Health inspection·November 8, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Director of Admissions stated she was responsible for checking with the hospital discharge planner to determine if the resident would readmit to the facility. Per the Director of Admissions, after the resident transferred to the hospital, she spoke with resident's spouse and informed the spouse that the facility was at capacity and therefore did not have a bed available for the resident. The Director of Admissions stated she referred the resident's spouse to other local skilled nursing facilities. The Director of Admissions stated during the resident's hospitalization, the hospital staff reached out to her and she informed the hospital staff that the facility did not have any beds available for the resident. During an interview on 11/07/2024 at 9:40 AM, the Director of Social [NAME] stated the admissions team was responsible for the issuance of all bed hold notices during transfer from the facility. During an interview on 11/08/2024 at 8:23 AM, the Director of Nursing (DON) stated a member of the admission teams would provide the bed hold documentation to the resident and/or the resident's responsible party during the admission process. Per the DON, if the resident had a change of condition that required a transfer to the hospital, staff would ask the resident and/or the resident's responsible party, if they wished to have a bed hold, and that request and/or denial would be documented in the resident's medical record. During an interview on 11/08/2024 at 1:02 PM, the Administrator stated he expected the staff to follow the facility policy and procedures related to bed hold notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 2 of 5 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 11/08/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, interview, and facility policy review, the facility failed to resubmit a Level I screening for 1 (Resident #6) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR, a tool to ensure residents are not inappropriately placed in nursing homes for long term care). This failure had the potential to affect the care the resident received. Findings included: An undated facility policy titled, Preadmission Screening and Resident Review, indicated 1. The facility will obtain/complete a Preadmission Screening and Resident Review timely. An admission Record indicated the facility admitted Resident #6 on 11/04/2019. According to the admission Record, the resident had a medical history that included diagnoses of adjustment disorder (an excessive reaction to stress), bipolar disorder (disorder characterized by mood swings between depressive lows and manic highs), and dementia. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses to include dementia and manic depression (bipolar disease), A letter from the State of California Department of Health Care Services, dated 10/26/2021, indicated Resident #6 had a positive Level I screening and a Level II mental health evaluation was required. A letter from the State of California Department of Health Care Services, dated 12/14/2021, indicated the Level II mental health evaluation was unable to be completed as Resident #6 was in isolation as a health and safety precaution. Per the letter, a new Level I screening must be submitted. Resident #6's medical record revealed no evidence to indicate a new Level I screening was submitted. During an interview on 11/06/2024 at 8:40 AM, the Director of Nursing (DON) stated she was able to retrieve a document that indicated a level II was attempted; however, Resident #6 was under isolation at the time of the attempt. The DON stated the facility did not attempt to file a new Level I screening after Resident #6 was removed from isolation. During an interview on 11/06/2024 at 9:10 AM, Licensed Vocational Nurse #1 stated the facility did not resubmit a new Level I screening for Resident #6 when the resident came off isolation. During an interview on 11/08/2024 at 12:53 PM, the Administrator stated he expected the staff to follow the PASARR policy for the completion of Level I screenings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 3 of 5 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 11/08/2024 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 Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene when soiled gloves were removed and before a new pair of gloves were put on during the provision of wound care for 1 (Resident #4) 1 sampled resident reviewed for pressure ulcer/injury. Residents Affected - Few This failure had the potential to cause the spread of infection between residents. Findings included: A facility policy titled, Handwashing/Hand Hygiene revised 08/2019, revealed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy specified, 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handing an invasive device; f. Before donning (putting on) sterile gloves; g. Before handing clean or soiled dressings, gauze pads, etc.; h Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects in the immediate vicinity of the resident; m. After removing gloves; Per the policy, 8. The use of gloves does not replace hand washing/hand hygiene. An Transfer / Discharge Report indicated the facility admitted Resident #4 on 08/24/2021. According to the Transfer/Discharge Report, the resident had a medical history that included diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), quadriplegia (a form of paralysis that affects all four limbs), acquired absence of the right leg above the knee, and neuromuscular dysfunction of the bladder. A quarterly Minimum Data Set (MDS, an assessment tool), with an Assessment Reference Date (ARD) of 09/15/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS, a tool to assess cognition) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one Stage 3 pressure ulcer (a deep wound when skin loss extends through the entire thickness of the skin into the underlying tissue, but not to muscle, tendon, or bone). Resident #4's Order Summary Report, that contained active orders as of 11/05/2024, revealed an order dated 08/17/2024 that directed staff to cleanse the resident's left buttock with cleanser, pat dry, and apply a thin layer of paste to the periwound (an area of tissue around a wound), and calcium alginate to the wound bed and cover with a foam dressing daily and as needed. During an observation of wound care for Resident #4 on 11/05/2024 at 2:26 PM, Licensed Vocational Nurse (LVN) #3 did not perform hand hygiene after she removed a soiled pair of gloves and before she applied a new pair of gloves. During an interview on 11/05/2024 at 2:48 PM. LVN #3 stated she was educated to perform hand hygiene and put on clean gloves between each step of wound care to include the removal of the old dressing, cleansing the wound, and the application of the clean dressing. LVN #3 confirmed she did not perform hand hygiene with hand sanitizer and/ or soap and water with gloves changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 4 of 5 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 11/08/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 11/07/2024 at 9:25 AM, the Infection Preventionist (IP) stated staff had been educated to perform hand hygiene during wound care whenever gloves were removed and a new pair was put on. The IP stated it was never acceptable to not perform hand hygiene. During an interview on 11/08/2024 at 8:12 AM, the Director of Nursing stated hand hygiene should be performed before applying gloves, with each glove change, and at the completion of the care provided. Event ID: Facility ID: 055919 If continuation sheet Page 5 of 5