Inspection·June 14, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 1's Unusual Occurrence-Elopement Final Report, dated [DATE], indicated the Administrator documented that on [DATE] at approximately 10:45 PM, a Certified Nursing Assistant (CNA) went to take vital signs (temperature, pulse, respirations, and blood pressure) and could not find the resident. She documented Resident 1 was found outside the facility and down the street at a restaurant at approximately 11:30 PM. Resident 1's Wanderguard was in place and functioning (alarming) upon return to the facility. The Administrator's documentation showed an interview with a CNA [CLP1] indicated she thought she heard the alarm sound around 10:35-10:45 PM for about 30 seconds but was attending to another resident. The CNA stated after she finished attending to the other resident, the alarm did not sound anymore. The CNA did not know who turned the alarm off. Another interview with Licensed Nurse (LN) A was conducted. She reported, at approximately 10:45 PM, she heard the alarm go off at the front door. When she arrived at the door, it was no longer sounding. Another interview statement from another LN [CLP2] indicated he heard an alarm go off, but it was disarmed quickly. He did not see anyone turn the alarm off. A Registered Nurse (RN) [CLP3] statement indicated an evening shift RN found Resident 1 down the street at a restaurant (.6 miles away). The Administrator documented under the Elopement review that Resident 1 had two Wanderguards in place (one on his ankle and one on his wrist). She concluded the Wanderguard bracelets worn by Resident 1 were in place and functional, since the alarm sounded; however, an unknown person disarmed the alarm at the front door. Review of Resident 1's Behavior Note, dated [DATE] at 8:29 AM, indicated on [DATE] at approximately 11 PM, Resident 1 could not be located inside the facility. Resident 1 was located 30-35 minutes later outside at a local restaurant with a skin tear to his left elbow. The licensed nurse documented Resident 1's Wanderguard was in working order and had not expired. Review of Resident 1's Interdisciplinary Department Team (IDT) Review note, dated [DATE] at 9:39 AM, indicated other risk factors that may have contributed to this elopement: cognitive communication deficit. The IDT recommended possible transfer to a locked facility. During a telephone interview with LVN C on [DATE] at 1:30 PM, he stated he was worked the evening shift on [DATE]. He stated he heard the Wanderguard alarm go off, but someone turned it off, so he thought the resident was found (Resident 1). LVN C stated when the Wanderguard alarm is triggered, the alarm sound stays on continuously until a staff member goes to the wall alarm box to turn it off/reset it. 2. On [DATE] at 9:21 AM, the facility notified CDPH that Resident 2 left the facility unattended. Review of Resident 2's clinical record indicated she was [AGE] years old and had a diagnosis of Alzheimer's Disease (a type of dementia). Review of Resident 2's Health Status Note, dated [DATE] at 10:53 PM, indicated at approximately 8:20 PM, a CNA began to ask staff if they had seen resident 2. Prior to this request, Licensed Vocational Nurse (LVN) A documented Resident 2 had a second Wanderguard (bracelet) added to her right wrist. Review of Resident 2's undated Unusual Occurrence-Elopement Final Report indicated, on [DATE] at approximately 8:20 PM, the same day the resident was admitted for a five-day respite stay (a short-term relief for primary caregivers), Resident 2 went missing from the facility. Resident 2 was found at a local shopping center (1.1 miles away) and returned to the facility at approximately 9 PM, still wearing her Wanderguard bracelet. Review of Resident 2's IDT Review regarding her [DATE] elopement episode indicated, risk factors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055959 If continuation sheet Page 2 of 6 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 055959 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Post Acute Center 525 Auto Center Drive Watsonville, CA 95076 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 identified that may have contributed to her elopement included wandering and confusion. Prior to her elopement episode, she had on two Wanderguard bracelets that triggered the alarm to sound when tested. The IDT recommended for Resident 2 to be placed on every 15-minute monitoring. The IDT concluded Resident 2 likely needed to be in a locked facility versus a secure facility. Review of Resident 2's Medical Provider SOAP Note, dated [DATE] at 6:50 PM, indicated the resident had a diagnosis of Alzheimer's dementia and was brought from home to the facility under respite care to give the resident's family member a needed break (from caring for the resident for a few days). The physician ' s assessment indicated the staff just needed to be careful regarding elopement for Resident 2 because she often tried to leave her own home. He documented Resident 2 had a Wanderguard (bracelet) in place and the staff were aware. Review of Resident 2's MDS, dated [DATE], indicated she had severe impaired cognition, ambulated with supervision, and wandered daily. 3. On [DATE] at 9:19 PM, the facility notified CDPH that Resident 3 left the facility unattended. Review of Resident 3's clinical record indicated she was [AGE] years old and was admitted to the facility with a diagnosis of Alzheimer's dementia. Review of Resident 3's MDS, dated [DATE], indicated a BIMS score of 2 (severely impaired cognition). In addition, the MDS identified the resident had daily episodes of wandering and was able to ambulate with supervision without any assistive devices (cane, walker, or wheelchair). Review of Resident 3's Order Listing Report (physician orders), dated [DATE], indicated an order to monitor the function of the resident ' s Wanderguard every night and to have it on at all times as a safety measure. Review of Resident 3's Health Status Note, dated [DATE] at 10:13 PM, indicated the resident was not in the facility at 8:22 PM. At 9:03 PM (43 minutes later), Resident 3 was located down the street at a restaurant 0.3 miles away from the facility. Review of Resident 3's IDT Review note indicated other risk factors that may have contributed to Resident 3 ' s elopement included wandering aimlessly, ambulating without assistance, history of elopement, and impulsivity. Interventions that were in place prior to her elopement included the use of a Wanderguard. Review of Resident 3's Elopement Final Report, dated [DATE], indicated the Administrator documented Resident 3 was last seen on [DATE] at approximately 8 PM before she eloped. Resident 3 was found outside the facility and down the street at a restaurant at 9:03 PM. The facility had a Wanderguard alarm system in place. The preventative maintenance log indicated the Wanderguard system was checked three times a week to ensure the system worked. The facility concluded Resident 3's Wanderguard bracelet triggered an alarm to sound both when she left the facility and when she returned to the facility. However, by the time staff reached the door after Resident 3 eloped, she was already out of site. Meanwhile, another resident with a Wanderguard bracelet simultaneously triggered the same alarm that Resident 3 triggered (upon Resident 3's elopement). This led the Charge Nurse to incorrectly believe it was only that one other resident who set off the alarm. Minutes later, a CNA alerted other staff that Resident 3 was missing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055959 If continuation sheet Page 3 of 6 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 055959 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Post Acute Center 525 Auto Center Drive Watsonville, CA 95076 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 4. On [DATE] at 1:15 PM, the facility notified CDPH that Resident 5 left the facility unattended. Level of Harm - Minimal harm or potential for actual harm Review of Resident 5's clinical record indicated she was [AGE] years old and admitted to the facility with diagnoses including psychotic disorder with delusions and unspecified dementia. Residents Affected - Some Review of Resident 5's Elopement Risk Assessment (during admission), dated [DATE] at 3:10 PM, indicated she was not independently mobile and had no history of elopement. Another Elopement Risk assessment dated [DATE] at 1:50 PM, indicated she ambulated independently, paces and wanders, and has a history of elopement. This [DATE] assessment also indicated Resident 5 left the facility twice while wearing a Wanderguard and was a danger to herself by inadvertently leaving the facility. Review of Resident 5's Psychiatric Diagnostic Interview, dated [DATE], indicated she was highly anxious, confused and tried to leave the facility. The NP documented Resident 5 was fearful, anxious, frustrated, and had poor attention/concentration, impulse control, insight/judgment, and recent memory. Review of Resident 5's physician ' s orders, dated [DATE], indicated an order to check the Wanderguard placement and functioning once a day. Review of Resident 5's Unusual Occurrence-Elopement Final Report, dated [DATE], indicated on [DATE] at approximately 10 PM, a CNA went into Resident 5's room and noted the resident was not in her bed. The CNA looked outside and saw the Police department were across the street at the car dealership. Resident 5 was seen sitting on a bench outside the dealership. Resident 5's Wanderguard (bracelet) was in place on her left ankle. LVN B saw Resident 5 at around 8 PM and knew the Wanderguard was on her left ankle; however, she could not remember hearing any alarm sound when the resident eloped. LVN B heard the alarm sound when Resident 5 returned to the facility. The Administrator documented Resident 5's interventions, which included changing the location of her Wanderguard from her ankle to her wrist and ordering a Psychiatric evaluation. Review of Resident 5's Medical Provider SOAP Note, dated [DATE] at 1:22 PM, indicated Resident 5 was transferred from skilled nursing facility (SNF) A to SNF B because she kept trying to leave SNF A. While the resident was at SNF B wearing a Wanderguard (bracelet), she made her way outside of the facility without the alarm going off and went across the street to a car dealership. Review of Resident 5's Minimum Data Set (MDS-an assessment tool), dated [DATE], indicated a BIMS score of 9 (moderately impaired cognition). In addition, the MDS identified the resident had episodes of wandering one to three days and was able to ambulate with supervision using a walker. 5. On [DATE] at 3:35 PM, the facility notified CDPH that Resident 6 left the facility unattended. Review of Resident 6's clinical record indicated she was [AGE] years old and admitted to the facility with diagnoses including anxiety disorder and cognitive communication deficit. Review of Resident 6's Order Listing Report, dated [DATE], indicated an order to monitor the function of the Wanderguard once a day and to have the staff check the placement of the Wanderguard every shift on her left ankle. Review of Resident 6's Elopement Risk Assessment (Admission), dated [DATE] at 9:58 PM, indicated she had episodes of pacing, wandering and/or trying to get out of the facility, and she had a history (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055959 If continuation sheet Page 4 of 6 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 055959 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Post Acute Center 525 Auto Center Drive Watsonville, CA 95076 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 of elopement. Resident 6 was considered a high risk for elopement. Level of Harm - Minimal harm or potential for actual harm Review of Resident 6's MDS, dated [DATE] indicated a BIMS score of 9 (moderately impaired cognition), ambulated with supervision, and had no history of wandering. Residents Affected - Some Review of Resident 6's IDT Review note, dated [DATE] at 9:54 AM, indicated other risk factors that may have contributed to elopement included episodes of wandering and elopement risk. Previous interventions that were put in place prior to the elopement on [DATE] was a Wanderguard (bracelet). The IDT recommended to change Resident 6 from a 1:1 (one staff member always with the resident) to every 15-minute monitoring. Review of Resident 6's Elopement Final Report, dated [DATE], indicated the Administrator documented the resident had diagnoses including dementia without behavioral disturbance and cognitive communication deficit. On [DATE] at 4:50 a.m., a CNA reported she could not find Resident 6. Resident 6 was found outside the facility and down the street speaking with a man. The staff assisted Resident 6 back to the facility at around 5:10 AM and the Wanderguard (bracelet) was replaced to her right ankle. An interview with the Charge Nurse indicated Resident 6's ankle bracelet failed to trigger the alarm upon elopement; and, when the resident was brought back to the facility, the ankle bracelet was immediately replaced. During an interview with the Assistant Administrator (AA) on [DATE] at 10:20 AM, she stated the facility had five exit doors with a Wanderguard system that sounded an alarm when a resident with a Wanderguard bracelet was close to the exit door or had exited the facility. The AA stated a receptionist sat at a desk close to the front door seven days a week from 8 AM - 7:30 PM. She stated the four other exit doors lock from the outside only; and, when they were opened from the inside, an alarm would sound until a staff member would go to the control box to punch in a code that would reset the alarm. When the AA was asked if the facility had done any tracking or trending related to residents that eloped, she replied she was unaware. She stated the Maintenance Director checked the Wanderguard system every week to ensure the system functioned properly. The AA stated: a. Resident 1 was confused, combative and wandered aimlessly for hours on end. b. Resident 2 was confused and at the facility for respite care. The resident wandered around the facility and eloped the 1st day she was admitted to the facility. c. Resident 3 was confused and wandered aimlessly. The resident also had aggressive behaviors towards the staff. d. Resident 5 was confused, yelled, and was combative towards the staff. The resident wandered around the facility and was not easily directed; and, e. Resident 6's Wanderguard bracelet did not sound an alarm when she left the facility; however, it sounded an alarm when she returned. During an observation of a Wanderguard bracelet sensor, on [DATE] at 11:15 AM, the Nursing Supervisor went to the front door with the bracelet and a very loud alarm sounded until the control box on the wall was reset. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055959 If continuation sheet Page 5 of 6 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 055959 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Post Acute Center 525 Auto Center Drive Watsonville, CA 95076 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 During an interview with the Social Service Director (SSD) on [DATE] at 1:20 PM, she stated all the facility's exit doors have the Wanderguard alarm system installed. She was not employed at the facility until [DATE] and did not recall the residents. During an interview with Licensed Vocational Nurse (LVN) A on, [DATE] at 1:25 PM, she stated: Residents Affected - Some a. Resident 1 was alert and confused. The resident was non-verbal most of the time and had behaviors including agitation and wandering from morning until night. He ambulated independently. b. Resident 2 was alert, but not oriented and not able to make her needs known. The resident's behaviors included wandering and exit seeking. She ambulated independently. c. Resident 3 was alert to person only and able to make her needs known. The resident's behaviors included wandering and exit seeking. d. Resident 5 was alert to person only. She ambulated with a walker or wheelchair and had exit seeking behaviors. e. Resident 6 was alert to person only and was able to make her needs known. The resident was transferred from SNF A to SNF B because she was exit seeking and this building (SNF B) had the Wanderguard system installed. LVN A stated all exit doors at the facility had the Wanderguard alarm system installed and the Maintenance Director checked the system every other day to ensure the alarm functioned/sounded. During an observation of the facility's exit doors with the AA on [DATE] at 2:50 PM, all five exit doors had alarms that sounded off very loudly when a Wanderguard bracelet sensor was brought near to trigger them. The AA had to manually input a code in the code box on the wall to silence and reset the alarm system. Review of the facility's policy and procedure (P&P) Wandering and Elopements, revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If residents are identified to be at risk for wandering/elopement, their care plans will include strategies and interventions to maintain their safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055959 If continuation sheet Page 6 of 6