Health inspection·March 11, 2022

F 0563 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, General Visitation Policy: dated 2/21/22, the P&P indicated, Our recommended visitation hours are 1p.m.-5p.m. in order to not interfere with resident ADL (activity of daily living) care and scheduled meals. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 2 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review the facility failed to care plan (care plans provide communication among nurses, their residents and other healthcare providers to achieve health care outcomes) its continued use of a position change alarm (an audible alarm that alerts staff the resident is getting up, and that should be used only when medically necessary and with intermittent reevaluation for continued use) for for 1 of 17 sampled residents (Resident 28). Resident 28 was known to remove the clip connected to the alarm. The failure to care plan resulted in the position change alarm constantly in use, and had the potential to diminish Resident 28's psychosocial well-being. Findings: During an observation on 3/7/22 at 11:10 a.m., Resident 28 was sleeping in her bed. A position change alarm device was visible at the head of her bed. During an observation and concurrent interview on 3/8/22 at 10:25 a.m., Resident 28 was resting in bed. Staff L stated Resident 28 prefers to get up after lunch. We get her up into a wheelchair and she moves herself around the facility. Staff L stated we use the position change alarm every time Resident 28 is in her wheelchair and added, Resident 28 can remove the clip and string attached to the position change alarm. During an observation and concurrent interview on 3/10/22 at 10:25 a.m., Resident 28 was in her wheelchair at the doorway to her room and the position change alarm was in place. Staff L stated we always use the alarm, and the use of the alarm should be a part of the care plan. During an observation and concurrent interview on 3/11/22 at 9:20 a.m., Resident 28 was seen in the hall, a few doors from her bedroom. Staff N stated we use the position change alarm while Resident 28 is in bed and when she is in the wheelchair. Staff N stated we use the alarm because she is a fall risk and an elopement risk. Staff N stated, Resident 28 can propel herself all around the facility and likes to go to the doors to look outside. Staff N stated Resident 28 knows how to remove the clip and string attached to the alarm and will hide the clip. Staff N stated Everyone (staff) is to lookout for her and to respond when the alarm sounds. During a record review of Resident 28's Medication Review Report (recap of Physician orders) March 2022, revealed that a position change alarm was not ordered by an MD. During a record review of Resident 28's care plan, (printed 3/11/22) The care plan included a focus for Risk for Wandering or Elopement. The interventions listed were offering to walk with Resident 28, redirecting her when seen going toward door, offering structured activities, food, conversations, television and reading materials and providing her with a consistent routine. During a record review of Resident 28's care plan, (printed 3/11/22) The care plan included a focus for Risk of Falls. The interventions listed were anticipate and meet Resident 28's needs, make sure call light is within reach and respond promptly, ensure Resident 28 has appropriate footwear and provide Resident 28 a safe environment such as clean, clutter free floors, good lighting and a working call light. The facilities policy Care Planning Interdisciplinary Team, dated 1/2022, indicated Our facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 3 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 4 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise a care plan with updated interventions for one (Resident 64) of 17 sampled residents, when facility staff reviewed the nutritional care plan but did not document new interventions to manage resident 64's continued weight loss. This failure resulted in Resident 64 suffering significant weight loss within one month. Findings: During a review of Resident 64's, admission Record she had been admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During a review of Resident 64's, Dietary Progress Notes, dated 2/15/22, the Dietary Progress Note indicated Resident 64 was admitted to the facility with a weight of 44.8 kilograms or 98.56 pounds. Resident 64 has been prescribed a tube feeding (nutrients are supplied through a tube for people who cannot get enough nutrients through eating) formula to be infuse 55 milliliters (ml) an hour (hr.) for 20 hours and to stop the feeding from 10:00 a.m. until 2:00 p.m., so Resident 64 could participate in therapy. Additional water had been added to meet 100% of her estimated nutritional needs. During a review of Resident 64's, Nursing Progress Notes dated 2/17/22, indicated the tube feeding hourly rate was going at a rate of 45 ml/hr. on 2/17/22, Dietary Progress Note, indicated the rate for the tube feeding was changed to 55 ml/hr per the doctor's order. Resident 64's weight was measured and indicated to be 94 lbs. During a review of Resident 64's, Dietary Progress Notes, dated 2/25/22 indicated Resident 64's weight had been measured at 90.8 lbs. The rate of tube feeding was recommended to be increased to 65 ml/hr. due to weight loss and additional water was added to meet nutritional needs. Blood sugar ranged from 117 to 390 with an average of 230 indicted in the dietary note. During a review of Resident 64's, Dietary Progress Notes dated 3/4/22 indicated Resident 64's weight had been measured at 89.4 lbs. Blood sugar levels were indicated to range from 90 to 389 with an average of 242. The dietary noted indicated Resident 64 had an unintended weight loss of 4.6 lbs. or 4.9% of total body weight. Dietary noted indicated Resident 64 remained on appropriate tube feed formula and she was meeting 100% or greater of her estimated needs. During an observation on 3/7/22 at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up and respond. During an interview on 3/10/22 at 3: 55 p.m. with RD J, she stated Resident 64 had high blood sugar levels and with those levels being so high, she would be unable to absorb the tube feeding formula and gain weight without additional insulin to lower the blood sugar levels and bring that sugar or energy back into the cells. RD J stated that more insulin would help Resident 64's body absorb the formula better and might allow her to gain weight. RD J stated she thought she should have followed up with the doctor regarding the consistently high blood sugar levels. RD J stated she had not spoken with the nursing staff to ask if Resident 64 had been getting all the formula being prescribed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 5 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if there were any challenges like the therapy schedule which might have interfered with her getting all the formula prescribed. RD J stated Resident 64's was considered significant and of concern since it had been going downward and not stabilizing or remaining the same. During a review of Resident 64's, Plan of Care dated 2/16/22 indicated Resident 64 would achieve a goal of tolerating her tube feedings. On 2/18/22, Resident 64's, Plan of Care had been updated on 3/4/22 to achieve a goal of maintaining her weight plus or minus four pounds with a set point of 89 pounds, indicating she had continued to lose weight since 2/17/22 (admission weight was 94 pounds). Resident 64's, Plan of Care was reviewed for updated interventions to stabilize or encourage weight gain but no updated interventions beyond 2/18/22 were observed. During a review of the facility's policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team dated, 2022, the P&P indicated, 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team .5. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face to face, teleconferences, written communications, etc.) is a the discretion of the Care Planning Committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 6 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adopt a discharge care plan that identified nutritional needs for one (Resident 64) of 17 sampled residents, when the facility's discharge plan for Resident 64 did not address weight loss and how to stabilize or gain weight. This failure had the potential to cause Resident 64 further weight loss and fatigue. Residents Affected - Few Findings: During a review of Resident 64's, Nursing Progress Notes, dated 11/11/21, indicated Resident 64 had been admitted to the facility with a diagnosis of acute renal failure (a condition which the kidneys suddenly cannot filter waste from the blood), requiring dialysis (a process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions) and surgery. During a review of Resident 64's, Nursing Progress Notes, dated 11/16/21, indicated Resident 64 had discontinued dialysis. During a review of Resident 64's, Dietary Progress Notes, dated 11/19/21, indicated Resident 64 had lost 5.2 pounds, or 4.3% of her total body weight, and weighed 121 pounds. The Dietary Progress note indicated Resident 64 had been eating approximately 41% of her meals. Resident 64's diet preferences had been changed to add sherbet for a snack and continue to monitor weights and follow-up. The Dietary Progress Note indicated Resident 64 had her own supply of a protein supplement drink. During a review of Resident 64's, Dietary Progress Notes, dated 11/26/21 indicated Resident 64 had lot a total weight of 5.6 pounds or 4.8% of her body weight within one week and her weight was measured at 110.8 pounds. Resident 64 had been consuming approximately 54% of her meals, plus the snack and protein supplemental drink, no new recommendations were included in the plan of care. The goal weight had been adjusted to stay within plus or minus four pounds of 110 pounds. During a review of Resident 64's, Dietary Progress Notes, dated 12/7/21, indicated Resident 64 had lost 13.6 pounds since admission [DATE]) or 11% of her total body weight and had a body weight measured at 108 pounds. The goal weight had been adjusted to stay within plus or minus four pounds of 110-pound body weight. The Dietary Progress Note indicated Resident 64 had met the goal weight range. The note indicated a recommended change to discontinue regular sherbet and add sugar free sherbet to her diet. During an interview on 3/10/22, at 3:55 p.m., Registered Dietician J (RD J) stated Resident 64 was admitted to the facility on dialysis, due to a condition that caused fluid build-up. RD J stated that fluid build-up caused a resident to gain weight, not lose weight. RD J stated she did not contact the dialysis center to learn Resident 64's dry weight (the resident's weight without the excess fluid that builds up between dialysis treatments). RD J stated Resident 64 indicated her desired weight was around 110 pounds, and the Resident 64's initial weight loss had been acceptable. RD J stated Resident 64 stopped dialysis while receiving care at the facility. RD J verbalized agreement that when a resident usually would gain weight rather than lose weight after stopping dialysis. RD J did not know the reason why Resident 64 continued to lose weight through her stay at the facility stay. RD J did not know why Resident 64's discharge plan did not include recommendations to ensure weight stability or to increase weight from 98.2 pounds, at discharge. When asked how Resident 64's protein (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 7 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0660 Level of Harm - Minimal harm or potential for actual harm shakes were calculated into the resident's dietary plan, RD J was unable to vocalize a process. RD J stated staff did not measure each drink container to determine how much was consumed each day. RD J stated Resident 64 lost a total of 13 pounds of body weight during the facility stay, and RD J considered a significant weight loss and concerning. RD J stated she provided no recommendations for managing Resident 64's weight loss. Residents Affected - Few During a review of Resident 64's, Nursing Progress Note, dated 12/13/21 indicated she would be discharged on 12/14/21 to home with follow up appointments, equipment needs addressed and referrals for Home Health services made. During a review of Resident 64's, Plan of Care, dated 11/11/21 had a discharge plan to follow up with kidney specialist, outlined medical devices she used but did not indicate any dietary changes to stabilize or gain weight. During a review of Resident 64's, Discharge Order, dated 12/13/21 or Resident 64's, Discharge Instructions dated 12/9/21 did not indicate a plan for Resident 64's weight loss or recommendations to stabilize or gain weight for Resident 64. Resident 64's Discharge Instructions indicated she had a documented weight of 98.2 pounds measured on 12/10/21. During a review of the facility's policy and procedure titled, RD (Registered Dietician) FOR HEALTHCARE, INC WEIGHT CHANGE PROTOCOL, dated 2018, the P&P indicated, Identify reasons for the weight loss, .Consider possible health effects from the weight change .Suggest interventions to correct the identified problem, diet supplementation, appetite stimulation .The evaluation process is done again if there is another significant weight change .The following criteria defined significant .Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 5% weight loss in one month . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 8 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 upon observation, interview and record review the facility failed to provide individualized activities for three of 17 sampled residents (Resident 43, 58, and 64). This deficient practice had the potential to affect the quality of life of residents by placing them at risk of sensory deprivation and decreased cognitive functioning. Residents Affected - Some Findings: 1. During a review of Resident 43's, admission Record, dated 2/10/22, indicated she had been admitted to the facility on [DATE] following a hip replacement surgery (surgery to implant an artificial hip joint), muscle weakness and low blood pressure when standing or sitting. A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/31/22, indicated the resident exhibited no cognitive deficits. During a concurrent observation an interview on 3/7/22, at 3:28 p.m., Resident 43 stated that no one had come to her bedside to offer books or or provide other activities to complete at the bedside. Resident 43 was asked if she attended activities that were schedule at the facility, she stated, No, I do not know anything about activities, what would that be? Resident 43's attention was directed to a calendar indicating March, posted on the resident's wall. The calendar indicated activites scheduled each day of the month, at various times. Resident 43 stated she could not read the activity calendar from her bed because it was too small to read. Resident 43 was asked if she might enjoy listening to New [NAME] music. The resident answered affirmatively and wanted to know when that had been scheduled. When Resident 43 was informed the activity had already taken place, the resident exhibited an expression of disappointment. During a review of Resident 43's, Plan of Care, dated 2/23/22, indicated staff would provide one-to-one visits for social interactions and to provide accommodations, such as discussing about Daily News/World News for leisure activities. During a review of Resident 43's, Activity Assessment Form, dated 2/23/22 indicated the resident liked to listen to music, keep up with the news and do things with people as very important. During a review of Resident 43's, Activity Attendance Record, for the month of March 2022 indicated the resident had not attended any activities outside of her room but was provided three in-room visits (3/1/22, 3/8/22 and 3/10/22) where conversation had taken place. A request had been made for, Activity Attendance Record for the month of February and the facility could not produce documentation. 2. During a review of Resident 58's, admission Record, dated 2/8/22, indicated Resident 58 had been admitted to the facility on [DATE] with a history of Diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a group of lung disease that block air flow and make it difficult to breathe) and high blood pressure. A review of Minimum Data Set (MDS), a standardized cognitive assessment dated [DATE], indicated she had minimal cognitive deficits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 9 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 Level of Harm - Minimal harm or potential for actual harm During an interview, on 3/8/22 at 10:04 a.m., Resident 58 stated no one had offered her engagement with activities while she was in bed. Resident 58 was asked if she was aware of the activity calendar for March 2022 posted on the wall in her room, and the resident stated, No. Resident 58 stated she was unable to view the calendar because of the effect diabetes had on her eyes. Resident 58 stated she was bored and thought it was very boring here. Residents Affected - Some During a review of Resident 58's, Plan of Care, dated 2/9/22 indicated the staff would provide one to one visit for social interaction and to provide accommodations such as outdoor leisure time activities. During a review of Resident 58's, Activity Assessment Record, dated 2/9/22, indicated listening to music, being with groups of people and doing her favorite activities were somewhat important. Resident 58 indicated the only activity as very important was going outside and getting fresh air. During a review of Resident 58's, Activity Attendance Record, dated the month of February 2022 indicated she had not attended any activities outside of her room and she had seven room visits (2/9/22, 2/10/22, 2/11/22, 2/15/22, 2/21/22, 2/24/22 and 2/28/22), during which conversation and social interaction had taken place. 3. During a review of Resident 64's, admission Record, the record indicated Resident 64 was admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. A review of Minimum Data Set (MDS), a standardize cognitive assessment dated [DATE], indicated she had moderate cognitive deficits. During an observation on 3/7/22 at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up and respond. During a review of Resident 64's, Plan of Care dated 2/17/22 indicated she liked to listen to music and for staff to be aware of resident's preferences and to provide care in a timely manner. During a review of Resident 64's, Activity Assessment Form dated 2/17/22, indicated her family provided the answers to the form. Listening to music was indicated to be somewhat important to Resident 64 per her family. During an observation on 3/9/22 at 9:57 a.m., in the hallway outside of room [ROOM NUMBER], MTG E was observed going into room [ROOM NUMBER] with no supplies and stayed in the room for a few minutes and then exited the room to go into another resident room. During an interview on 3/9/22 at 4:29 p.m., with MTG E, she stated she had no other staff to carry out activities as she was the sole employee for the Activity Department. MTG E stated she did not have a list of residents that require one to one time in their rooms. MTG E stated she would visit each resident every morning to do a check in on how everyone was feeling. MTG E stated she did not like bringing a cart to check-in on residents and if a resident requested materials like coloring pages, she could then go back to the activity room and bring a binder full of various coloring pages. MTG E stated she did not think it was a problem to conduct daily visits then head back to her activity room which was located at the end of a resident hallway to provide supplies and then start activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 10 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some per the March calendar by 10:30 a.m., Monday through Friday. MTG E stated she did not work on the weekends. MTG stated there were 80 residents in the building and she would visit each resident from one minute to 15 minutes if they wanted to speak with her. MTG E stated she arrived at the facility at usually 8:00 a.m. to start visiting residents. MTG E could not explain when she had time to document if residents were attending activities or how often room visits were conducted. MTG E stated for Resident 64 as an example, she would provide the room visit documentation for the month of February. MTG E could not produce documentation regarding room visits for February 2022. MTG E stated she had March 2022 documentation and by observing the document, Resident 64 had two room visits (3/2/22 and 3/7/22 where sensory touch stimulation had been done. MTG E stated that meant she had stroked Resident's hands or face. During a review of the facility's policy and procedure (P&P) titled, Activity Programs, dated 2022, the P&P indicated, Activities are scheduled 7 (seven) days a week .All activities are documented in the medical record .b. Are offered at hours convenient to the residents, including evenings, holiday and weekends: . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 11 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0692 Provide enough food/fluids to maintain a resident's health. 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 maintain acceptable nutrition for one (Resident 64) of 17 sampled residents. This resulted in Resident 64 suffering a significant weight loss within one month of admission, which effected her overall health and well-being. Residents Affected - Few Findings: During a review of Resident 64's, admission Record she had been admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During a review of Resident 64's, Dietary Progress Notes, dated [DATE], the Dietary Progress Note indicated Resident 64 was admitted to the facility with a weight of 44.8 kilograms or 98.56 pounds. Resident 64 has been prescribed a tube feeding (nutrients are supplied through a tube for people who cannot get enough nutrients through eating) formula to be infuse 55 milliliters (ml) an hour (hr.) for 20 hours and to stop the feeding from 10:00 a.m. until 2:00 p.m., so Resident 64 could participate in therapy. Additional water had been added to meet 100% of her estimated nutritional needs. During a review of Resident 64's, Nursing Progress Notes dated [DATE], indicated the tube feeding hourly rate was going at a rate of 45 ml/hr. on [DATE], Dietary Progress Note, indicated the rate for the tube feeding was changed to 55 ml/hr per the doctor's order. Resident 64's weight was measured and indicated to be 94 lbs. During a review of Resident 64's, Nursing Progress Notes dated [DATE], indicated Resident had a change in condition by appearing less responsive, very sleep and had a blood sugar level of 577 (per MedicineNet/WebMD, normal blood sugar for an adult with diabetes should be less than 180). The medical doctor was notified, and insulin (a hormone that controls the amount of sugar in the bloodstream and helps the body store glucose (simple sugar) in the liver, fat and muscles) medication had been prescribed. During a review of Resident 64's, Dietary Progress Notes, dated [DATE] indicated Resident 64's weight had been measured at 90.8 lbs. The rate of tube feeding was recommended to be increased to 65 ml/hr. due to weight loss and additional water was added to meet nutritional needs. Blood sugar ranged from 117 to 390 with an average of 230 indicted in the dietary note. During a review of Resident 64's, Dietary Progress Notes dated [DATE] indicated Resident 64's weight had been measured at 89.4 lbs. Blood sugar levels were indicated to range from 90 to 389 with an average of 242. The dietary noted indicated Resident 64 had an unintended weight loss of 4.6 lbs. or 4.9% of total body weight. Dietary noted indicated Resident 64 remained on appropriate tube feed formula and she was meeting 100% or greater of her estimated needs. During an observation on [DATE] at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up and respond. During a concurrent interview and observation on [DATE] at 2:32 p.m., with Licensed Staff O at Resident 64's bedside, she stated the tube feeding at the bedside was turned off and disconnected so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 12 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 64 could attend physical therapy. Licensed Staff O stated she had previously requested from the Rehabilitative Therapy Department to work with her during 10:00 a.m. and 2:00 p.m. while the feeding was scheduled to be turned off. Licensed Staff O then left the room to demonstrate physical therapy was working with Resident 64 in the hallway just outside of her room. Licensed Staff O stated Resident 64 was tolerating her tube feedings as nursing would check if the formula was not being absorbed by the stomach. At 2:45 p.m., Resident 64 was working with physical therapy and the tube feeding continued to be turned off. During an interview on [DATE] at 3: 55 p.m. with RD J, she stated she was aware of Resident 64's wieght loss and stated each time she was weighed there were new calculations regarinding required nutritional needs. RD J stated she was aware the current tube feeding regime had not been assisting Resident 64 in stablizing if not gaining weight but stated the calculation were based on evidence based practice for dieticians. RD J stated, Resident 64 had high blood sugar levels and with those levels being so high, she would be unable to absorb the tube feeding formula and gain weight without additional insulin to lower the blood sugar levels. RD J stated that more insulin would help Resident 64's body absorb the formula better and might allow her to gain weight. RD J stated she thought she should have followed up with the doctor regarding the consistently high blood sugar levels. RD J stated she had not spoken with the nursing staff to ask if Resident 64 had been getting all the formula being prescribed and if there were any challenges like the therapy schedule which might have interfered with her getting all the formula prescribed. RD J stated Resident 64's was considered significant and of concern since it had been going downward and not stabilizing or remaining the same. During a concurrent interview and observation with Licensed Staff P, on [DATE] at 9:32 a.m. at Resident 64's bedside, she stated there was approximated 300 milliliters of formula left in the tube feeding bag and the tube feeding would be stopped at 10:00 a.m., per the doctor's order. Licensed Staff P stated the tube feeding bag might be used for the tube feeding when it would be started back up at 2:00 p.m., since the bag would not have expired. Licensed Staff P stated for charting purposes she would document when she turned off the feeding and when it was turned back on, and on a separate piece of paper she would document the water given to Resident 64 and how many millileters of the feeding was infused during the shift. Licensed Staff P demonstrated where then tube feeding milliliter numbers were documented. A review of Resident 64's, Intake and Output Record indicated for the month of March, the following days did not indicate 24-hour totals were calculated, [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 11:43 with DON, she stated there is no weight loss committee, but the Department managers discussed what was going on with residents daily. DON stated she was not aware that physical therapy was working with Resident 64 outside of the times set aside for therapy (10:00 a.m. to 2:00 p.m.). During a review of the facility's policy and procedure titled, RD (Registered Dietician) FOR HEALTHCARE, INC WEIGHT CHANGE PROTOCOL, dated 2018, the P&P indicated, Identify reasons for the weight loss, .Consider possible health effects from the weight change .Suggest interventions to correct the identified problem, diet supplementation, appetite stimulation .The evaluation process is done again if there is another significant weight change .The following criteria defined significant .Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 5% weight loss in one month . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 13 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on observation, interview and record review, the facility failed to provide necessary behavioral health care and services for 1 out of 17 residents (Resident 50), when facility staff failed to facilitate the resident's referral for psychological services and evaluation. This failure resulted on Resident 50 showing increased anxious behavior and receiving a new medication to address her anxiety, and did not ensure services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, Findings: During an observation, interview and record review with Resident 50 on 3/7/22 at 3:00 p.m., Resident 50 was crying. Resident 50 stated she's sad and anxious but refused to discuss the matters further. Review of admission Minimum Data Set (an assessment tool) dated, 2/09/22, the facility admitted Resident 50 on 2/07/22 with a diagnosis of Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and a Brief Interview for Mental Status (BIMS, a brief test is used to learn how well a person functions cognitively; a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) score of 9 out 15. During an interview and concurrent record review with Staff H on 3/09/22 11:11 a.m., Staff H verified Resident 50 had a Physician standing order for Psychologist Referral. The order, dated 2/7/22, indicated the facility would contact a psychologist (a professional who practices psychology and studies normal and abnormal mental states, emotional and social processes and behavior). Staff H stated the facility's process required Social Services to review the order and secure the referral with a psychologist. Staff H stated Resident 50 was started on a medication as needed (PRN) on 3/06/22 for anxiety. Staff H stated Resident 50 had not received any medication for anxiety until 3/05/22. During concurrent interview and record review with Management (Mgt) B on 3/09/22 at 11:27 a.m., Mgt B stated she made the referral with Psychologist K on 2/11/22. Mgt B stated Resident 50 had not been evaluated by Psychologist K. Mgt B stated she thought there was a barrier with Resident 50's insurance or payment source, which resulted in no evaluation. Mgt B stated she contacted Resident 50's insurance company on 2/14/22, and learned Psychologist K was listed on the insurace company's approved clinician list. Mgt B confirmed she had no documentation indicating she notified Psychologist K of the insurance's approval for Resident 50's services. During an interview and concurrent record review with Staff H on 3/09/22 at 3:47 p.m. Staff H stated Resident 50 received a medication on 3/5/22 for expressing feeling down due to resident 50 not having a husband, episodes of crying, and wanting to go home. Staff H confirmed Resident 50 having episodes of crying on 3/01/22 and 3/02/22. Upon review of the Medication Administration Record (MAR) of Resident 50, Staff H verified Resident 50 was not on any medication to address anxious behavior until 3/05/22. During interview with DON on 3/10/22 at 10:38 a.m., DON confirmed Resident 50 had not been seen by Psychologist K. DON stated Resident 50 needed to be seen by Psychologist K because her mood changes so fast. DON stated there was a small risk of Resident 50's anxiety increasing if she was not seen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 14 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 0740 by Psychologist K. Level of Harm - Minimal harm or potential for actual harm The facility's Policy and Procedure titled Referrals, Social Services indicated Social Services shall coordinate resident referrals with outside agencies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 15 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the drug regimen for one of 17 residents (Resident 33) was free from unnecessary drugs, when facility staff administered laxitive medication to Resident 33 when the resident had loose bowel movements, contrary to physician order. This failure resulted in Resident 33 receiving medication that was not clinically indicated, which had the potential to cause unnecessary discomfort and stress to the gastrointestinal (GI) tract, and delay diagnosis for the cause of the GI resident's distress. Residents Affected - Few Findings: During a review of Resident 33's Discharge summary, dated [DATE], this document indicated Resident 33 was in the hospital 11/16/21 to 11/21/21 for epididymitis/orchitis (inflammation and infection of the scrotum and testicles). The summary indicated Resident 33 was started on antibiotics in the hospital and continued taking them at the facility, until the end date of 12/1/21. During a review of Resident 33's Bowel Elimination task report for 12/2021 documented Resident 33 was having large loose/diarrhea stools. On 12/1/21 and 12/3/21 Resident 33 had 1 normal and 1 large loose stool. On 12/4/21 Resident 33 had 2 large loose stools. On 12/8/21 Resident 33 had 1 large loose stool. On 12/9/21 Resident 33 had 1 normal stool and 1 large loose stool. On 12 /10/21 Resident 33 had 2 large loose stools and 1 large putty like stool. On 12/11/21 Resident 33 had 1 normal stool and 2 loose stools. On 12/12/21 Resident 33 had 2 large loose stools. During a review of Resident 33's Medication Administration Record (MAR), dated 12/2021, the MAR revealed that Resident 33 had been on 2 antibiotics for cellulitis that was started 11/22/21. The last dose of antibiotics was scheduled for 12/1/21 and administered. In addition to antibiotics, the MAR indicated Resident 33 was on Senna (a laxative to prevent constipation), 1 tablet to be given twice-a-day (morning and evening). The MAR indicated to hold (e.g., not administer) the Senna if Resident 33 had loose stools. Resident 33's MAR indicated Senna was administered everyday, twice-a-day, from 12/1/21 to 12/10/21. The Senna was not administered on 12/11/21. On 12/12/13, the MAR indicated the morning dose was given, but the evening dose was held. In addition to Senna, the MAR indicated Resident 33 also received MiraLAX (a laxative used to treat occasional constipation), for administered once everyday, but held if the resident exhibited diarrhea. Similarly to Senna, MiraLAX was administered to Resident 33 from 12/1/21 to 12/10/21, held on 12/11/21, but administered on 12/12/21 and 12/13/21. During a review of Resident 33's Progress Notes, on 12/10/21 at 1:15 p.m., Staff L documented Resident 33 had a bout of diarrhea before lunch, and staff would continue to monitor. During a review of Resident 33's Progress Notes, on 12/12/21 at 7:53 p.m., Staff M documented that the physician was notified that Resident 33 had a change of condition, a fever of 101.3 degrees Fahrenheit. Recommendations by the physician were to get urine and blood work done if fever recurs. During an interview on 3/11/21 at 10:30 a.m., DON stated that it was known that Resident 33 had some diarrhea, and they held his laxatives. DON stated Resident 33 normally had one large normal stool every day. DON stated that the bout of diarrhea that she knew of did not appear to be a stool infected with Clostridioides difficile (C. Diff., a germ that causes severe diarrhea and inflammation of the colon, presents in most cases when an individual is taking antibiotics). DON stated they did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 16 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 investigate further, did not start an infection surveillance check list, and did not notify the physician. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review on 3/11/21 at 10:30 a.m., DON stated they had documented Resident 33's infection on the Infection Prevention and Control Surveillance Log . Review of the Infection Prevention and Control Surveillance Log for 12/2021 showed that Resident 33 was on the log for C Diff. due to antibiotic use, and listed the onset date as 12/19/21. Residents Affected - Few During a review of Resident 33's Discharge summary, dated [DATE], the record indicated Resident 33 visited an [Emergency Department] for further evaluation of fevers, nausea, abdominal pain and diarrhea. Resident 33 was found to have C Diff Positive. Illness from Clostridioides difficile typically occurs after use of antibiotic medications. It most commonly affects older adults in hospitals or in long-term care facilities. The most common signs and symptoms of mild to moderate C. difficile infection are watery diarrhea three or more times a day for more than one day and mild abdominal cramping and tenderness. Signs and symptoms of severe infection include: Watery diarrhea as often as 10 to 15 times a day abdominal cramping and pain which may be severe, fever and nausea. This information is from the CDC webpage: CDC Healthcare-associated Infections (HAI) Diseases and Organisms. The facilities policy Surveillance for Infections, dated 2/2022, instructed the IP or DON will conduct ongoing surveillance for Healthcare-Associated Infections and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precaution . Infections that should be included were pneumonia, urinary tract infections and Clostridioides difficile. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 17 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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** 2. During a review of Resident 33's Discharge summary, dated [DATE], this document indicated Resident 33 was admitted to a hospital from [DATE] to 11/21/21, for epididymitis/orchitis (inflammation and infection of the scrotum and testicles). Resident 33 was started on antibiotics in the hospital and continued taking them at the skilled nursing facility until the end date of 12/1/21. Residents Affected - Some During a review of Resident 33's Bowel Elimination task report for 12/2021 documented Resident 33 was having large loose/diarrhea stools. On 12/1/21 and 12/3/21 Resident 33 had 1 normal and 1 large loose stool. On 12/4/21 Resident 33 had 2 large loose stools. On 12/8/21 Resident 33 had 1 large loose stool. On 12/9/21 Resident 33 had 1 normal stool and 1 large loose stool. On 12/10/21 Resident 33 had 2 large loose stools and 1 large putty like stool. On 12/11/21 Resident 33 had 1 normal stool and 2 loose stools. On 12/12/21 Resident 33 had 2 large loose stools. During a review of Resident 33's Medication Administration Record for 12/2021, this revealed that Resident 33 had been on 2 antibiotics for cellulitis that was started 11/22/21. The last dose was for 12/1/21 and this was documented as given. Resident 33 was on Senna ( a laxative to prevent constipation,) 1 tablet to be given twice a day (morning and evening,) and to be held if resident had loose stools. Resident 33's MAR shows that this medication was given everyday as ordered, that is for 12/1/21 to 12/10/21. The Senna was not given on 12/11/21. On 12/12/13 the morning dose was given, and the evening dose was not given. Resident 33 was also on MiraLAX (a laxative used to treat occasional constipation) ordered to be given once a day and held if resident had diarrhea. This medication was given to Resident 33 on 12/1/21 to 12/10/2 and not given 12/11/21, then given 12/12/21 and 12/13/21 in the morning. During a review of Resident 33's Progress Notes, on 12/10/21 at 1:15 p.m., Staff L documented Resident 33 had a bout of diarrhea before lunch, and staff would continue to monitor. During a review of Resident 33's Progress Notes, on 12/12/21 at 7:53 p.m., Staff M documented that the physician was notified that Resident 33 had a change of condition, related to a fever of 101.3 degrees Fahrenheit. the physician recommended to obtain urine and blood work done if the fever recurred. During a review of Resident 33's Progress Notes, on 12/13/21 at 2:30 p.m., Staff N documented that on the way to a physician's appointment Resident 33 vomited. The physician advised the transport team to send Resident 33 to the Emergency Department. During an interview on 3/11/21 at 10:30 a.m., DON stated that it was known that Resident 33 had some diarrhea, and they held his laxatives. DON stated Resident 33 normally had one large normal stool every day. DON stated that the bout of diarrhea that she knew of did not appear to be a stool that would have been infected with Clostridioides difficile. DON stated they did not investigate further, did not start an infection surveillance check list, and did not notify the physician. During an interview and concurrent record review on 3/11/21 at 10:30 a.m., DON stated facility staff had documented Resident 33's infection on the Infection Prevention and Control Surveillance Log for 12/2021. Review of the Infection Prevention and Control Surveillance Log indicated the facility documented on 12/19/21 that Resident 33 had C. Diff. due to antibiotic use. The Log indicated the onset date as 12/19/21. The Log indicated no record of infection surveillance of Resident 33 during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 18 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 - Some first two weeks of December 2021, the time when the resident had loose bowel movements and immediately after the resident completing concurrent courses of antibiotics. During a review of Resident 33's Discharge summary dated [DATE] indicated Resident 33 presents back to the ED for further evaluation of fevers, nausea, abdominal pain and diarrhea. Resident 33 was found to have C Diff Positive which is Clostridioides difficile. Illness from Clostridioides difficile typically occurs after one's use of antibiotic medications. The germ most commonly affects older adults in hospitals or in long-term care facilities. The most common signs and symptoms of mild-to-moderate C. difficile infection are watery diarrhea three or more times a day for more than one day, and mild abdominal cramping and tenderness. Signs and symptoms of severe infection include: Watery diarrhea as often as 10 to 15 times a day abdominal cramping and pain which may be severe, fever and nausea. This information is from the CDC webpage: CDC Healthcare-associated Infections (HAI) Diseases and Organisms. The facilities policy Surveillance for Infections, dated 2/2022, instructed the IP or DON will conduct ongoing surveillance for Healthcare-Associated Infections and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precaution . Infections that should be included were pneumonia, urinary tract infections and Clostridioides difficile. 1) During an observation on 03/09/22 10:00 a.m., in Resident 14's room, the IP prepared sterile liquid to wash and clean the wound/pressure ulcer in right hip and applied wound gel then covered the wound with sterile bandage. IP removed the dirty gloves and placed them inside the dirty plastic bag and sealed the bag with her bare hands. IP handed the dirty plastic bag to Certified Nursing Assistant to put in garbage. IP opened the resident's bathroom door using her bare hands, but the bathroom was occupied by a resident. IP then opened the other exit door with her bare hands. During an interview on 3/9/22 at 10:15 a.m., with IP stated the hand sanitizers were located outside resident's rooms in the hallway. During an interview on 03/10/22 09:27 a.m., with IP stated, Resident 14 was colonized (MRSA was present but not causing illness) with MRSA. IP stated Resident 14's condition only required standard precautions (e.g., universal precautions used fo avoiding contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields). IP stated she did not clean the doorknobs after she touched it with her dirty hands. IP stated the Primary Medical Doctor (PMD) did not order isolation precaution for Resident 14. During an interview on 3/10/22 at 9:29 a.m., the Director of Nursing (DON) stated IP's dirty hands touched dirty doorknobs, what's the difference, both were dirty? During an interview on 03/10/22, at 10:13 a.m., the Director of Staff Development (DSD) stated staff must use contact precaution when faced with the potential exposure of body fluids, to prevent the spread of an infection to other resident, staff, and visitors. The DSD stated, all surfaces needed to be clean and disinfect with bleach. During a telephone interview on 03/11/22, at 09:44 a.m., the Primary Medical Doctor (PMD) for Resident 14 stated the resident's wound was colonized with MRSA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 19 of 20 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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 - Some A review of medical records for Resident 14 titled Nursing Care plan dated 1/13/22, indicated the wound was reinfected with green purulent drainage. A review of the facility Policy & Procedure (P&P) titled Handwashing/Hand hygiene dated 1/2019 revealed, The facility considers hand hygiene the primary means to prevent the spread of infections., #2 All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #3 Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. #7j After handling used bandages, contaminated equipment, etc. #7 m. after removing gloves. #8 Hand hygiene is the final step after removing and disposing of personal protective equipment. A review of facility (P&P) titled Isolation-categories of Transmission-based Precautions dated 12/2020, indicated: It is the intent of this facility that all resident blood body fluids, excretions and secretions other than sweat will be considered potentially infectious so standard precautions will be used for all residents. Contact Precautions 1) Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms (germs) that can be transmitted by direct contact with the resident. 4) Staff . will wear gloves (clean, non-sterile) when entering the room. When caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed, and hand hygiene performed before leaving the room. Based on observation, interview and record review, the facility failed to follow the Infection Control Policy for 2 of 17 residents (Residents 14 and 33) when: 1. The Infection Preventionist (IP) did not perform hand hygiene between concluding a wound care and treatment for one resident (Resident 14) and touching doorknobs inside the resident's room. In 7/2021, Resident 14's wound became colonized with an infection caused Methicillin-resistant Staphylococcus aureus (MRSA, a strain of bacteria resistant to certain antibiotics and spread by contact with infected people, surfaces, or things that carry the bacteria); 2. Resident 33 exhibited potential symptoms of C. Diff. (a healthcare-associated infection causing loose stools) but the facility delayed implementation of its infection surveillance policy. These failures delayed monitoring and treatment for Resident 33's infection, and had the potential to spread MRSA and C. Diff infections among residents in the facility. Findings: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 20 of 20