Health inspection·April 23, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/22/25 at 1:51 p.m., IPN stated that on 3/24/25 someone came and told her that Resident 1 had left his room and she went outside to talk to Resident 1. IPN stated he was in the front of the building without shoes or a mask, just his walker. IPN stated Resident 1 was angry and he stated he felt hot. IPN stated she asked Resident 1 to go back to his room to talk, which he did. IPN stated that when they got to his room, Resident 1 told her the air purifier in his room was too noisy, the room was hot, and he said he wanted to get away from you f---ing people. IPN stated she told Resident 1 she would get him a fan, and Resident 1 asked for lorazepam (an antianxiety medication) which Resident 1's nurse, Licensed Staff B, gave to him. IPN stated that while she got the fan, Resident 1 left his room again. IPN stated Licensed Nurse C approached her and told her, We need to 5150 (an involuntary psychiatric hold) him. IPN stated DON told staff to call 911, which they did. IPN stated she spoke to the dispatcher and explained Resident 1's situation and told them a peace officer would be good to de-escalate Resident 1. IPN stated an officer came and talked to Resident 1 in the dining room. IPN stated the officer started yelling and shuffling around, and then called for backup and a second officer came. IPN stated the two officers tried to restrain Resident 1 and Resident 1 hit one of the officers. IPN stated the police escorted Resident 1 out and put him in the police car. IPN denied any visitors or residents were out in the front of the building during the time of this incident. When queried, IPN stated Resident 1 was never aggressive prior to this incident. IPN stated Resident 1 would let his needs be known, and he would let staff know if he was anxious, which was handled with lorazepam, and then she would talk to him about how he was doing. When queried, IPN stated any time a resident was on isolation the resident could be outside safely with PPE and the resident could take their mask off when outside to get fresh air. IPN stated she had not in-serviced the staff on how to let someone on isolation go outside safely. During an interview on 4/22/25 at 2:08 p.m., Receptionist A stated that on 3/24/25 Resident 1 was agitated, he was unmasked and COVID- positive. Receptionist A stated that when Resident 1 headed towards the door, he (Receptionist A) tried to approach Resident 1, but he bashed me with his walker. I got out of the way, and I got help from other staff members. Receptionist A stated Resident 1 said, F--- you. I'm going outside, I'm getting the f--- out of here, and Resident 1 went outside. Receptionist A stated, It happens (resident aggression towards staff), it's not the first time. I just roll with it. During an interview on 4/22/25 at 2:27 p.m., Licensed Nurse B verified he was Resident 1's nurse the day he went to jail. Licensed Nurse B stated Resident 1 was on isolation for COVID, and it was reported to him that Resident 1 was out of his room going to the main door to go out. Licensed Nurse B stated IPN guided Resident 1 back to his room. Licensed Nurse B stated Resident 1 was very anxious, Resident 1 was verbalizing that he was feeling isolated, and he was anxious and confused about what was going on. Licensed Nurse B stated he administered lorazepam to Resident 1 for his anxiety and then after that Resident 1 attempted again to get out of the room. Licensed Nurse B stated he was following Resident 1, letting him know he was on isolation, and he has to go back to the room. Licensed Nurse B stated Resident 1 went to the dining room and he and DON and were watching Resident 1 at that time. Licensed Nurse B stated Resident 1 was aggressive in the dining room, he put his leg on a box, and he was trying to grab something, and we were trying to get it away from him because we thought he might throw it. Licensed Nurse B stated Resident 1 was very anxious. When queried, Licensed Nurse B stated that was his first day working with Resident 1 and he did not know the plan for Resident 1's anxiety except to give the lorazepam as needed. When queried, Licensed Nurse B stated that what Resident 1 needed in that moment was to get out of the room. Licensed Nurse B stated Resident 1 could not be out of his room at that time because he was on isolation, so his (Licensed Nurse B's) understanding was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 2 of 3 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 04/23/2025 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 0561 that all activities, therapy, and visitation happened in his room. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 4/22/25 at 4:15 p.m., Licensed Nurse C stated that on 3/24/25 Resident 1 had COVID, no mask, no shoes, and no socks and had gone outside. Licensed Nurse C stated he tried to get Resident 1 to come inside, but Resident 1 was saying, I want to go, this is like a jail. Licensed Nurse C denied anyone else was outside at the time, except maybe staff. Residents Affected - Few During an interview on 4/23/25 at 1:24 p.m., Social Services Director (SSD) stated Resident 1 did not have aggressive behaviors prior to 3/24/25, just frustrated behaviors. SSD stated Resident 1 found out about his cancer diagnosis just before he got here, he lost his ability to live independently and found out he was not going to be able to go home to the same situation, he lost his apartment, and then he got the COVID diagnosis, which delayed his transfer out, and all that compounding was a lot for him. During an interview on 4/24/25 at 3:32 p.m., Administrator stated yes, Resident 1 could absolutely go outside as long as he followed protocol for infection control. Administrator verified someone could have brought Resident 1 a chair and his shoes. During a record review on 4/23/25 at 4:05 p.m., Resident 1's medication administration record for March 2025 indicated Resident 1 had a physician order for lorazepam 0.5 mg (milligrams) every six hours as needed for anxiety and Licensed Nurse B documented a dose given to Resident 1 on 3/24/25 at 11:41 a.m. Review of Resident 1's nurse progress notes indicated a note written by IPN dated 3/20/25 at 11:51 a.m., Resident tested positive for COVID 19 on 3/20/2025. He presents with a low grade fever and overall feeling of weakness. No other documentation of COVID symptoms was noted. Review of Resident 1's vital signs (blood pressure, pulse, respiratory rate, and temperature) revealed no fever after 3/20/25. Review of facility policy Resident Self Determination and Participation, last revised 8/2022, indicated, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 If continuation sheet Page 3 of 3