Health inspection·June 28, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/24/2024 at 10;48 a.m., Resident 32's F/C drain bag was secured to Resident 32's bed frame, uncovered. During an interview with registered nurse F (RN F) on 6/24/2024 at 11:00 a.m., RN F confirmed Resident 31 and 32's F/C drain bags were not covered and that nursing staff should have covered their F/C drain bags with a privacy bags to provide privacy and dignity. During an interview with facility's chief nursing officer (CNO) on 6/28/2024 at 10:33 a.m., CNO stated nursing staff should have used privacy bags to cover the F/C drain bags for residents' privacy and dignity. Review of facility's policy and procedure (P&P) titled, Confidentiality, Patients, revised 01/2023, indicated, Privacy will always be protected by appropriate screening and draping as a demonstration of the employee's appreciation of the patient as an individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 2 of 22 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 06/28/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directives (AD, a written instruction for healthcare when the individual is incapacitated) and for completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for 7 of 8 sampled residents (Residents 9, 22, 24, 26, 31, 32, and 184). These failures have the potential for delivery of medical services against residents' wishes. Findings: Review of Resident 9's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE]. Review of Resident 9's POLST form, dated 7/14/2016, indicated section D for AD's all three options were left blank, therefore not completed. Review of Resident 22's FS indicated Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's clinical record indicated, there was no document for AD. Further review of 22's clinical record indicated there was no documented evidence that the facility discussed, offered help to execute, or requested copy of an executed AD for Resident 22. Review of Resident 22's POLST form dated 4/15/2024 indicated, section D for AD's all three options were left blank, not completed. Review of Resident 24's FS indicated Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's clinical record indicated there was no document for AD. Further review of Resident 24's clinical record indicated there was no documented evidence that the facility discussed, offered help to execute, or requested copy of an executed AD for Resident 24. Review of Resident 24's POLST form date prepared on 10/23/2023 indicated, section D for AD's all three options were left blank, not completed. Review of Resident 26's FS indicated Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's POLST form, dated on 7/20/2021, indicated section C for artificially administered nutrition (AAN, a form of nutrition given as liquids through a tube inserted into a vein, under skin, or into the stomach) and section D for AD's all three options were left blank, not completed. Review of Resident 31's FS indicated Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's clinical record indicated, there was no documented evidence that the facility discussed, offered help to execute, or requested copy of an executed AD for Resident 31. Review of Resident 31's POLST form, dated 2/23/2024, indicated section C for AAN's and section D for AD's all three options were left blank, not completed. Review of Resident 32's FS indicated Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's clinical record indicated there was no documented evidence that the facility offered help to execute an AD or requested copy of an executed AD for Resident 32. Review of Resident 184's FS indicated Resident 184 was admitted to the facility on [DATE]. Review of Resident 184's clinical record indicated there was no documented evidence of facility discussed for AD or offered help to execute an AD or requested copy of executed AD for Resident 184. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 3 of 22 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 06/28/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 184's POLST form, dated 6/14/2024, indicated section C for AAN's and section D for AD's all three options left blank, not completed. During an interview with the facility's chief nursing officer (CNO) on 6/28/2024 at 10:59 a.m., CNO confirmed the above AD and POLST form record review findings for Residents 9, 22, 24, 26, 31, 32, and 184. The CNO stated case management staff /social service staff should have discussed, or assisted to execute an AD, or requested for a copy of an executed AD, and documented in the resident's medical record for Residents 22, 24, 26, 31, 32 and 184. CNO also stated nursing staff should have completed all sections of POLST form for Residents 9, 22, 24, 26, 31, and 184. Review of facility's P&P titled, Advance Directive, revised 4/2022, indicated, Registration/Admitting staff will document in the medical record whether the patient has completed an advance directive and that information concerning advance directives has been given to the patient/significant other during the registration process. To the extent that the patient/significant other requests additional information or further explanation regarding to PSDA or advance directives, referrals will be made to Social Service/Case Management for follow-up interaction with patient and significant others, as appropriate. Should the patient wish to formulate an advance directive while receiving services in this institution, the Social Service Department will be contacted to assist the patient or refer the patient as necessary to accomplish the desire to formulate the directives. Review of facility's P&P titled, POLST, revised 3/2021, indicated, A health care provider such as a nurse or social worker can explain the POLST form to the patient and/or the patient's legally recognized health care decision maker and may complete the form after having a conversation with patient to understand his/her wishes and goals of care. The POLST form is to be completed based on the patient's expressed treatment preferences and medical condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 4 of 22 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 06/28/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans for six out of thirteen sampled residents (Residents 15, 8, 3, 5, 1, and 29), when the activity care plans of Residents 15, 8, 3, 5, 1, and 29, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 15's clinical records (history of someone's health) indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease (CKD, when the kidneys have mild to moderate damage and are less able to filter waste and fluid out of the blood), dementia (loss of memory) with behavioral problem, and hypertension (high blood pressure). During an observation of Resident 15 on 6/24/24 at 12:40 p.m., Resident 15 sat reclined in her wheelchair with her head slightly elevated. She was alert but confused and could not respond to questions asked. Resident 15 appeared calm, clean, and comfortable. Review of Resident 15's active physician orders, as of 6/25/24, indicated Resident 15 may participate in activities, ordered on 10/1/23. During the interview with the activity coordinator (AC), on 6/26/24 at 12:11 p.m., AC stated that Resident 15 liked to listen to music from a [computer tablet brand name], doodle (draw), get manicures (nail care), and get visited by activity staff every morning. Review of Resident 15's activities care plan care plan lacked specifics of what the AC mentioned were activities Resident 15 liked to do and were provided to her. The interventions in Resident 15's activity care plan were not comprehensive and resident-centered. During an interview with AC on 6/26/24 at 12:40 p.m., AC verified Resident 15 did not have the specific activities that were provided to her in her activity care plan. AC verified, Resident 15's activity care plan was not comprehensive and resident-centered, which should have included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. 2. Review of Resident 8's clinical records indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses including alcoholic liver disease, depression (a mood disorder), and paraplegia (a paralysis of one or more limbs). During an observation of Resident 8 on 6/24/24 at 1:40 p.m., Resident 8 was sitting in his wheelchair in the hallway. He appeared alert, calm, and verbally responsive. Review of Resident 8's active physician orders as of 6/25/24 indicated, Resident 8 may participate in activities, ordered on 10/2/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 5 of 22 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 06/28/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the interview with AC on 6/26/24 at 12:18 p.m., AC stated Resident 8 liked to watch television at the nurses' station. He also liked to join the candlelight dinner, usually at the beginning of the month, and sometimes they would take him shopping. Resident 8 would get visits every morning. Review of Resident 8's care plans lacked these specific activities that were provided to him in his activity care plan. The interventions in Resident 8's activity care plan were not comprehensive and resident-centered. During an interview with AC on 6/26/24 at 12:43 p.m., AC verified, Resident 8 did not have the specific activities, that were provided to him in his activity care plan. AC verified, Resident 8's activity care plan was not comprehensive and resident-centered, which should have included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. 3. Review of Resident 3's clinical records indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease, congestive heart failure (a condition in which the heart pumps inefficiently) and hypertension. During an observation of Resident 3 on 6/24/24 at 10:07 a.m., Resident 3 lay in her bed. She appeared alert, oriented, calm, comfortable and verbally responsive. Review of Resident 8's active physician orders as of 6/25/24 indicated, Resident 3 may participate in activities, ordered on 10/1/23. During the interview with AC, on 6/26/24 at 12:22 p.m., AC stated that Resident 3 liked to go to the activity room for the haircuts, nail care, live music, and doodles. AC stated that Resident 3 liked to join the candlelight dinners (meal illuminated by candles), special lunches, horse races, and make video calls with her son, once a week. Review of Resident 3's care plans lacked these specific activities that were provided to her in her activity care plan. The interventions in Resident 3's activity care plan were not comprehensive and resident-centered. During an interview with AC on 6/26/24 at 12:45 p.m., AC verified, Resident 3 did not have the specific activities, that were provided to her in her activity care plan. AC verified, Resident 3's activity care plan was not comprehensive and resident-centered, which should have included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. 4. Review of Resident 5's clinical records indicated, Resident 5 was admitted to the facility on [DATE] with diagnoses including history of vertebral compression fracture (small breaks or cracks in the bones that make up the spinal column), history of bilateral knee amputation (BKA, surgery to remove the leg below the knee) and chronic back pain (back pain that is present for more than three months). During an observation of Resident 5 on 6/24/24 at 1:55 p.m., Resident 5 was sitting in her bed. She appeared alert, oriented, calm, comfortable and verbally responsive. Review of Resident 8's active physician orders as of 6/25/24 indicated, Resident 5 may participate in activities, ordered on 10/1/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 6 of 22 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 06/28/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the interview with AC, on 6/26/24 at 12:24 p.m., AC stated that Resident 5 liked to join most of the group activities, and she gets morning round visits. AC stated Resident 5 liked to have the nail care, haircuts, to join the candlelight dinners, special lunches, and breakfast buffet. Review of Resident 5's care plans lacked these specific activities that were provided to her in her activity care plan. The interventions in Resident 5's activity care plan were not comprehensive and resident-centered. During an interview with AC on 6/26/24 at 12:48 p.m., AC verified, Resident 5 did not have the specific activities, that were provided to her in her activity care plan. AC verified, Resident 5's activity care plan was not comprehensive and resident-centered, which should have included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. 5. Review of Resident 1's clinical records indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease, type 2 diabetes mellitus (condition of high levels of sugar in the blood) and hypomagnesemia (condition of having a lower-than-normal level of magnesium in the blood). During an observation of Resident 1 on 6/24/24 at 1:48 p.m., Resident 1 lay in his bed. He appeared alert, oriented, calm, comfortable and verbally responsive. Review of Resident 1's active physician orders as of 6/25/24 indicated, Resident 1 may participate in activities, ordered on 11/25/23. During the interview with AC, on 6/26/24 at 12:28 p.m., AC stated that Resident 1 liked watching Spanish mass on the television, calling his family, socializing in the hallway with staff and other residents, and observing arts & crafts. AC stated Resident 1 also liked joining special lunches and breakfast buffets. Review of Resident 1's care plans lacked these specific activities that were provided to him in his activity care plan. The interventions in Resident 1's activity care plan were not comprehensive and resident-centered. During an interview with AC on 6/26/24 at 12:50 p.m., AC verified, Resident 1 did not have the specific activities, that were provided to him in his activity care plan. AC verified, Resident 1's activity care plan was not comprehensive and resident-centered, which should have included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. 6. Review of Resident 29's clinical records indicated, Resident 29 was admitted to the facility on [DATE] with diagnoses including vertebral artery occlusion (blockage of an opening of the major artery in the neck that provides blood to the brain and spine), coronary artery disease (CAD, narrowing of a major blood vessel of the heart) and anxiety (feeling of fear, dread and uneasiness). During an observation of Resident 29 on 6/24/24 at 10:18 a.m., Resident 29 sat in her wheelchair. She appeared alert, oriented, calm, comfortable and verbally responsive. Review of Resident 29's active physician orders as of 6/25/24 indicated, Resident 29 may participate in activities, ordered on 10/1/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 7 of 22 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 06/28/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the interview with AC, on 6/26/24 at 12:31 p.m., AC stated that Resident 29 liked doing arts and crafts in her room. AC stated Resident 29 got morning visits and watched crime shows on television and her laptop. Review of Resident 29's care plans lacked these specific activities that were provided to her in her activities care plan. The interventions in Resident 29's activity care plan were not comprehensive and resident-centered. During an interview with AC on 6/26/24 at 12:55 p.m., AC verified, Resident 29 did not have the specific activities, that were provided to her in her activity care plan. AC verified, Resident 29's activity care plan was not comprehensive and resident-centered, which should have included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. During an interview with chief nursing officer (CNO), on 6/28/24 at 12:15 p.m., CNO verified that residents should have comprehensive, resident-centered activity care plans that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and that the activity care plans needed to be updated. Review of the facility's policy and procedure titled, Assessment and Comprehensive Plan of Care for Skilled Nursing Facility (SNF), revised 6/2024, indicated, [name of the healthcare facility] will complete an interdisciplinary resident assessment and implement a resident-centered care plan for the SNF program resident. [name of the healthcare facility] will develop an interdisciplinary resident-centered care plan in consultation with the resident or resident representative consistent with resident rights, which includes measurable objectives and timelines to meet the resident's medical, nursing, rehabilitation, and psychosocial needs which are identified in the interdisciplinary assessment. The resident-centered plan of care will include . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 8 of 22 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 06/28/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 follow their policy and procedure (P&P) for oxygen (gas that supports life) therapy for 1 of 3 sampled residents (Resident 31), when oxygen was administered to Resident 31 without a physician's order for it. This failure resulted in Resident 31 receiving oxygen without a physician's order. Residents Affected - Few Findings: Review of Resident 31's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 31 admitted to facility on 3/25/2024. Review of Resident's admission diagnoses included renal cell carcinoma (type of kidney cancer), metastatic cancer of spine (cancer cells spread to spine [back bone] from elsewhere in the body), severe anemia (a condition when decreased red blood cells cannot provide sufficient oxygen to body), and palliative care (specialized form of care that provides symptom relief, comfort, and support to residents living with serious illnesses). Review of Resident 31's current physician's orders indicated there was no order for oxygen. Further review of Resident's 31's discontinued orders indicated order for oxygen was discontinued on 5/20/2024. Review of Resident 31's minimum data set (MDS, clinical and functional assessment tool) assessment dated [DATE] indicated Resident 31's brief interview for mental status (BIMS) score was 15 (0-7 = severe cognitive impairment, 8-12 = moderate cognitive impairment, 13-15 = intact cognition) During an observation on 6/24/2024 at 10:27 a.m., Resident 31 was receiving oxygen via nasal canula (NC, a thin, flexible tube that delivers oxygen to the resident's nose). Further observation of the wall mounted oxygen flow meter indicated the oxygen rate was set at 2 liters/minute (2l/min, measurement of oxygen flow to deliver) for Resident 31. During an interview with Resident 31 on 6/24/2024 at 10:27 a.m., Resident 31 stated she used oxygen since she was admitted to facility. During a second observation on 6/25/2024 at 9:18 a.m., Resident 31 was receiving oxygen via NC, and the oxygen rate was set at 2l/min. During an interview with registered nurse G (RN G) on 6/27/2024 at 2:50 p.m., RN G confirmed Resident 31 was receiving oxygen, and that there was no physician order for oxygen for Resident 31. RN G stated nursing should not administer oxygen to a resident without physician's order. RN G also stated a licensed nurse should have verified that an active physicians order was in place for oxygen before administering oxygen to Resident 31. During an interview with chief nursing officer (CNO) on 6/28/2024 at 10;14 a.m., CNO acknowledged an order for oxygen was discontinued on 5/20/2024, and there was no active order for oxygen for Resident 31. CNO stated the licensed nurse should not have administered oxygen without physician's order for oxygen. CNO further stated the licensed nurse should have verified that an active order for oxygen from a physician was in place before administering oxygen for Resident 31, according to the facility's policy for oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 9 of 22 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 06/28/2024 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 0695 Review of facility's policy and procedure (P&P) titled, Oxygen Therapy, revised 06/ 2016, indicated, Verify the physician's order. 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: 056443 If continuation sheet Page 10 of 22 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 06/28/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure food and nutrition services staff carried out the functions of food and nutrition service competently according to facility policy and standards of practice when: 1. Two kitchen staff were unable to properly test the dish machine sanitizer solution concentration. 2. Kitchen staff did not correctly verbalize the cool down process for cooked foods. 3. Kitchen staff did not wash melons prior to cutting. These failures had the potential to expose residents to bacterial contamination, that can result in food borne illnesses for all residents who consume food from the kitchen. Findings: 1. During a concurrent kitchen observation and interview on 6/24/24 at 10:41 a.m. with Dietary AideDishwasher (DSW) E demonstrated how to test the concentration of the sanitation solution for the dish machine. After DSW E washed multiple loads of dishes through the dish machine, DSW E dipped a test strip (used to detect the concentration of chemical sanitizing solution) in the dish machine solution tank. DSW E then compared the test strip to a container with multiple shade colors of green and blue, and stated the strip was greenish-blue and it was between 100-200. The Dietary Manager (DM) acknowledged DSW E did not correctly describe the normal sanitizer range for the dish machine solution. During a concurrent kitchen observation and interview on 6/24/24 at 1:45 p.m. with [NAME] (CK) I and the DM, CK I stated, it was his second time to wash dishes. CK I demonstrated how to check the sanitizer of the dish machine. CK I dipped a test strip in the solution inside the dish machine and compared the strip on its color-coded container label to check the level of sanitizer. CK I stated the strip color should be about 200. The DM acknowledged the test process by CK I and stated, We test the source (solution from the dish machine). Review of the facility document titled Food Safety Management System .D8 Cleaning and Sanitizing Food Contact Surfaces, dated 4/1/22, indicated, .A low temperature dish machine, must have a minimum 50 -100 ppm concentration of chlorine at the plate surface, verified by a chlorine test strip . 2. During an interview on 6/24/24 at 3:34 p.m. with CK B, CK B stated, the cool down process is four hours. CK B stated, the first two hours is from 180 to 60 degrees Fahrenheit (F, unit of temperature measurement) and then from 80 F to 38-40 F in another two hours. According to the 2022 Federal FDA Food Code, Section 3-501.14, The Cool Down process occurs because bacteria rapidly grow between the temperatures of 40 degrees and 140 degrees Fahrenheit (F). Therefore, the cool down process is a method to prevent bacteria growth by safely reducing the temperature of cooked and prepared foods for later consumption. The Food Code identifies cooling as an essential control measure for food safety, particularly after cooking meats or preparing perishable foods with ingredients that are at ambient temperatures. When cooling cooked foods, after it reaches a safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 11 of 22 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 06/28/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many minimum final internal cooking temperature (> than 145 degrees F), within two hours the temperature shall reach 70 degrees F or less, and within an additional four hours, it should reach 41 degrees F or less. For foods prepared with ingredients at ambient temperature, such as canned tuna, the food shall be cooled to a temperature of 41 degrees F or less within 4 hours. A copy of the facility's policy on Cooling Foods Cool down process was requested on 6/26/24 but not provided. 3. During a concurrent observation and interview on 6/24/24 at 10:28 a.m. with Dietary Aide (DA D), DA D was chopping honeydew and cantaloupe melons. Three uncut melons were on the counter and dry when touched. DA D stated he removed the melons from the walk-in refrigerator. DA D stated he did not wash them prior to cutting them. DA D placed the chopped melon slices in a container and dated it. DA D further stated he was not trained to wash produce, including melons, with water or a brush prior to cutting and serving them. According to the recommendation of the United States Food and Drug administration, 4. Gently rub produce while holding under plain running water. There's no need to use soap or produce wash. 5. Use a clean vegetable brush to scrub firm produce, such as melons and cucumbers. 6. Dry produce with a clean cloth or paper towel to further reduce bacteria that may be present. (https://www.fda.gov/consumers/consumer-updates/7-tips-cleaning-fruits-vegetables#:~:text=Gently%20rub%20produce%2 Review of the facility's policy and procedure (P&P) titled Washing Fruits and Vegetables, dated 4/1/22 indicated, Before cutting, the rind of the whole melon must be scrubbed vigorously (i.e., with a clean designated produce brush) and rinsed in clean water. Concurrent interview on 6/25/24 at 2:54 p.m.with the DM and record review of the Kitchen Staff's In-services dated 6/2023 through 6/2024, indicated an in-service titled Cool down foods, Diet Textures, and Open Enrollment dated 11/22/23 but it did not have the education document attached to attendance sign-in sheet. The DM stated there were no in-services provided to kitchen staff on the dish machine sanitizer testing or washing melons and produce prior to cutting and serving from 6/2023 through 6/2024. The DM further acknowledged the kitchen staff needed more training to increase their ability to perform their job tasks. During an interview with the Registered Dietitian (RD) on 6/25/24 at 3:36 PM, the RD stated it was important for the kitchen staff to know how to perform their jobs correctly and be trained on their job tasks in order to prevent the residents from exposure to contaminated foods and practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 12 of 22 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 06/28/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure approved menus were followed and emergency menus were developed to properly feed residents in an emergency. These failures had the potential for the facility to not meeting Residents' nutritional needs. Findings: 1. During an interview on 6/24/24 at 10:00 AM in the kitchen with the Dietary Manager (DM), a copy of the facility's therapeutic menu spreadsheet was requested but the DM stated they did not use a therapeutic menu spreadsheet. The DM stated the Cooks use a daily production tally sheet with the serving size amounts for each food item and total number of diet meals to make on it. A review of the facility's Regular menu titled Season's Harmony Week 5 Menu 6/23/24-6/29/24, indicated, .Tuesday .Lunch- Garden salad with cherry tomatoes, salad dressing, Pesto grilled salmon, Orzo with lemon & herbs, Italian vegetable blend, tartar sauce, snickerdoodle cookies . A review of kitchen's Daily Production Tally, dated 6/24/24 indicated, . Meal: Lunch .Orzo with lemon and herbs, ½ cup . (cup, a unit of measurement equivalent to 8 ounces, which is another unit of measure). During a tray line concurrent observation and interview on 6/24/24 at 11:36 a.m. with the [NAME] (CK A) and the DM, the CK A used a 2-ounce ladle to scoop the orzo (a form of short-cut pasta shaped like a large grain of rice). CK A stated he could not find a 4-oz ladle before trayline. The DM acknowledged the wrong scoop was used by the [NAME] to serve the orzo, and stated the [NAME] should have made sure he had the correct ladle before the trayline started. A review of the facility's policy and procedure (P&P) titled Section 2: Diets and Menus Portion Control, dated March 2017, indicated, . Standardized portions of food will be planned and served for all menu items to ensure standards for nutritional content and food cost are met. 3. The correct type and size of utensils will be used for each menu item. Scales should be available to weigh meat as needed . 2. During an interview on 6/25/24 at 1:20 p.m., the DM stated the facility would use all the existing food in the kitchen in an emergency. The DM further stated they did not have an emergency food menu developed but stated there was enough food in the kitchen and outdoor connex (mobile storage trailer container) with rehydrated (meals that require water to be consumed) to feed the residents, visitors, and staff. The DM stated they did not have a written emergency menu plan for the emergency food supplies at the facility. During an observation and interview on 6/25/24 at 2:20 p.m. with the DM and the MPO (Manager of Plant Operations), the large white outdoor connex had 38 cases of rehydrated meals with an expiration date 2039, and each case had six #10 cans of different rehydrated foods. The DM stated the perishable (refrigerated) and dry foods in the kitchen would be used first during an emergency, then the cases of rehydrated foods in the connex. The MPO stated his staff checked the rehydrated meals in the connex and the emergency water supplies twice a year. The DM acknowledged the facility did not have a detailed emergency menu or food plan that described how all the foods would be used for the residents on regular and therapeutic diets to meet their nutritional needs, for all types of emergencies, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 13 of 22 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 06/28/2024 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 0803 according to the regulation. Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 6/25/24 at 3:36 p.m. with the Registered Dietitian (RD), the RD stated it was important for the kitchen staff to follow the approved menus for the residents to receive the proper nutrition. The RD further stated it was important to have a well defined emergency food and water plan with an appropriate emergency menu to feed the facility residents during an emergency. Residents Affected - Some Review of the facility's policy and procedure (P&P) titled Section 4 Disaster Plan, Department Disaster Plan, dated 1/2016, indicated . The Food & Nutrition Services Department Disaster Plan is documented . and is available for reference by all personnel. The sample department disaster plan may be used as a template that must be individualized to each community . Guidelines for meal planning and foodservice operations during an emergency or disruption to normal service are as follows: 1. The facility should be self-sustaining for a minimum of 6 days with perishable items on-hand for routine foodservice operations and nonperishable foods designated for emergency stores . 2. Estimate the number of people to be served, include residents, staff, and volunteers. 3. Determine food, water and disposable ware quantities - what is necessary and what is on hand. Identify source of potable water supply. Menu Planning . A menu plan will be outlined for the duration of the disaster based on food supplies & labor available. Menu plans for three (3) days should take into consideration disruption in cooking facilities, refrigeration, and safe water supply and for each of the following sets of contingencies: 1. Safe water, improved cooking facilities, no refrigeration. 2. No safe water, no cooking facilities, no refrigeration. The nutritional needs of the residents and the community will be considered as much as possible . Each meal should offer some form of protein in addition to carbohydrates. This may be meat, poultry, cheese, eggs, beans, or peanut butter. Fruit, milk, and carbohydrates should be served in addition. Vegetables should be included if available. Foods should be served in texture modifications that are required. Food that does not require texture modifications should be used first. In the event that equipment is not available to mechanically blend foods and foods not requiring modification are not available, these foods should be finely chopped and mashed by hand, and then thinned with liquid as necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 14 of 22 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 06/28/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when hot foods were served cold and cold foods were served hot, and when pureed food recipes was not followed, which resulted in lumpy foods for three residents. These deficient practices had the potential to decrease the food intake of residents and negatively impact their nutritional status. Residents Affected - Some Findings: During the initial kitchen tour observation and interview on 6/24/24 at 10:04 a.m., an uncovered metal sheet pan with cooked green peas was resting on warm water on the trayline. A [NAME] (CK A) stated the green peas were prepared around 9:15 a.m. for that day's lunch. Another large metal sheet pan with cooked chili (a type of stew that typically contains ground meat, beans, and tomatoes) was resting inside the food warmer with other sheet pans of cooked foods. CK A stated the chili was for dinner. The DM stated the daily mealtimes when the trayline started were breakfast 7:30 AM, lunch 11:30 A.M., and dinner 5:30 P.M. A review of the facility's Alternate lunch menu on 6/24/24 indicated, Jumbo cheese ravioli with marinara, [NAME] Peas, and Grated parmesan cheese. A review of the facility's Regular dinner menu on 6/24/24 indicated, Turkey Black Bean Chili, Cornbread, Chopped spinach, and fresh fruit salad. Review of the facility's Resident Council Meeting Minutes dated 6/19/24, the meeting minutes indicated, . One resident stated her meals are cold when she receives them . Review of the Week 5 Season's Harmony Menu for Tuesday Regular Lunch meal indicated Garden salad with cherry tomatoes, Salad dressing, Macaroni & cheese, Steamed fresh Zucchini, red seedless grapes . The Pureed Lunch meal indicated . [NAME] Machine, Baked macaroni & cheese, puree; Zucchini, fruit cup . During an observation and interview on 6/25/24 at 11:42 a.m. of the lunch meal trayline, CK A stated he prepared three pureed meals for three residents. CK A further stated the Regular and pureed lunch meals were usually prepared and they are placed on the trayline or in the food warmer by 9:20 a.m. every day. CK A stated additional cheese sauce was poured on top of the pureed macaroni and cheese entrée to keep it creamy. CK A stated he blended three cups of baked macaroni and cheese in the robocoup (a food blender) with some milk for a minute to make the pureed macaroni & cheese. CK A also stated a cup of vegetable broth was added to the Zucchini to make the pureed zucchini. There was also a large plastic bin with twenty-six 4-ounce cups of milk. A Dietary Aide (DA) D stated he did not take the milk temperatures before the lunch trayline started at 11:30 a.m. During a test tray observation and interview on 6/25/24 at 12:14 p.m. with the Registered Dietitian (RD) and the DM, the temperature of the milk was 56.6 degrees Fahrenheit (F) and the regular macaroni & cheese entrée was 129 degrees F. Both the RD and DM agreed the pureed macaroni and cheese was lumpy and should have had a smooth pudding-like texture. The RD stated the regular macaroni & cheese was a little cold. The RD stated the pureed macaroni & cheese entrée had more flavor than the regular macaroni and cheese (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 15 of 22 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 06/28/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/26/24 at 3:23 p.m. with the RD, the RD stated the facility approved recipes and menus should be followed by the kitchen staff to ensure the residents receive the proper nutrition. The RD also stated cooking foods hours before trayline service could alter the nutrient quality. Review of the facility's Baked Macaroni & Cheese Puree recipe, dated 6/29/24, indicated, . prep Macaroni & Cheese, Baked, Corn Flakes . 12 and 1/2 OZ, add 3 Tablespoons (TBSP) and 2 and 1/8 Teaspoon (TSP) of skim milk . In a robot coupe or food processor, add pasta and warm milk. Process for 2 to 3 minutes, until smooth . A review of the facility's policy and procedure (P&P), dated March 2017, titled Section 2: Diets and Menus Portion Control, indicated, . 2. Standardized recipes with the yield and serving size indicated will be used . A review of the facility's policy and procedure (P&P), dated 10/1/21, titled Hot & Cold Food Serving Temperature Log indicated, . 5) Time: Document the time the first temperature is taken - this should occur at the time of set up and before service time; 6) Food Item: Document the name of the food item/recipe name being recorded; 7) Starting Temp: Document the first temperature of the food at time of set up; 8) 2 Hours: Document the temperature of the food after 2 hours; 9) 4 Hours: Document the temperature of the food after 4 hours; Standard/Critical Limit: Hot TCS/PHF (time temperature control for food safety foods/potentially hazardous foods) held and served at 140 degrees F . or above, Cold TCS/PHF foods held and served at 40 degrees F . or below - Record product temperatures on this log at two (2) hour intervals during holding and serving. If service time is less than two hours a final holding temperature must be recorded if the food is not discarded . Cold food: . If product is above 40 degrees F for more than 2 hours discard product. Hot foods: If food is between 135-139 degrees F reheat to 140 degrees F . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 16 of 22 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 06/28/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure to accommodate food dislikes and preferences for one out of three sampled resident (Resident 30). This failure had the potential for negative effects on health secondary to decreased food intake for Resident 30. Findings: During lunch observation in facility's dining room on 6/24/2024 at 12:17 p.m., cut carrot pieces mixed with Italian vegetables was served, and soup was not served, for Resident 30's lunch meal. Review of Resident 30's lunch tray card dated 6/24/2024 indicated under dislikes, No Carrots, and under preferences, it indicated, soup daily at lunch & dinner. Review of facility's lunch menu for 6/24/2024 indicated, Italian vegetable blend, along with other food items. During a concurrent interview, and record review of Resident 30's lunch tray card, dated 6/24/2024, with certified nursing assistant H (CNA H) on 6/24/2024 at 12:21 p.m., CNA H acknowledged carrots were indicated under dislikes and soup daily at lunch and dinner were under preferences for Resident 30. CNA H stated dietary staff should not have provided carrots and served soup for lunch to Resident 30, as indicated on his tray card's food dislikes and preferences. During a concurrent interview and record review of Resident 30's lunch tray card, dated 6/24/2024, with the facility's dietary manger (DM) on 6/24/2024 at 12:54 p.m., the DM confirmed Resident 30's lunch tray card indicated carrots for food dislikes, and soup daily at lunch and dinner for food preferences. DM stated dietary staff should have followed the lunch tray card for food dislikes and preferences when serving the meal tray for Resident 30. The DM also stated dietary staff should not have served carrots and should have served soup for lunch to accommodate Resident 30's food dislikes and preferences. Review of facility's policy and procedure (P&P) titled, Food Preferences, revised 5/2023, indicated, 1. Communication with new and readmitted residents about food and beverage preferences and other pertinent information will occur within 72 hours of admission. Items covered may include: 2. food and fluid preferences including: cultural, ethnic, or religious preferences; 3. food intolerances, allergies .; 2. Information may be communicated via a food preference form and/or welcome brochure distributed to the resident and/or family upon admission. When possible, the food service manager, dietitian, or designee will conduct a personal interview. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 17 of 22 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 06/28/2024 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, interview and record review, the facility failed to ensure food safety and sanitation methods were followed according to standards of practice and facility policy when: Residents Affected - Many 1. The ice machine had visible pink slime and tan colored residue on the ice making parts. 2. Two drainage pipes did not have air gaps. 3. Three floor sink drains were visibly dirty with dark black and brown stains, crumbs, and food debris. 4. Expired sliced cheese, sliced pears, and cranberry juice were found in the reach-in and walk-in refrigerators. 5. [NAME] bell peppers had grayish and black spots resembling mold in the walk-in refrigerator. 6. Metal shelves on a dish drying rack and inside the walk-in refrigerator were rust. 7. A reach-in freezer door gasket was dirty with black and brown sticky grime and residue. 8. Serving scoops with food debris stuck in the scoop were stored with clean scoops. 9. Cutting boards were deeply worn with multiple cuts and tan stains in the center. These failures had the potential to expose residents to contaminants that could cause foodborne illness. Findings: 1. During a concurrent kitchen observation and interview on 6/24/24 at 3:43 p.m. with the Stationary Engineer (STE) and the Dietary Manager (DM), the STE stated he used a water and vinegar solution of one of cup vinegar and three cups of water to clean the ice machine's ice-making parts including the ice machine curtain, water tray, baffle, and ice sensor. A Surveyor wiped a white paper towel inside the ice bin, on the ice curtain, baffle and water tray which yielded a pinkish slime residue onto the paper towel. The STE confirmed the ice machine curtain, water tray, baffle and ice sensor had pink slime that was wiped off with a white paper towel. The silver mesh filter on the back of the ice machine had gray lint hanging off the filter grids and some densely packed gray lint in the grids. The STE stated he cleaned the ice machine top ice making parts every other month but was not responsible for cleaning the ice bin. The STE further stated he could not remember when the silver mesh filter behind the ice machine was cleaned. The STE further stated he should have followed the manufacturer's guidelines and used their cleaning and sanitizing products to clean the ice machine. The DM acknowledged the pink stains on the white paper towel and the lint packed silver mesh filter and stated the ice machine should be cleaned correctly using the manufacturer's guidelines. According to the [Brand name: Ice machine manufacturer] cleaning and sanitizing maintenance guidelines, .(Ice machine brand manufacturer) Ice Machine Cleaner and Sanitizer are the only products approved for use . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 18 of 22 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 06/28/2024 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 Residents Affected - Many According to the 2022 Federal Food Drug Administration (FDA) Food Code, section 4-602.11, titled Equipment Food-Contact Surfaces and Utensils, . equipment contacting food . such as . ice bins must be cleaned . to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . A review of facility's policy and procedures (P&P) titled Food Safety Management System D-9 Cleaning and Sanitizing Frequency, revised 4/1/22, indicated, . Stored food contact equipment and utensils must be clean to the sight and touch. 2. During a kitchen observation and interview on 6/25/24 at 9:46 a.m., a drainage pipe under the dish washer machine and one connected to the ice machine were directly plumbed into the floor sinks without air gaps. The DM stated he was unaware of the pipes being directly plumbed into the floor drains. During an observation and interview on 6/25/24 at 4:22 p.m., the STE observed the two drainage pipes directly plumbed into the floor sinks, and stated they should air gaps to prevent backflow. According to the 2022 Federal Food Code, section 5-202.13, titled Backflow Prevention, Air Gap, indicated, . water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system . to prevent the introduction of this liquid into the water supply through back siphonage, various means may be used . 3. During a kitchen observation and interview on 6/25/24 at 9:46 a.m., three floor sink drains had dark black and brown residue and food debris in them. The DM confirmed the floor sinks were dirty and stated they should be cleaned by the evening kitchen staff. According to the 2022 Federal Food Code, section 4-602.13, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 4. During the initial kitchen tour observation and interview on 6/24/24 at 9:22 a.m. with the DM, the reach-in refrigerator had a large Ziploc bag with an opened package of sliced American cheese. The cheese had a used by date: 6/3/24 and prep date: 6/17/24. The DM stated the cheese was mislabeled and he was unsure of the correct use-by date so it should have been thrown out. On 6/24/24 at 9:35 a.m., an observation and interview of the walk-in refrigerator was conducted with the DM. The refrigerator had a plastic container of sliced pears with a use by date 6/22/24 and prep date: 6/17/24. The DM stated the pears should have also been thrown out. On 6/24/24 at 12:34 p.m., an observation and interview of the resident's nourishment refrigerator was conducted. The resident's nourishment refrigerator had an opened, three quarters full 32-ounce bottle of cranberry juice with written date of 4/14/24 on the bottle. RN F stated food stored for residents in the nourishment refrigerator should be thrown away after 3 days of being stored in the refrigerator. RN F stated she was unsure who the cranberry juice belonged to but stated it should have been thrown out. According to the 2022 Federal FDA Food Code, section 3-501.17 (A) (B) (C) (D) indicated, .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 19 of 22 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 06/28/2024 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 procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . Review of an undated facility document taped on the resident's nourishment refrigerator indicated .All food must be in tightly closed container labeled with use-by-date . Leftover food will be discarded after 3 days . Residents Affected - Many A review of facility's policy and procedures (P&P) titled Section: Sanitation and Infection Control Subject: Labeling and Dating, dated May 2023 indicated, . All foods are labeled, dated, and securely covered, and used-by dates are monitored and followed . 5. During the initial kitchen tour observation and interview on 6/24/24 at 9:41 a.m. with the DM, a full undated case of green bell peppers in the walk-in refrigerator had two peppers on the top of the others with black and grayish spots resembling mold. The DM confirmed the two bell peppers with mold resembling spots and stated he believed the case was delivered two weeks ago. The DM further stated the bell peppers should have been checked in the morning by the kitchen staff. According to the 2022 Federal Food Code, Annex 4 Table 2a, . Check condition at receiving; do not use moldy or decomposed food . A review of facility's policy and procedures (P&P) titled Section: Sanitation and Infection Control Subject: Labeling and Dating, dated May 2023 indicated, . All foods are labeled, dated, and securely covered and used-by dates are monitored and followed. 6. During a kitchen observation and interview on 6/24/24 at 9:35 a.m., metal shelves with deep rust were found on the food storage racks inside the walk-in refrigerator and a large dish drying rack. The DM acknowledged the rusty shelves inside the walk-in refrigerator and dish drying rack could be potentially harmful. According to the 2022 Federal FDA Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicate (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 7. During the initial kitchen tour observation on 6/24/24 at 9:25 a.m. with the DM, the reach-in freezer had a black grimy substance along the entire rubber gasket, at the top, bottom left and right sides. The DM confirmed the reach-in freezer had a black substance along the gasket, and stated the kitchen staff must have missed it while cleaning the freezer. According to the 2022 Federal FDA Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . 8. During the initial kitchen tour observation and interview on 6/24/24 at Approximately 9:25 a.m., four serving scoops were found with crusted food debris stuck inside them. The DM acknowledged the serving scoops were dirty and should be clean. According to the 2022 Federal FDA Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicates, indicated, (A) Equipment food-contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 20 of 22 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 06/28/2024 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 surfaces and utensils shall be clean to sight and touch . Level of Harm - Minimal harm or potential for actual harm 9. During a kitchen observation on 6/25/24 at 4:32 p.m. with the DM, three green, two red, and two white cutting boards were deeply scraped and worn-out. The DM confirmed the green, red, and white cutting boards were used for chopping vegetables and meats, but they were worn out and should be replaced. Residents Affected - Many According to the 2022 Federal FDA Food Code, Section 4-501.12 and Annex Section 3, titled Cutting Surfaces, indicated, . surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Pathogenic microorganisms can be transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . Review of facility's policy and procedures (P&P) titled Food Safety Management System D-6 Cutting Surfaces, revised 4/1/22, indicated, Cutting boards must be in good condition, without cracks, deep groves, and discoloration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 21 of 22 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 06/28/2024 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 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** Based on observation, interview, and record review, the facility failed to implement proper infection prevention and control practices for one out of five residents observed for medication administration, (Resident 16), when the registered nurse did not perform hand hygiene; such that, after throwing used gloves in the trash bin, she proceeded to prepare medications of Resident 16. This failure had the potential to spread infections, and compromise residents' health and safety in the facility. Residents Affected - Few Findings: During the medication pass observation with registered nurse G (RN G), on 6/26/24 at 9:10 a.m., RN G threw away her used gloves in the trash bin that was attached to the side of the medication cart, and then proceeded to prepare medications to administer to Resident 16 without performing hand hygiene. During another medication pass observation with RN G, on 6/26/24 at 9:50 a.m., RN G again threw away, her used gloves in the trash bin that was attached to the side of the medication cart, and then proceeded to prepare medications for administration to Resident 16 without doing hand hygiene. Review of Resident 16's clinical records indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses including alcoholic liver disease, left hip arthritis (joint inflammation), and hypertension (high blood pressure). During the interview with RN G on 6/26/24 at 10:50 a.m., RN G verified that she twice did not do hand hygiene after she threw away her used gloves and proceeded to prepare medications for Resident 16. RN G stated that she should have performed hand hygiene after she threw away the used gloves in the trash bin and before she had prepared the medications of Resident 16. During an interview with the infection preventionist (IP) on 6/28/24 at 11:30 a.m., the IP verified that the registered nurse should have done hand hygiene after she [NAME] away the used gloves in the trash bin of the side of the medication cart, and before preparing the resident's medications. Review of the facility's policy and procedure titled, Hand Hygiene in Healthcare Settings, revised 6/2024, indicated, Hand hygiene and skin antisepsis are critical components of infection prevention . Perform hand hygiene after contact with inanimate objects . within the patient's environment. Perform hand hygiene after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 22 of 22