Inspection·June 20, 2022

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to store medications appropriately when: Residents Affected - Some 1. Two of three medication carts were left unlocked and unattended; and 2. Residents 9's sevelamer (medication used to control high blood levels of phosphorus in people with chronic kidney disease) 800 milligrams (mg, a metric unit of mass) was left on the medication cart unattended. These failures had the potential to result in the access of medications by unauthorized personnel or residents. Findings: 1. During an observation on 6/14/22 at 2:09 p.m., licensed vocational nurse G (LVN G) was sitting inside the nurse station. Her medication cart was parked on the side of the nurse station, and it was unlocked. During and observation on 6/16/22 at 5:20 p.m., the director of staff development (DSD) was sitting inside the nurse station. Her medication cart was parked outside of the nurse station, and it was unlocked. During the interviews with LVN G and the DSD on 6/14/22 at 2:09 p.m. and on 6/16/22 at 5:20 p.m., LVN G and the DSD stated the medication carts should be locked when they were unattended. 2. During a medication pass observation on 6/14/22 at 2:18 p.m. at the nurse station, LVN G placed one tab of Resident 9's sevelamer 800 mg in a medication cup ready to give it to Resident 9. When LVN G walked from the nurse station to the activity room to give Resident 9 his medications, she left the cup with sevelamer 800 mg inside on top of the medication cart. In the activity room, after realizing Resident 9's sevelamer 800 mg was not with her, LVN G walked back to the nurse station to picked up the cup with sevelamer 800 mg inside. Resident 9's sevelamer 800 mg was on top of the medication cart unattended. During a concurrent interview, LVN G stated residents' medication should not be left unattended. Review of the facility's policy, Administration of Medications, dated 8/2021, indicated No medications should be left unattended by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 2 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 16% error rate when four medication errors out of 25 opportunities were observed during a medication pass for 3 of 14 residents (16, 17, and 31). These failures resulted in medications not given in accordance with prescriber's orders, which had the potential for residents to not receiving the full therapeutic effect of the medications (in the case of underdosing) or had the potential to for preventable side effects for the residents (in the case of overdosing). Residents Affected - Some Findings: 1. During a medication pass observation on 6/14/22 at 11:46 a.m., with licensed vocational nurse C (LVN C), LVN C checked Resident 17's blood sugar and it was 321. However, LVN C recorded 231 on Resident 17's Medication Administration Record (MAR) as Resident 17's blood sugar, and she administered 12 units of aspart insulin (used to treat high blood sugar) to Resident 17 instead of 16 units according to the sliding scale (a method used to determine the dose of insulin based on the blood sugar level just before the meal). During an interview with LVN C on 6/14/22 at 12:47 p.m., LVN C reviewed Resident 17's blood sugar on the glucometer (a small, portable machine that's used to measure how much sugar in the blood) and confirmed Resident 17's blood sugar was 321. LVN C stated she wrongly recorded Resident 17's blood sugar and Resident 17 should have received 16 units of aspart insulin instead of 12 units. LVN C stated she would talk to the skilled nursing facility manager (SNFM) to see what she needed to do. 2. During a medication pass observation on 6/14/22 at 5:24 p.m., with LVN D, LVN D administered Refresh ocular lubricant (eye drop used to relieve mild to moderate symptoms of eye dryness) two drops to Resident 16's right eye and three drops to Resident 16's left eye. Review of Resident 16's physician order indicated she had an order for Refresh ocular lubricant one drop to both eyes four times a day, started on 10/1/21. During an interview with LVN D on 6/14/22 at 5:31 p.m., she confirmed she administered two drops to Resident 16's right eye and three drops to Resident 16's left eye, not one drop to both eyes as ordered. 3. During a medication pass observation on 6/15/22 at 10:39 a.m., with the director of staff development (DSD), the DSD administered one drop of Artificial Tears ocular lubricant (eye drop used to relieve dry, irritated eyes) one drop to Resident 31's both eyes. The DSD also administered 15 milliliters (ml, a metric unit of volume) of lactulose (used to treat chronic constipation and to treat or prevent complications of liver disease) to Resident 31. The label on Resident 31's lactulose bottle indicated 10 milligrams (mg, a metric unit of mass) per 15 ml. Review of Resident 31's physician order indicated she had orders for Artificial Tears ocular lubricant two drops to both eyes four times a day, started on 12/30/21, and lactulose 15 mg which was 22.5 ml every morning, started on 1/17/22. During an interview with the DSD on 6/16/22 at 5:26 p.m., the DSD reviewed Resident 31's physician order and the label on the lactulose bottle and confirmed she should have administered two drops of Artificial Tears ocular lubricant and 22.5 ml of lactulose to Resident 31 as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 3 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 0759 Review of the facility's policy, Administration of Medications, dated 8/2021, indicated Mee Memorial has the following seven rights for medication safety: 1. The right patient; 2. The right medication; 3. The right dose . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 4 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 0760 Ensure that residents are free from significant medication errors. 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 one of 12 residents (16) was free of a significant medication error when Resident 16 received insulin degludec (a long-acting insulin, medication to lower blood sugar level) nine times (doses) past the expiration date. This failure had the potential for ineffective use of the insulin (secondary to degraded potency of expired medication), resulting in uncontrolled high blood sugar for the resident. Residents Affected - Few Findings: Review of Resident 16's admission Record indicated she was admitted to the facility on [DATE] with diabetes (a disease that occurs when the blood sugar is too high) diagnosis. On [DATE] at 3:23 p.m., during an observation of medication cart #2, with the director of staff development (DSD), an 100 units/milliliter (ml, a metric unit of volume) insulin degludec pen (injection pen, prefilled with insulin degludec) for Resident 16 was found with an expiration date of [DATE]. Review of Resident 16's Medication Administration Record (MAR) indicated she had been administered 8 units of insulin degludec at hour sleep since [DATE]. On [DATE] at 4:15 p.m., during an observation of medication cart #2 with licensed vocational nurse G (LVN G), Resident 16's insulin degludec pen with an expiration date of [DATE] was still in the cart. LVN G confirmed this pen was the only opened insulin degludec pen for Resident 16; the new pen which was delivered on [DATE] was unopened and was in the medication room. Therefore, Resident 16 had been administered the expired insulin degludec since [DATE], which was nine doses past the expiration date. Review of the facility's policy, Unit/Clinic Inspections, dated 3/2022, indicated Hospital and Clinic staff shall always check a medication's expiration date prior to administering the agent to a patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 5 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure: Residents Affected - Some 1. Two expired medications and 46 expired 8-oz boxes of renal supplement were made unavailable for resident use; and, 2. Two opened multi-dose eye medications were dated with an open and discard date (to ensure they were not used beyond the discard date). These failures had potential for residents to receive medications with reduced potency from being used past their discard date. Findings: 1. During an observation of medication cart #2 on 6/16/22 at 3:23 p.m., with the director of staff development (DSD), an 100 units/milliliter (ml, a metric unit of volume) insulin degludec (a long-acting insulin, medication to lower blood sugar level) pen (injection pen, prefilled with insulin degludec) for Resident 16 was found with an expiration date of 6/8/22. On 6/17/22 at 4:15 p.m., during an observation of medication cart #2 with licensed vocational nurse G (LVN G), Resident 16's insulin degludec pen with an expiration date of 6/8/22 was still in the cart. During an interview with the DSD on 6/20/22 at 10:46 a.m., the DSD stated she was unable to have the replacement for Resident 16's expired insulin degludec pen, so she endorsed to the next shift nurse and left the expired insulin degludec pen there for the next shift nurse to see. The DSD stated expired medication should be discarded. During an observation in the medication room of the front station on 6/16/22 at 3:40 p.m. with licensed vocational nurse D (LVN D), 46 boxes of 8-oz Novasource Renal Supplement were found with a use-by date of 5/10/22. During an observation of the medication cart #3 on 6/16/22 at 4 p.m. with LVN D, Resident 13's latanoprost (eye drops used to treat increased pressure in the eye) was found with an expiration date of 5/16/22. During a concurrent interview with LVN D, she stated the expired medication and supplement should be discarded. During an interview with the skilled nursing facility manager (SNFM) on 6/20/22 at 10:55 a.m., she stated it was important to discard the expired medication right away and she would educate the licensed nurses on this. Review of the facility's policy, Multi-Dose Vials/Containers Storage and Expiration Dates, dated 3/2022, indicated Any expired/soiled/contaminated multidose medications are to be discarded in the blue and white medications disposal container or sent to the pharmacy for proper disposal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 6 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During an observation of medication cart #2 on 6/16/22 at 3:23 p.m. with the DSD, Resident 16's opened olopatadine (eye drops used to treat itching and redness in the eyes due to allergies) container indicated expired after 60 days of open, however, it lacked documented open date labeling with expiration date. During an observation of the medication cart #3 on 6/16/22 at 4 p.m. with LVN D, Resident 25's opened Soothe Lubricant Eye Ointment was found without documented open date labeling with expiration date. During a concurrent interview, LVN D stated the medication should be labeled with the open date. Review of the facility's policy, Multi-Dose Vials/Containers Storage and Expiration Dates, dated 3/2022, indicated Nursing will write the date the multidose container is opened and the 28 day expiration date on the pharmacy provided label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 7 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: Residents Affected - Many 1. Undated food, food past their used-by date, and rotten lettuce were found in the refrigerators and on the shelves in the kitchen; 2. Dietary Aid A (DA A) did not cover his beard with a hair net; and, 3. [NAME] B (CK B) did not cover the hair in the back of her head in a hair net. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 31 residents eating at the facility. Findings: 1. On 6/13/22 at 10:15 a.m., during an observation of the refrigerators and the storage shelves in the kitchen, with the dietician (DT), the following were observed: a. Two cans of nacho cheese with a used-by date of 12/26/21 b. Eight burger buns with a used-by date of 6/2/22 c. Nine english muffin with a used-by date of 6/12/22 d. Eleven hoagie rolls with a used-by date of 6/12/22 e. Four bags of 12 burger buns in each bag with a used-by date of 6/12/22 f. One container of red beans with a used-by date of 6/12/22 g. One container of green bell pepper with a used-by date of 6/11/22 h. One container of cut fresh fruit with a used-by date of 6/12/22 i. One container of chocolate pudding with a used-by date of 6/11/22 j. One opened box of rice pilaf with a used-by date of 6/12/22 k. One container of multiple peanut butter and grape jelly sandwiches with a used-by date of 1/1/22 l. Thirty-five undated pasteurized eggs m. One undated container of potatoes n. One undated container of red potatoes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 8 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 o. Six undated cans of sliced apples Level of Harm - Minimal harm or potential for actual harm p. One undated can of white hominy q. One undated can of sliced beets Residents Affected - Many r. One undated container of roman lettuces which were rotten During a concurrent interview with the DT, he stated undated food, over use-by date food, and rotten food should have not been on the shelves and should have been discarded. Review of the facility's policy, Sanitation and Infection Control Labeling and Dating, dated 1/2016, indicated All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. 2. During an observation in the kitchen on 6/16/22 at 11:20 a.m., dietary aid A (DA A) was chopping cooked zucchini, and his beard was hanging without the hair net. During a concurrent interview with DA A, he stated he should put on a hair net for his beard. 3. During a tray line observation on 6/16/22 at 11:55 a.m., as cook B (CK B) prepared the residents' dishes, the hair of the back of her head was not covered in the hair net. During a concurrent interview with CK B, she stated the hair in the back of her head should be covered inside the hair net. Review of the facility's policy, Professional Appearance, dated 9/2021, indicated Employees in designated areas must wear hair bonnets for sanitary and/or infection control reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 9 of 10 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 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to notify residents' representatives and families of those residing in the facility by 5 p.m., the next calendar day following the occurrence of a confirmed infection of COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) and scabies (an intensely itchy skin condition that spreads quickly through close physical contact) for two of 12 residents (14 and 16). Residents Affected - Few These failures had the potential to result in residents' representatives and families, not receiving timely notification regarding the status and impact of COVID-19 and scabies in the facility. Findings: 1. During an interview on 6/20/22 at 3:35 p.m., with the brother of Resident 14, he verified that he was not informed by the facility when there were cases of COVID-19 and scabies in the facility, last January, 2022. During an interview on 6/20/22 at 12:50 p.m., with the Manager of Regulatory, Quality Assurance and Risk (MRQAR), she confirmed that they did not have a log or documentations that representatives or family members of the facility's residents were notified when they had cases of COVID-19 and scabies in January, 2022. During an interview on 6/20/22 at 2:37 p.m., with the Skilled Nursing Facility Manager (SNFM), she verified that she could not find a log or documentations that the facility notified the residents' representatives or family members when they had cases of COVID-19 and scabies last January, 2022. SNFM further stated that she already informed the Infection Preventionist (IP) that they needed to update their way of reporting to residents' representatives or family members, if there will be cases of COVID-19 or scabies in the facility. 2. Review of Resident 16's admission Record indicated she was admitted to the facility on [DATE]. During an interview with the manager of regulatory, quality assurance, and risk (MRQAR) on 6/20/22 at 3:20 p.m., she confirmed the facility had COVID-19 and scabies outbreaks in 1/2022, but she was unable to locate the record that indicated Resident 16's family members was notified about the outbreaks. The MRQAR stated the facility should inform Resident 16's family members about COVID-19 and scabies outbreaks, and the notification should be documented. Review of the facility's undated policy, Coronavirus Disease 2019 (COVID-19) Mitigation Plan: Communication, indicated, Skilled Nursing Facility (SNF) Manager, SNF Director of Staff Development (DSD) and Social Services Director (SSD) will communicate with staff, residents and their families to inform and update on the impact of COVID-19 in the facility daily as needed on an ongoing basis. Family members will be informed via phone and/or mail. Communication will include any confirmed cases in staff and residents as per Centers for Medicare and Medicaid Services (CMS) guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 10 of 10