Health inspection·April 4, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/24/25 at 4:40 p.m., [NAME] K stated she made the chicken and tuna salad at 1:30 p.m. During an observation on 3/24/25 starting at 4:50 p.m., the kitchen thermometer near the kitchen entrance read 90 F. At 4:55 p.m. the pureed tuna salad's internal temperature was 51 F. Residents Affected - Many During an observation on 3/24/25 at 5 p.m., the RD L was helping [NAME] K try to get the internal temperatures of the tuna and chicken salad sandwiches to cool down to 41 degrees or below. RD L moved all the sandwiches to cookie sheets, placed the sandwiches in a single layer, then put the cookie sheets in the freezer. By 5:13 p.m. the internal temperature of the chicken salad sandwiches read 49 F and by 5:15 p.m., the tuna salad sandwiches internal temperature read 54 F. RD L continued to try to get the tuna and chicken salad sandwiches to cool down to 41 F. At 5:30 p.m. the internal temperature of the tuna salad was 54 F, chicken salad sandwiches 49 F, and the pureed chicken salad sandwiches 46 F. The facility P/P titled, Cooling and Reheating of Potentially Hazardous or Time/ Temperature Control for Safety Food: Policy: Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety . Ambient Temperature Food: PHF or TCS food shall be cooled within 4 hours to 41 degrees Fahrenheit or less, if prepared from ingredients at ambient temperature, such as reconstituted food and canned tuna. Use the Cool Down Log/or Ambient Temperature Food . 2. During a tour of the facility's commissary kitchen, on 3/22/25 at 5:45 a.m., with the Dietary Manager (DM), [NAME] K was preparing food but was not wearing an apron. The DM stated cooks were supposed to wear an apron. During an observation on 3/23/25 at 9:49 a.m., Dietary Aide Q was not wearing an apron when washing the dishes. The DM stated there were disposable aprons, which the dietary aide should wear and change if they are going from washing dishes to handling and/or preparing food. During an interview on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated cooks should wear a black cloth apron while prepping food and cooking and the dishwasher should wear a plastic apron to prevent cross contamination of the residents' food. 3. During a tour of the facility's commissary kitchen, on 3/22/25 at 5:45 a.m., noted the absence of a touch free garbage can next to the handwashing sink. There was only a garbage can with a lid for the food prep area. This led to dietary staff having to lift the garbage can lid with their clean hands leading to the dietary staff's hands becoming contaminated. The facility's Policy and Procedure (P/P) titled, Sanitation, dated 2023, indicated, Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food . All Food & Nutrition Services staff shall know the proper hand washing technique .The hand washing sink shall have .appropriate receptacles for wastepaper . 4. During an observation on 3/22/25 at 7:03 a.m., the van driver arrived at the commissary kitchen to load the serving containers with the residents' breakfast into the van. [NAME] K was about to hand off the containers to the driver when [NAME] K had to be reminded to take the internal temperatures of the prepared hot food items and log the temps. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 2 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility P/P titled, Meal Service, dated 2023, indicated: POLICY: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer that has been cleaned and sanitized . 5. The standard of practice requires that Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow (USDA Food Code 4-901.11). During an observation on 3/22/25 at 9:30 a.m., [NAME] M was stacking wet pots and pans, not allowing for the pots and pans to air-dry (lets the dishes dry naturally on a rack or dish drying mat, without touching one another). During an interview on 4/3/25 at 2 p.m., the DM stated it was important to air dry to prevent bacteria (germs) from growing. The facility's P/P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated, POLICY: . dishwashing procedures Set up area for air drying . All items are air-dried, which means no water droplets are present 6. During an observation on 3/22/25 at 9:30 a.m., Dietary Aide Q was washing dirty pots and pans in the three-compartment sink (a manual ware washing system used in commercial kitchens, consisting of three separate compartments for washing, rinsing, and sanitizing dishes and utensils). Surveyor needed to remind Dietary Aide Q pots and pans needed to be fully submerged in the sanitizer solution for 30 seconds per the bleach container directions to be affective in killing bacteria. The facility P/P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated: POLICY: . manual dishwashing procedures . Step One: Clean and sanitize all work surfaces. Set up area for air drying. Step Two: Rinse, scrape, or soak all items before washing . Step Three: The first compartment is for washing. Step Four: The second compartment is for rinsing.Step Five: The third compartment is for sanitizing. Fill the third compartment with clean, clear water to the fill line L_ gallons .Then add .sanitizer. Immerse all washed items for ____ (note time). 7. During an observation on 3/24/25 at 4:20 p.m., the thermometer on the commissary kitchen wall read 88 F. During an observation on 3/24/25 starting at 4:50 p.m., the kitchen thermometer near the kitchen entrance read 90 F and bin containing bread was stored in the area. During a record review of facility logs titled, Cold Storage Temperature Logs and Storage Room (general commissary kitchen) Temperature Log on 3/25/25 at 3:07 p.m., both logs were not filled out for the 3/25/25 AM shift nor for the PM shift. During an observation on 3/25/25 at 3:40 p.m., the commissary kitchen thermometer read 86 F. During an interview on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated The DM stated the Cold Storage Temperature Logs for the walk-in refrigerator and freezer and the Storage Room (general commissary kitchen) Log should be recorded on during the AM and PM shifts. The DM stated you want to make sure food is being stored at safe temperatures to prevent spoilage of food, which could cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 3 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many foodborne illnesses. The DM stated storage of pantry food items at a high room temperature could spoil the food items and bread could become moldy. The kitchen should be at a safe cool temperature for the can goods, baking items and for staff. The facility P/P titled, Storage of Food and Supplies, dated 2023, indicated, Policy: Food and supplies will be stored properly and in a safe manner. The storeroom should be . well-ventilated, cool . Thermometers should be placed in all storage areas and checked frequently . Recommended temperature is 50° F -85° F if dry food storage goes over 85°F take corrective action (see Corrective Action policy, page 6. 7) . 8. The standard of practice would be to ensure sanitation methods that ensure food debris on equipment and utensils are scraped over a waste disposal unit or garbage receptacle or shall be removed in a warewashing machine with a prewash cycle (USDA Food Code, 2022). During an observation and interview on 3/25/25 at 3:40 p.m., with RD L, Dietary Aide R was rinsing off a dirty pan in the food production sink. RD L directed Dietary Aide R to stop and scrap the food debris from the dirty pots and pans into the garbage can and then use the three-compartment sink to wash, rinse and sanitize the pots and pans. RD L stated the food production sink was used for food preparation and was considered a clean area not appropriate for dirty dishes. The facility Policy and Procedure (P/P) titled, Sanitation, dated 2023, indicated, Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for . disposal of waste . kitchen wases which are not disposed of by garbage disposal units shall be kept in leak-proof, non-absorbent and tightly closed containers .If an employee does need to go from soiled end to clean end, a strict hand washing routine must be followed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 4 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility's administration (the person/s responsible for the overall operation and management of a skilled nursing facility, ensuring the facility meets regulations and provides quality care for residents) failed to use their resources effectively and efficiently, when corrective actions were not completed following the issuance of the County's Department of Health Services (CDHS) Site Review Inspection Report in October 2024. Residents Affected - Many This failure resulted in the interruption of food services for 57 out of 59 residents who received food from the facility's kitchen when CDHS suspended the facility's Retail Food Permit which required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and to remain in effect until the facility can meet CDHS requirements (cross reference with F908). Findings: During a concurrent interview and record review on 3/18/25 at 4:34 p.m., with Administrative Staff B (ADM B), Site Review Inspection Report, dated 10/28/24, was reviewed. ADM B confirmed she received the report which indicated the grease trap was in disrepair and the facility's kitchen was not in compliance with the California Retail Food Code (Calcode- outlines structural, equipment, and operational requirements for all retail food facilities in California, ensuring food safety and sanitation, and is enforced by local environmental health agencies and the California Department of Public Health). Administrative Staff B stated County Health Inspector C had visited the facility in the morning of 3/18/25 when wastewater was overflowing on to the kitchen floor from the grease trap and suspended the facility's retail Food Permit and closed down the facility's kitchen were they prepared resident foods. ADM B stated the facility's previous Administrator had resigned a couple of weeks prior to the 3/18/25 site visit and ADM B was taking over until a new administrator was hired. ADM B stated when taking over for the Administrator, there was no communication related to the County Site Review Inspection Report from 10/28/24 and the grease trap had not been repaired. During an interview on 4/2/25 at 5:10 p.m., Administrative Staff J (ADM J) stated she did the handoff (process where the responsibility for a specific task transfers from one person to another) between the Administrator who left and ADM B who took over. ADM J stated the previous Administrator did not address the Site Review Inspection Report, received by the facility on10/28/24, detailing the items needing to be addressed in the kitchen. ADM J stated it was the responsibility of the Administrator to follow through with addressing the kitchen repairs needed in order to comply with current Calcode requirements. During a phone review on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated herself as well as the previous Administrator and the Maintenance Manager had received the Site Review Inspection Report on 10/28/24 via email. The DM stated during the facility's Stand-up meeting (morning meeting that includes all department heads) she brought up several kitchen issues, including the grease trap disrepair, that needed to be addressed per the Site Review Inspection Report. The DM stated despite bringing it up, and the Administrator acknowledging the kitchen repairs needed to be addressed, the Administrator did not follow up with the County's kitchen repair requirements. A review of the facility job description titled, Administrator, revised 10/16/15, indicated: Position Summary: The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated [promoted or make widely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 5 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0835 Level of Harm - Minimal harm or potential for actual harm known] by government agencies to ensure proper health care services to residents . Superintends [be responsible for the management or arrangement] physical operations of the Center . implements corrective action and budgetary constraints as required . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 6 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program, when the facility's QAPI program did not address code compliance corrective actions, related to the physical environment of dietetic services, issued to the facility by the County Department of Health Services (CDHS) on 10/28/24. Residents Affected - Many This failure resulted in the interruption of food services for 57 out of 59 residents who received food from the facility's kitchen when CDHS suspended the facility's Retail Food Permit and required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and to remain in effect until the facility can meet CDHS requirements (cross reference with F908). Findings: During a concurrent interview and record review on 3/18/25 at 4:34 p.m., with Administrative Staff B (ADM B), Site Review Inspection Report, dated 10/28/24, was reviewed. ADM B confirmed she received the report which indicated the grease trap (a plumbing device intended to capture fats, oils and grease from wastewater) was in disrepair and the facility's kitchen was not in compliance with the California Retail Food Code (Calcode- outlines structural, equipment, and operational requirements for all retail food facilities in California, ensuring food safety and sanitation, and is enforced by local environmental health agencies and the California Department of Public Health). Administrative Staff B stated an inspector from CDHS had visited the facility on the morning of 3/18/25, when wastewater (includes substances such as food scraps, oils, soaps and chemicals) was overflowing on to the kitchen floor from the grease trap. The ADM B confirmed the CDHS inspector subsequently suspended the facility's retail Food Permit and closed the facility's kitchen, where they prepared resident foods, until repairs could be completed. ADM B stated the facility's previous Administrator had resigned a couple of weeks prior to the 3/18/25 site visit and ADM B was taking over until a new administrator was hired. ADM B stated when taking over for the previous Administrator, there was no communication related to the County Site Review Inspection Report from 10/28/24 and the grease trap had not been repaired. During a phone review on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated herself as well as the previous Administrator and the Maintenance Manager had received the Site Review Inspection Report on 10/28/24 via email. The DM stated the previous Administrator had a monthly QAPI meeting but never brought up the CDHS's County Site Review Inspection Report or kitchen repairs needing to be addressed. The DM stated the previous Administrator just ignored the CDHS report and requests for the various kitchen items to be repaired. During an interview on 4/3/25 at 5:40 p.m., Administrative Staff J stated she reviewed the QAPI program documentation and could not find any documentation indicating administration had ever addressed the CDHS inspection report, which was received on 10/28/24, detailing kitchen repairs that needed to be completed to follow Calcode requirements. A review of the facility's policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, released 1/2018, indicated, Policy: The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. 1.The administrator, whether a member of the QAPI committee or not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 2. The governing body is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 7 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete responsible for ensuring that the QAPI program: a. is implemented and maintained to address identified priorities; b. is sustained through transitions of leadership and staffing . focuses on problems and opportunities that reflect processes, functions and services provided to the residents . help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care . coordinates the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals . Special meetings may be called by the administrator as needed to present issues that need to be addressed before the next regularly scheduled meeting . Event ID: Facility ID: 056259 If continuation sheet Page 8 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 57 out of 59 residents who received food from the facility's kitchen, when:1. a grease trap (a plumbing device, type of drain, intended to capture fats, oils and grease from wastewater), located in the dishwashing area under the two-compartment sink, was not maintained in good repair and caused wastewater (includes substances such as food scraps, oils, soaps and chemicals) to back-up on to the kitchen floor. This occurred while a County Department of Health Services (CDHS) Inspector was present on 3/18/25.2. did not ensure that the facility identified and resolved the source of the wastewater backup into the kitchen, despite evidence that staff were aware of wastewater coming up from the grease trap and drain under the grease trap prior to the survey. And,3. did not implement code compliance corrective actions, related to the kitchen (the physical environment of dietetic services) and including the grease trap in disrepair, issued to the facility by the CDHS on 10/28/24.These failures resulted in the County suspending the facility's retail food permit which required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and remains in effect until the facility can meet CDHS requirements. The facility's kitchen closing resulted in the interruption of dietetic services and facility having to find a commissary kitchen (a rentable commercial kitchen), to prepare food for the residents.On 3/19/25 at 12:47 p.m., Administrative Staff A and Administrative Staff B were verbally notified of the Immediate Jeopardy (IJis a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) of the facility's failure to maintain the grease trap in the dishwashing area causing wastewater back-up on to the kitchen floor while County Health Inspector C was present, and leading to suspension of the facility's Food Permit. The Health Facilities Evaluator Nurse (HFEN also referred to as Surveyor) informed Administrative Staff A and Administrative Staff B of the Surveyor's findings that the facility's food permit would remain suspended until: the grease trap and plumbing issues were addressed, and dietetic services was brought into compliance based on results of the CDHS routine inspection which occurred on 10/22/24 and summarized in County Site Review Inspection report dated 10/28/24. Suspension of the facility's Food Permit resulted in the inability of the facility to meet the nutritional needs of 57 residents from the onsite kitchen.On 3/21/24 at 2:35 p.m., the facility presented an approved Action Plan (an IJ removal plan documents the immediate action a facility will take to prevent serious harm from occurring or recurring), which included but not limited to: 1) Food for residents to be prepared by the dietary staff at a commissary kitchen, 2) Residents' prepared food to be transported to the facility via a rental van in insulated food containers designed to maintain food temperatures during food transport, 3) Conversion of the facility staff breakroom into the temporary dietetic service space (area where the food from the commissary kitchen would be transferred to and residents meal trays arranged per the resident's diet card, and 4) Facility will contact HCAI (Department of Healthcare Access and Information: insures healthcare institutions are safe) to work out the details of moving the grease trap and arrangements will be made for HCAI, the city and county to meet at the facility to assess and guide for further actions.Findings:During a phone interview on 3/18/25 at 1:04 p.m. County Health Inspector C, who was still at the facility, stated she was completing a routine inspection to see if the facility had completed the required kitchen repairs, including the grease trap, as advised from a notification on 10/28/24. County Health Inspector C stated she noticed water on the floor under the two compartment-sink (used for soaking and rinsing dirty dishware) where the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 9 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many grease trap was located. County Health Inspector C stated she heard the Dietary Manager tell the dietary aide running the dishwasher not to run the dishwasher at the same time as draining the two-compartment sink. County Health Inspector C stated wastewater was coming up from the grease trap and flooding the kitchen floor. County Health Inspector C stated because there was a wastewater back-up, the County was suspending the facility from preparing food or using the kitchen equipment. County Health Inspector C stated the facility had a plumber come out to the facility but the plumbers could not do a hydro jet procedure (uses high pressure-water to clear clogs and debris from pipes) because there was too much water in the grease trap. The facility also called the company who serviced the grease trap to remove the wastewater from the clogged grease trap so the plumbing company could attempt to unclog the grease trap. Once the wastewater was removed the plumbing company was to come back to the facility to try and unplug the grease trap. County Health Inspector C stated the Santa [NAME] City Department of Environmental Compliance came out to the facility to inspect the grease trap on 3/18/25 and indicated the facility was in violation because of lack of maintenance of the grease trap. Santa [NAME] City Department of Environmental Compliance had indicated the facility should have had the grease trap serviced every one to two weeks instead of monthly based on the amount of food served daily. In addition, the grease trap looked like it was an inadequate size for the number of meals being prepared. County Health Inspector C stated since the facility was under a new ownership, the facility had a Conditional Permit whereby they had a number of items in the kitchen to fix, including the grease trap, in order for the kitchen to be up to California Retail Food Code (Calcode- outlines structural, equipment, and operational requirements for all retail food facilities in California, ensuring food safety and sanitation, and is enforced by local environmental health agencies and the California Department of Public Health), which the facility failed to do.During a concurrent interview and record review on 3/18/25 at 4:34 p.m., with Administrative Staff B (ADM B), Site Review Inspection Report, dated 10/28/24, was reviewed. ADM B confirmed she received the report which indicated the grease trap was in disrepair and the facility's kitchen was not in compliance with the Calcode. Administrative Staff B stated County Health Inspector C had visited the facility in the morning of 3/18/25 when water was overflowing on to the kitchen floor from the grease trap and suspended the facility's retail Food Permit and closed the facility's kitchen where they prepared resident foods. ADM B stated the facility's previous Administrator had resigned a couple of weeks prior to the 3/18/25 site visit and ADM B was taking over until a new administrator was hired. ADM B stated when taking over for the Administrator, there was no communication related to the County Site Review Inspection Report from 10/28/24 and the grease trap had not been repaired.During an interview on 3/18/25 at 3:53 p.m., in the facility's kitchen, the Dietary Manager (DM) stated there had been an issue with the grease trap and plumbing causing wastewater to flow on to the kitchen floor. The DM stated it was a big problem causing the kitchen to be closed completely by CDHS until resolved.During a concurrent observation and interview on 3/18/25 at 4:05 p.m., the plumbing company was at the facility. Three plumbers were working on grease trap and were about to try to hydro jet the grease trap. Administrative Staff B confirmed the kitchen would remain closed since CDHS would not let the kitchen operate while there was a plugged grease trap. Administrative Staff B stated the County had approved for the facility to use the Emergency food for dinner 3/18/25 and for 3/19/25 breakfast but the facility needed to have an alternative meal preparation by lunch time.During an interview on 3/18/25 at 4:10 p.m., with Unlicensed Staff E translating Spanish to English, Dietary Aide D stated she had noticed water coming up from the grease trap for the last two months when the dishwasher is running and when she drains the two-compartment sink at the same time. Dietary Aide D stated a lot of wastewater can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 10 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many come up from the grease trap when the dishwasher was running. Dietary Aide D stated she had been directed by the DM to not drain the two-compartment sink while the dishwasher was running. Dietary Aide D stated the kitchen staff was serving the Emergency Food on paper plates, with plastic utensils and disposable cups, and no coffee was being severed.During a concurrent observation and interview on 3/18/25 at 4:35 p.m., three plumbers were working on the grease trap. Plumber F stated the issue with the grease trap had been building up for years whereby the bottom of the grease trap had decayed (deteriorated over time, often due to corrosion, rust, or other forms of damage, making it unsafe or ineffective). Plumber F stated when they used the drain snake (a flexible, slender tool used to dislodge and remove clogs from drains and pipes), they were hitting dirt. Plumber F stated if they tried to hydro jet the clog, they would just be blowing dirt. The drain snake was being fed to clear a blockage but all they heard was a grinding noise, which meant they were hitting rock, clay and mud. Plumber F stated when he pulled the drain snake back rock, clay and dirt was on the drain snake which meant the exit line for the grease trap had disintegrated.During a concurrent observation and phone interview on 3/18/25 at 5:20 p.m., the County Director was on the phone with Administrative Staff B. The County Director explained to Administrative Staff B she would not let the kitchen operate with a sewage back-up and wanted to know how the facility planned to provide meals to the residents while the kitchen was closed. Administrative Staff B did not explain the facility's meal plan. Surveyor joined the phone call and explained the facility was using their emergency food supply, utilizing canned and non-perishable foods, based on the facility Emergency Menu for dinner on 3/18/25 and breakfast 3/19/25 but the facility would still need to arrange for meals to be catered until the facility could find another place to prepare the residents meals. The County Director was agreeable with the plan for the time being.During an interview on 3/19/25 at 8:06 a.m., County Health Inspector G was standing by the nurse's station, which was located to the right of the entrance to the kitchen. County Health Inspector G stated he was given the facility document titled, Emergency Disaster Procedure Surveyor explained to County Health Inspector G, Administrative Staff B was fully aware per her conversation with the County Director last evening, the facility had to have a meal plan in place by 3/19/25 12:30 p.m The plan needed to identify how the facility was going to provide the residents their physician ordered diets. County Health Inspector G stated because of the amount of repair work required, the kitchen would remain closed for all activities.During an interview on 3/19/25 at 8:30 a.m., the Maintenance Manager stated he would have to unplug the grease trap two to three times a year using a drain snake. The last time he unplugged the grease trap was in January 2025.During an interview on 3/19/25 at 8:55 a.m., Administrative Staff A stated County Health Inspector C had approved a commissary kitchen. The facility still had not submitted a meal plan for the resident's lunch, which was expected to be served at 12:30 p.m. Administrative Staff A stated the previous Administrator did receive the County Site Review Inspection report from the CDHS dated 10/28/24, which addressed multiple kitchen repairs, including the grease trap, that needed to take place, and the kitchen was operating under a conditional status until plans were submitted.During an interview on 3/19/25 at 2 p.m., Administrative Staff A stated Administrative Staff B had not relayed to her that the CDHS and the California Department of Public Health (The Department) expected the facility to have an alternate meal plan for the residents starting by 3/19/2 at 12:30 p.m Administrative Staff A stated Administrative Staff B had not relayed to her the conversation that took place with Administrative Staff B and the County Director last evening whereby the County Director wanted an alternate meal plan to put into place by lunchtime.During a concurrent record and review and interview on 3/19/25 at 2:16 p.m., the facility's Action Plan number one to remove the IJ was reviewed. The Department's Surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 11 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many and Nutrition Consultant explained to Administrator Staff A the Action Plan could not be approved since the facility could not show a safe plan for delivery of the required food and nutrition services in the absence of a kitchen and equipment for dietetic services.During a concurrent record review and interview on 3/20/25 at 9:10 a.m., the facility's Action Plan number two was reviewed with Administrative Staff A and explained the Action Plan could not be approved since the facility could not show a safe plan for delivery of the required food and nutrition services in the absence of a kitchen and equipment for dietetic services.During a concurrent record review and interview on 3/20/25 at 4:30 p, m., the facility's Action Plan number three was reviewed with Administrative Staff A and explained why the Action Plan could not be approved. While the facility reached a verbal agreement with the owner of the commissary, the rental agreement was not signed by the owner. The contract also indicated there was no garbage removal at the commissary kitchen. The Plan of Action number three did not include evidence of garbage removal at the commissary kitchen, proof of when a dumpster would be delivered at the commissary kitchen, how often garbage service would occur, and how was the garbage going to be discarded over the weekend since the garbage dumpster was not going to arrive at the commissary kitchen until Monday, 3/24/25.During an interview on 3/21/25 at 10:25 a.m., Administrative Staff A stated she had found out the garbage company could not deliver the garbage dumpster to the commissary kitchen site until Monday, 3/24/25. Administrative Staff A stated she would have the commissary kitchen contract updated reflecting the owner of the commissary kitchen would remove the trash Saturday, 3/22/25 and 3/23/25.On 3/21/25 at 2:35 p.m., Administrator Staff A was notified Action Plan number three was accepted. The action plan indicated the facility secured a contract with an offsite kitchen that would be utilized for food production, in accordance with physician ordered diets, in a safe, effective and timely manner.During the initial tour of the commissary kitchen on 3/22/25 from 5:45 a.m. to 7:03 a.m., the following was observed: 1. Handwashing sink faucet was loose and hot water knob difficult to turn off, 2. Paper towel dispenser next to the handwashing sink was broken, 3. Two-compartment sink faucet leaking, and 4. wall soap dispenser not working.A review of County Health Inspector G's Permanent Food Inspection Report, dated 3/22/25, indicated an inspection of the commissary kitchen took place during the preparation of the residents' lunch on 3/22/25. County Health Inspector G observed the following: The handwash sink had water leaking onto the floor from the waste pipe, the paper towel dispenser was not working, the food preparation sink had cold and warm water, but was leaking at the base of the faucet, and the ware washing sink (sink used to wash dishware, cookware, glassware, and other items) lacked the right drainboard to properly airdry the dishes.A review of County Health Inspector G's Permanent Food Inspection Report, dated 3/23/25, indicated an inspection of the commissary kitchen occurred during the preparation of the residents' breakfast on 3/23/25. County Health Inspector G observed the paper towel dispenser was still broken.During an observation on 3/24/25 at 3:25 p.m., the room temperature of the commissary kitchen was 84 degrees Fahrenheit. It was also noted the front door to the kitchen was open to help with air circulation, however there was no screen door. The paper towel holder next to the handwashing sink was still broken.During a concurrent observation and review of the Storage Room Temperature Log on 3/24/25 at 4:20 p.m., the temperature of the commissary kitchen had reached 88 degrees Fahrenheit. The Storage Room Temperature Log indicated the Storage Room Temperature should range between 50 -85 degrees Fahrenheit.During a observation on 3/24/25 at 4:50 p.m., the thermometer on the wall right of the front door read 90 degrees Fahrenheit.As of 3/24/25 at 5:40 p.m., the time the surveyor left the facility, the facility was unable to demonstrate minimum compliance with regulatory requirements for food production activities as evidenced by the inability to ensure the daily nutritional needs in a safe and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 12 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete effective manner for 57 residents in a facility census of 59.During a concurrent observation and interview on 3/25/25 at 3:07 p.m., the DM was mopping the commissary kitchen floor. The DM stated the Dietary Aide had unplugged the three-compartment sink (used to wash, rinse, and sanitize dishes) drains all at the once. The floor drain located underneath the sink could not withstand the amount of water draining from the three sinks all at once causing the wastewater to backup on to the kitchen floor. The entire kitchen floor was wet including the food prep area and the cooking area. [NAME] M stated when the three- compartment sink drains were unplugged simultaneous, the drain underneath the sinks could not withstand the amount of water draining causing the water to flood the entire kitchen floor. Maintenance N was working on the three compartment sink pipes and drain to see if there was a clog.During an observation on 3/25/25 at 4:35 p.m., Maintenance N was still working on the three-compartment sink drain system. Maintenance N was using a drain snake to clear a blockage of the drainpipe.The facility P/P titled, Storage of Food and Supplies, dated 2023, indicated: Policy: Food and supplies will be stored properly and in a safe manner. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50 F -85 F- if dry food storage goes over 85 F take corrective action (see Corrective Action policy, page 6. 7) . The Facility P/P titled, Sanitation, dated 2023, indicated: Policy: The Food and Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working repair . 6. Employees are to alert the FNS Director immediately to any equipment needing repair. 7. The FNS [Food and Nutrition Services] Director (and/or cook in their absence) will report any equipment needing repair to the maintenance man. 8. The Maintenance Department will assist Food & Nutrition Services as necessary in maintaining equipment and in doing janitorial duties which the Food & Nutrition Services employees cannot do and maintain maintenance records on all equipment . 15. The Food & Nutrition Services Department shall be ventilated in such a manner as to prevent excessive condensation, to maintain comfortable working conditions, and to remove objectionable odors and fumes . The hand washing sink shall have running hot and cold water, soap, paper toweling, and appropriate receptacles for wastepaper . The facility P/P titled, General Cleaning of Food and Nutrition Services Department, dated 2023, indicated: . Drain: Floor drains must be scheduled for routine cleaning in order to be maintained in a functional condition. 1. FNS staff should remove large debris as it accumulates and are encouraged to clean drains weekly. 2. The Maintenance Department will assist with more thorough cleanings to ensure the viability of the plumbing features . The facility P/P titled, Shelves, Counter, and Oher Surfaces Including Sinks Surfaces Including Sinks (Handwashing, Food Preparation, etc.), dated 2023, included: Note that for sink drains, Food and Nutrition Services staff are encouraged to remove large debris as it accumulates and to clean drains weekly. The Maintenance Department will assist with more thorough cleanings to ensure the viability of the plumbing features . Event ID: Facility ID: 056259 If continuation sheet Page 13 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure an effective pest control program when: Residents Affected - Many 1) Evidence of a rodent infestation was at the offsite commissary (a rentable commercial kitchen) and 2) A fly infestation was present in the designated dietetic service space (formerly the facility breakroom). These failures had the potential to cause foodborne illness (any illness resulting from eating contaminated/spoiled foods) for 57 of 59 residents who received food from the facility ' s kitchen. Findings: 1) During an interview at the facility on 3/28/25 at 3:37 p.m., the Dietary Manager stated all resident food was being prepared in their commissary kitchen due to remodeling of their onsite kitchen. During an interview on 3/28/25 at 4:05 p.m., [NAME] M stated she was working earlier in the day when a County Health Inspector (Inspector C) visited the commissary kitchen. [NAME] M stated Inspector C found bags of stuffing mix that had been chewed and subsequently discarded the bags. [NAME] M stated Inspector C found rat poop behind the stove and a hole in the ceiling. During a tour of the commissary kitchen and concurrent interview on 3/28/25 at 4:13 p.m., [NAME] M indicated the ceiling above a red refrigerator contained a hole. [NAME] M stated Inspector C told her rats could be entering the kitchen through the opening. A photo was taken of the area. During an observation and concurrent interview on 3/28/25 at 4:15 p.m., a plastic grocery bag was located inside a plastic basket next to the red refrigerator. [NAME] M opened the bag and revealed multiple dirty-looking rodent traps; the traps appeared to have been previously used. Photos were taken of the traps. During an observation and concurrent interview on 3/28/25 at 4:16 p.m., [NAME] M pulled the red refrigerator away from the wall. The floor contained the following: sawdust-like material, dirt, and multiple brown/black droppings resembling rodent feces. [NAME] M stated the droppings were rat poop. Photos were taken of the area. During an observation and concurrent interview on 3/28/25 at 4:18 p.m., the area next to the red refrigerator was cluttered with furniture. Droppings that looked like rodent feces were located behind a black armchair. Photos were taken of the material behind the chair. During an observation and concurrent interview on 3/28/25 at 4:25 p.m., [NAME] M pulled the stove away from the wall. The floor contained dirt, food particles, and multiple droppings resembling rat feces. [NAME] M stated the droppings were definitely rat poop. Photos were taken of the area behind/under the stove. During a telephone interview on 3/28/25 at 4:29 p.m., County Health Inspector O (Inspector O) stated he would inspect the commissary kitchen the following morning at 5 a.m., before food preparation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 14 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0925 began. He stated a pest control company would be onsite that night. Level of Harm - Minimal harm or potential for actual harm Review of Company P's pest report, dated 3/28/2025, indicated, .rodent feces/activity was reported inside the kitchen . set 8 traps inside the kitchen . Residents Affected - Many Review of Inspector O's report titled, Permanent Food Facility Inspection Report (dated 3/29/25) indicated, .Specialist observed the following: Large quantity of rodent dropping (approximately >50) on top of walk-in refrigeration unit along with chewed up insulation and boxes which appeared to be used as nesting material for rodents . Review of Company P's pest report, dated 3/29/2025, indicated, . I began to move some boxes on top of the freezer, and immediately found rat nesting material. Rats had chewed through boxes and pulled insulation from the attic in our nesting on top of the freezer . workers are going to do cleaning of this area. They are going to remove the rest of the boxes and remove the insulation and feces . During a telephone interview on 4/1/2025 at 1:58 p.m., Administrative Staff J stated the facility began using the commissary kitchen on 3/22/25 and they discovered rats in that kitchen on Friday, 3/28/25. When asked if the owner of the offsite kitchen had a pest mitigation program, Administrative Staff J stated she was not sure; she stated she had not discussed that with the owner. 2) During a concurrent observation and interview on 3/21/25 at 10:50 a.m., County Health Inspector C stated there were multiple flies in the temporary dietetic service space (Staff Breakroom). Surveyor entered the temporary dietetic service space and observed several small flies on the ceiling light fixture, ceiling walls, and windowsill. There were multiple chocolate mints on the windowsill and one dead ant. County Health Inspector C directed the housekeeping and kitchen staff to pull everything out of thetemporary dietetic service space, close the door, kill and get rid of the flies, then wash and sanitize everything from top to bottom. The dietary staff was reminded they needed to follow the same infection control protocols in the temporary dietetic service space as they would in the facility kitchen. The door to the temporary dietetic service space needed to be kept closed, the windowsill should not be used to store food, there should be a garbage can with a lid, which there was not, and the tables and counters should be washed and sanitized routinely to prevent flies and other insects. A review of County Health Inspector C ' s Permanent Food Inspection Report, dated 3/21/25, indicated: Several flies were observed throughout the temporary dietetic service space. Staff were instructed to remove all single-use items, food, and equipment, and to alleviate flies in the affected area. Staff were encouraged to maintain entrance door leading into the temporary dietetic service space closed to prevent entrance of flies and other insects. The screen on the window of the temporary dietetic service space was observed to be damaged. During a concurrent observation and interview on 3/24/25 at 3:25 p.m., upon arrival to the commissary kitchen, it was noted the kitchen door was wide open and there was no screen door. Dietary Staff D stated the RD had opened the door because it had gotten extremely warm in the kitchen. Review of County Health Inspector O's report titled, Permanent Food Facility Inspection Report (dated 3/31/25) indicated, . Side door next found to be unlocked and wind kept blowing it open during inspection. Operator was unable to lock it and placed a table in front of it in the meantime to prevent it from staying ajar. Ensure door is able to remain closed to prevent entrance of vermin/flies into the facility . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 15 of 16 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 4/3/25 at 2 p.m., when the DM was asked if the commissary kitchen door should be left open, the DM stated the kitchen door should be kept closed to prevent flies and other insects from entering. The DM stated the door to the commissary kitchen and the temporary dietetic service space should be kept closed. The DM stated the dietary staff should not store their personal food in the commissary kitchen and the temporary dietetic service areas in order to prevent the infestation of flies and other insects. Review of facility policy and procedure (P/P) titled, Pest Control, subtitled, Process (dated 1/2018) indicated, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . The facility P/P titled, Sanitation, dated 2023, indicated: . 10. On a monthly basis, a pest control company will inspect and service the Food & Nutrition Services Department. If at any time additional servicing is needed, the pest control company will be notified . The facility P/P titled, Miscellaneous Areas, dated 2023, indicated: .Fly and Vermin Control: Flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food & Nutrition Services Department. Suggestions for Fly and Vermin Control: 1. All doors and windows must be properly screened. 2. Food must be properly covered and stored. 3 The Food & Nutrition Services Department must be kept free of soil and clutter. 4. Arrangements should be made by the Administrator for pest control service on a routine basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 16 of 16