy. DON stated the facility was non compliant when the nurse administered Tylenol to Resident 78 when he was complaining of chest pain. The DON verified that although Resident 78 had no order for Nitroglycerin, the nurse should have called the physician for an order. DON stated that Resident 78 could have a heart attack and could have irreversible negative outcome such as death, paralysis and change in mental status and functionality. Residents Affected - Few During an interview on 11/17/22 at 3:15 p.m., the Director of Staff development (DSD) stated that chest pain radiating to left arm could be a sign that Resident 78 was experiencing stroke (a medical emergency, resulting in damage to the brain from interruption of its blood supply). She stated that once a resident had this type of symptom, staff should have called 911 immediately. She stated that administering Tylenol to a resident complaining of chest pain was not an appropriate intervention. She stated Resident 78 was placed at risk for irreversible negative outcome such as death or paralysis. During an interview on 11/18/22 at 10:03 a.m., the DON verified the assessment and intervention the nurse did in response to Resident 78's complaint of chest pain was inappropriate and dangerous. She stated Resident 78 could end up with paralysis (the loss of the ability to move some or all of your body), functional changes or worse, death. During a review of Nitroglycerin on National Library of Medicine, updated 9/27/22, it stated that Nitroglycerin was a vasodilator (medications that open (dilate) blood vessel) used primarily to provide relief from angina (type of chest pain caused by reduced blood flow to the heart). It was currently Food Drug Administration (FDA) approved for the acute relief of an attack or acute prophylaxis (preventive) of angina pectoris (chest pain) secondary to coronary artery disease (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). During a review of facility's policy and procedure (P&P) titled,Pain Assessment and management, undated, the P&P indicated its purpose was to help the staff identify pain in resident's .pain management interventions should address the underlying cause of resident's pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 33 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 and interviews, the facility failed to follow its policy and procedure in safe storage of food in the dry storage area when one expired item (seasoning sauce) was stored with other food items. The dietary staff wrote on the seasoning sauce container that it was opened on 10/26/21, and a used by date of 10/26/2022. The sauce container had a manufacturer's recommendation indicating it was best to use date by 7/31/2022. This failure had the potential to result in food borne illnesses to the residents of the facility. Findings: During a concurrent observation and interview on 11/16/22, at 9:55 a.m., with the Dietary Manager, at the kitchen's dry storage area, it was observed that a special sauce container with its content, was on the pantry along with other food items. The container had a hand-written date indicating it was opened on 10/26/21, and the use by date written was 10/26/22. Stamped on the sauce container was a manufacturer's recommendation that it was best to use by 7/31/22. A picture of the sauce container, along with the dates written on the container, was taken while the Dietary Manager was holding the container and also looking at the dates written and stamped on the sauce container. The Dietary Manager stated that the food item should have been discarded. The Dietary Manager was observed taking the expired sauce out of the dry storage area. During and interview on 11/16/22, at 10:31 a.m., with the Dietitian, he stated that the Dietary Manager and Dietary Staff A were responsible to check for expiration dates on the food items at the dry storage area at the end of each month. The dietitian stated that the expired sauce found on the pantry was missed and was not taken out of the storage area. A facility policy and procedure (P&P) titled, Canned and Dry Goods Storage, dated 2018, indicated, All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. All open food items will have an open date and use-by-date per manufacturer's recommendation .New stock must be placed behind old stock so oldest items will be used first. Products should be dated to assure FIFO-First In-First Out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 34 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff demonstrated the appropriate use of PPE, when one direct care staff demonstrated inappropriate PPE re-use and santizing practices. These failure did not minimize the risk of spreading infection in the facility and did not comply with facility policy and procedure. Residents Affected - Few Findings: During an interview on 11/17/22 at 1:38 p.m., the IP verified Human metapneumovirus (hMPV) is a common respiratory virus that causes an upper respiratory infection (like a cold or flu). She stated residents with hMPV should be placed on contact and droplet precautions (transmission-based precautions used when caring for patients whose illness may trasmit to other humans in contact with surfaces in a resident's room or when in close proximity to the resident) to prevent spread of infection. During a concurrent observation and interview in room [ROOM NUMBER] on 11/17/22, at 3:00 p.m., Certified Nursing Assistant (CNA) R was observed wearing two masks--a surgical mask placed atop of an N95 mask (a mask that offers the highest level of protection). CNA R stated she was double-masking and stated double-masking was the facility's policy. When not worn, CNA R stored her N95 and a face shield in a the brown bag. Unlicensed Staff stated she wiped down the inside and outside of the faceshield with santizing wipes, and placed the still-wet face shield inside the brown bag immediately after wiping it down. CNA R stated she did not know the contact time (e.g., the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, to effectively kill germs) for the santizing wipes she used. CNA R checked the package of the santitizing wipes and verified the wipes required 2 minutes contact time. CNA verified she did not wait for 2 minutes before placing the face shield inside the brown bag. During an interview on 11/17/22 at 3:30 p.m., the IP verified it was not the facility's policy to double mask. IP verified N95 is not even needed to be worn when caring for residents with an active infection of hMPV. IP stated a surgical mask should have sufficed. IP verified that the staff should have waited for 2 minutes before placing the face shield in the brown bag. She stated that brown bag were porous and placing a wet item inside the bag could compromise the integrity of the bag. She stated this could result to the brown bag getting ripped or torn easily, allowing bacteria to seep through the brown bag. IP stated the facility does not practice re using N95 since this requires staff to touch the mask frequently which could result to contamination. IP stated donning and doffing N95 frequently affects the over all fit of the mask which could affect the ability of the mask to adequately protect staff from virus. She stated this practice was an infection control issue and could result to residents or staff getting sick and acquiring infection. During a review of facility's policy and procedure (P&P) titled,Personal Protective Equipment- Face Mask, undated, the P&P indicated masks were used only once and discarded. During a review of facility's policy and procedure (P&P) titled, Isolation--Categories of Transmission based Precautions, undated, the P&P indicated that staff caring for residents on droplet precaution should wear a medical grade face mask. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 35 of 36 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the bathrooms used by residents in 34 of 34 resident rooms had a call light system accessible to residents lying on the floor. This failure placed all the 74 facility residents at risk of being unable to alert staff via the facility's communication system if they fell in the bathroom and were unable to get up. One of 18 sampled residents fell twice in the bathroom in 2022 and had to verbally call for staff assistance (cross-reference to tag F-689). Residents Affected - Many Findings: During observations and interviews on 11/16/22, starting at 8:30 a.m., with the Director of Maintenance (DM), the call light system installed in the bathrooms used by residents in 34 of 34 rooms (room numbers 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) consisted of a button placed on the wall next to the toilet seat at elbow height (while seated on the toilet) and within reach of a person sitting on the toilet or standing in front of it. Pressing the button activated the light above the resident's room and relayed the request for assistance to staff. The DM measured the height of the call light button in the bathrooms and stated it was placed at a height of 37.75 inches, or approximately three feet, from the floor. The call light button in the bathrooms did not have a string attached to it reaching the floor, which could be used by a resident to activate it while lying on the floor on the bathroom. During an observation of the bathroom used by residents in room [ROOM NUMBER], the surveyor simulated a fall from the toilet and, while on the floor in front of the toilet, attempted to reach and press the call light button but the call light was out of reach from the position of a person sitting or lying on the floor. A review of facility policy titled Answering the Call Light, Revised March 2021, indicated a call light was available to residents in the bathrooms but did not indicate it needed to be accessible to residents lying on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 36 of 36