Other·January 4, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated standard survey of three complaints and two entity reported incidents. Complaints: 496300, 505900, and 506274 Entity reported incidents: 489920 and 494082 The inspection was limited to the specific complaints and entity reported incidents investigated and does not represent the findings of a full inspection of the facility. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 37850 HFEN 37581 Health Facilities Evaluator Supervisor (HFES) 15419 HFES 31709 No deficiencies were issued for Complaint 505900. Deficiencies were written for Complaint 506274 at F 201, F 202, F 203, and F 204 and Complaint 496300 at F 327. Deficiencies were written for Entity Reported Incident 494082 at F 157, F 309, and F 327 and Entity Reported Incident 489920 at F 329 and F 502. As a result of the investigation for Complaint 506274, Immediate Jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm, for the inappropriate, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 1 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unsafe discharge of Resident 1. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm. As a result of the investigation for Complaint 496300 and Entity Reported Incident 494083, substandard quality of care was identified and a partial extended survey conducted. Census: 79 Sample: 12

F157 SS=E NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(b)(11)

F157 12/06/2016 A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 2 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the physician regarding a clinical complication for one of 12 sampled residents when they did not notify the physician that Resident 3 did not have a bowel movement for a period of nine days and they did not implement the physician orders for as needed (PRN) bowel care related to constipation. This failure led to Resident 3 being admitted to the hospital with a partial small bowel obstruction (blockage) secondary to constipation (difficulty emptying the bowels, usually associated with hardened stools) and obstipation (severe or complete constipation), requiring treatment that included fluid replacement via IV (through the vein), NG tube placement (a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), a diet of nothing by mouth, and had the potential for other residents to not receive bowel care when needed which could lead to constipation or bowel obstruction. Refer to F 309 for additional information. Findings: Resident 3's record was reviewed and indicated Resident 3 was admitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 3 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility on 7/26/13 with diagnoses that included Alzheimer's disease (a condition that causes problems with memory, thinking and behavior), hypertension (elevated blood pressure), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and muscle weakness. A review of Resident 3's constipation care plan, dated 4/26/16, indicated Resident 3 was at risk for constipation secondary to decreased mobility with a goal to have continued satisfactory bowel movements every 1 to 3 days, as evidenced by soft formed stools. The facility approach to achieving this goal included: administer medications per MD order, encourage fluid intake unless contraindicated, and notify MD if decreased bowel sounds/abdominal pain/distention/decreased appetite or fever. A review of physicians orders, dated 7/29/168/19/16, included Milk of Magnesia (MOM) 30 milliliters (ml) once a day as needed for constipation prevention, Dulcolax laxative suppository 10 mg 1 suppository once a day as needed if MOM was ineffective, and Fleet enema 1 enema once a day if Dulcolax suppository ineffective. A review of the PRN medication flowsheet, dated 8/1/16-8/31/16, indicated Resident 3 received one dose of MOM on 8/8/16 and one dose on 8/9/16. There were no indications the medication was effective or that the resident received any doses of the Dulcolax suppository or Fleet enema during the dates of 8/1/168/31/16. A review of the facility's bowel care log records, dated 8/1/16-8/14/16, showed that no bowel movement was documented for Resident 3 between the dates of 8/3/16-8/11/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 4 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 3's ADL flow sheet, dated 8/2016, showed no bowel movement was documented between the dates of 8/2/168/11/16. During an interview and concurrent record review with the Director of Nurses (DON) on 10/13/16 at 3:20 pm, the DON reviewed all records and searched through electronic records and stated he was unable to find documentation indicating Resident 3 had a bowel movement, unable to find any documentation of intervention done to manage constipation other than the two doses of MOM given, one dose on 8/8/16 and one dose on 8/9/16 and he stated he could not find any charting to indicate when or if the physician was notified Resident 3 had not had a bowel movement for a period of nine days. The DON stated the facility did not have a policy or specific protocol to address bowel care or constipation.

F176 SS=D RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE CFR(s): 483.10(n)

F176 12/06/2016 An individual resident may self-administer drugs if the interdisciplinary team, as defined by §483.20(d)(2)(ii), has determined that this practice is safe. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure medication self administration was safe for one of 12 sampled residents (Resident 12) when inhalant medications were left at the resident's bedside for self use. This had the potential for Resident 12 to self FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 5 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administer too much or too little inhalant medication which could adversely affect his health and well-being. Refer to F 327. Findings: Resident 12's record was reviewed and indicated he was admitted to the facility on 10/11/16 with diagnoses that included chronic lung disease, heart failure, kidney disease, and urinary tract infection (UTI). Review of physician orders, dated 10/11/16, included the following inhalant medications used to treat lung disease to be administered via an inhalation device: -Spiriva once daily; -Symbicort two inhalations twice daily as needed; -Xopenex two inhalations every four hours as needed; and -Levalbuterol solution via nebulizer (inhaled) every two hours as needed. Physician's orders, dated 10/12/16, included: Oxygen to be delivered via the nose at 2 liters per minute, as needed for oxygen saturation levels (percent of oxygen in the blood) below 88% and monitor oxygen saturation every shift. A review of the 10/2016 medication administration record indicated there was no documented oxygen saturation check for the night shift on 10/14/16. A review of a physician's history and physical examination, dated 10/16/16, indicated Resident 12's shortness of breath was improved, and he had congestive heart failure. The physician's plan was to obtain a repeat chest X-ray and restrict fluid intake. The physician indicated Resident 12 may go home FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 6 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in "a few days." Review of a nurses note, dated 10/18/16 indicated Resident 12 had four inhalers left at his bedside and was noted to have had a significant drop (low 80's %) in oxygen saturation when walking to the restroom. Review of a nurses note, dated 10/19/16, timed 4:39 pm, indicated Resident 12 complained of shortness of breath after walking to the restroom, his oxygen saturation was 82%, he was assisted to bed and oxygen was placed back on him, and he had a temperature of 101.2 degrees Fahrenheit. The physician was notified of the change in condition and Resident 12 was transferred to the hospital on 10/19/16 for shortness of breath and wheezing. On 10/21/16, during an interview, the Director of Nursing stated the facility allowed Resident 12 to self medicate with inhalers and did not have a system in place to monitor frequency of use or total administered dosage.

F201 SS=J REASONS FOR TRANSFER/DISCHARGE OF F201 RESIDENT CFR(s): 483.12(a)(2) 12/06/2016 The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 7 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or The facility ceases to operate. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have an acceptable discharge reason for one of 12 sampled residents (Resident 1) when the facility discharged Resident 1 to a room and board establishment (unlicensed living arrangement where lodging and food are furnished for a set price, nonmedical, landlord tenant situation where resident does not need 24 hour supervision) without the residents health improving sufficiently to be moved to this lower level of care. This failure resulted in Resident 1 being discharged to a place that could not provide adequate care for his needs, such as supervision, behavior monitoring, medication administration, and wound care, jeopardizing his health and welfare, placing him at risk for harm. The room and board owners called 9-11 and the police responded and transported Resident 1 to a hospital for further evaluation and treatment, where he required constant hospital staff supervision and psychiatric evaluation and treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 8 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Immediate Jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm, for the inappropriate, unsafe discharge of Resident 1. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm. Refer to F 202, F 203, and F 204. Findings: On 10/10/16, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was discharged to a room and board establishment and the facility did not disclose the resident's behavior to the room and board owner. Once Resident 1 arrived at the room and board he became agitated and threatened to kill his roommate, was then brought to the hospital by police officers for further evaluation and treatment. The complainant alleged that the facility's administrator was involved in the transfer to the Room and Board and the facility refused to take the resident back indicating Resident 1's functional level was too high for skilled nursing level of care. A review of Resident 1's record on 10/11/16 indicated he was re-admitted to the facility on 7/30/16 with diagnoses of left leg cellulitis (painful, inflamed, infected skin) requiring wound vac (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds), cognitive memory deficit (defined as a conditional state between normal aging and dementia), anxiety disorder (worry that interferes with ability to lead a normal life), morbid obesity (100 pounds over ideal body weight), chronic obstructive pulmonary disease FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 9 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (lung condition that makes it difficult to breathe that is not curable), and atrial fibrillation (afib, irregular heartbeat) on Coumadin (blood thinning medication used to prevent blood clots caused by atrial fibrillation). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. He had resided at a board and care (a licensed 4 to 16 bed non-medical facility that provided room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring)..... for many years prior to being hospitalized and admitted to facility. Resident 1 was a full code (all resuscitative efforts are to be made in the event of cardiopulmonary arrest). A review of Resident 1's Interdisciplinary Team (IDT, a team of facility staff who meet to review and plan for resident care needs) conference notes dated 8/2/16 conducted by Social Services Director (SSD) with attendees including a therapist, Resident 1 and Resident 1's sister via phone, indicated that family wanted Resident 1 to stay at the facility as a long term resident. Resident 1's sister stated she wanted resident to be conserved by the County and that he already had a payee. During an interview with the SSD on 10/11/16 at 2:55 pm, she stated Resident 1 wanted to go back to his original "board and care," but they would not take him back. She stated he was originally accepted to another local "board and care," then denied admittance, due to his behaviors. SSD stated Resident 1's family wanted resident to go to a locked facility due to his behaviors. SSD stated Resident 1 was loud and would get in people's faces, he liked to "sunbathe" and would get naked outside. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 10 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of a social services progress note, dated 8/17/16 at 10:17 am, indicated Resident 1 could not be re-admitted to his previous "board and care." Review of a social services progress note, dated 9/8/16 at 12:05 pm, indicated Resident 1 was not accepted to the "retirement home" because the owners of the home stated resident was "unstable to go there." A review of Resident 1's physician progress note, dated 8/22/16, indicated, "Resident has tried to elope (run away) several times during skilled nursing facility stay. He is alert and oriented to self. Facility is trying to find placement for him....being followed by wound medical doctor for right (wrong ankle documented by medical doctor) ankle wound. Wound vac was discontinued due to patient continuously pulling vac out. Resident is on Coumadin for afib and will continue to monitor international normalized ratio (INR, a lab measurement to determine the effects of Coumadin on the body's blood clotting)....continues to work with physical therapy and occupational therapy (PT/OT)......Left ankle wound clean/dry/intact." A review of Resident 1's physician progress note, dated 9/7/16 stated, "Resident is alert and oriented to self. He is currently on Coumadin and INR is monitored...Resident currently on Risperdal (an antipsychotic medication used to decrease mood instability) for mood stability after elopement (run away) attempts and aggressive behavior towards staff...left ankle wound clean/dry/intact...discontinue Coumadin as resident is not a candidate for INR monitoring in an independent living facility. Will start on Xarelto (another medication used to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 11 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE blood clots)...for anticoagulation." A review of Resident 1's physician progress note, dated 9/14/16 stated, "multiple medical issues including psych issues...has a wound, left ankle...still having behavior issues on and off." A review of Resident 1's physician progress note, dated 9/27/16 (the date he was discharged) indicated, "Resident is alert and oriented to self. He is discharging to a "board and care" in Sacramento...currently on Risperdal....for mood stability after elopement attempts and aggressive behavior towards staff. Left ankle wound clean/dry/intact." A review of Resident 1's nurses notes, dated 7/29/16 through 9/27/16, indicated Resident 1 had multiple episodes of inappropriate behaviors including yelling, shouting, leaving the facility unattended, resident to resident altercations and undressing himself in public. Resident 1 was administered Ativan (sedating medication to decrease anxiety) twice a day and Risperdal was started. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated that Resident 1 had a history of a mental disorder and while at the facility, he stripped his clothes off in public and urinated on cars. She further stated that Resident 1 needed constant supervision, due to his behaviors. During an interview with Nurse Practitioner (NP) on 10/12/16 at 12:35 pm, she stated she will never forget Resident 1; he had loud, inappropriate behaviors. She wrote the order to discharge Resident 1 to a "board and care facility." She indicated that a "board and care" facility should be able to provide care to Resident 1 because they could give him his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 12 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications and meals. NP asserted that Resident 1 was a candidate to be transferred to the "board and care" despite his leg wound requiring wound care, further stating, "his wound was healing, his dressing was clean, dry and intact." A concurrent record review of an order, dated 9/22/16, indicated to "cleanse....ankle with normal saline, pat dry, apply Maxorb calcium alginate rope (a specialized moist dressing), cover with kerlix (absorbent cotton) and ace wrap, change every other day for 14 days and then re-assess." NP stated she was under the impression assisted living staff could help with wound treatments. In regards to Resident 1's orientation status being acceptable for a "board and care," NP stated he had "good days and bad days depending on his level of agitation." NP stated she thought a psychiatrist had seen Resident 1 about his behaviors. A concurrent record review showed no evidence that a psychiatrist had seen Resident 1 during his stay at the facility. During a review of Resident 1's Physician's Report for Residential Care Facilities for the Elderly, (a California Department of Social Services form used to help a "board and care" or "assisted living" determine if a resident or prospective resident is a good fit for the facility), signed by the discharging MD (MD A) on 9/23/16, indicated residential care level includes primarily non-medical care and supervision to meet the needs of the person and " THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE." The document indicated Resident 1 was 6'1" tall and weighed 253 pounds, could not manage his own treatment/medication/ equipment, and had mild cognitive impairment. The document indicated Resident 1 did not have confusion or inappropriate, aggressive or wandering behaviors and was not able to leave the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 13 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unassisted. The document indicated Resident 1 was not able to administer his own medications or oxygen. Physical health status was "Good." The document did not depict any of Resident 1's behaviors that had been documented in his facility record. Review of a social services progress note, dated 9/12/16 at 10:37 pm, indicated despite two denials from different board and care homes, Resident 1's inappropriate behaviors, poor orientation status with inability to make decisions on his own, left leg wound requiring nursing care and no documentation supporting Resident 1's health status had improved sufficiently, the facility's plan continued to be "look for lower level placement," for Resident 1. A review of Resident 1's nursing progress note, dated 9/24/16, indicated treatment nurse (LVN F) documented Resident 1's wound to the left medial ankle measured 2.0 centimeters (cm) by 5.0 cm by 0.1 cm. The wound bed was described to have "granulation tissue (lumpy, pink tissue), light to moderate amount of serosanguinous drainage (light red to clear liquid coming from wound)....continue with current order.." Resident 1 was discharged from facility on 9/27/16. A physician's order, dated 9/27/16 and signed by NP, indicated, "discharge to board and care with medications and narcotics." During an interview on 10/11/16 at 10:30 am, with Hospital Staff A (a registered nurse) she stated, Resident 1 had a history of Bipolar disorder (mental problem characterized by mood swings with emotional highs and lows), had a diagnosis of dementia (loss of brain function affecting memory, thinking and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 14 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE behavior), and was not competent to make his own decisions. She indicated Resident 1 was reportedly throwing furniture, threatening to kill staff and his roommate at the room and board where he was discharged to, and that the room and board staff were not notified of Resident 1's inappropriate behaviors, prior to his arrival. Hospital Staff A stated the only suitable placement for Resident 1 would be a locked unit facility. Resident 1 required a one to one sitter (a person designated to directly supervise him at all times) while at the hospital for multiple elopement attempts and threats to kill staff. Hospital Staff A stated the facility "dumped" Resident 1 and the hospital believes his discharge was inappropriate. During an interview with room and board owner (RB) on 10/11/16 at 1:34 pm and continued on 10/13/16 at 1:00 pm, he stated "we are a room and board, not a board and care." RB stated the facility told him Resident 1 was independent, high functioning and did not need help with his medications. RB stated the plan was to provide Resident 1 with three meals a day, a room to sleep in, and for him to be independent and compliant with normal landlord/tenant rules. The owner stated Resident 1 arrived at 3:15 pm on 9/27/16, with a large bag of medications, and no instructions. He did not know anything about Resident 1's wound on his left leg. RB described Resident 1 as having aggressive behaviors towards the other room and board tenants. RB stated Resident 1 was stealing food from others, threatening to hurt them, and shoved his roommate and said "I'll kick your ass... pour this soda in your face." Resident 1 arranged the stolen food in a line and told his roommate not to touch "my food." RB's wife attempted to speak with Resident 1 about his behaviors, he threatened to hurt her. RB stated the resident had been at his room and board for less than FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 15 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 24 hours when they had to call 9-1-1 for assistance with Resident 1. The police arrived and Resident 1 threatened his roommate in front of the police, they arrested him and stated he was not appropriate to stay at the room and board establishment. During an interview with SSD on 10/11/16 at 2:55 pm she stated Resident 1 was discharged to a "board and care." During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated, she did not know the facility Resident 1 was being admitted to was a room and board, she was under the impression the facility was an assisted living. During an interview with NP on 10/12/16 at 12:35 pm, she indicated Resident 1 was discharged to a "board and care." (Resident 1 was discharged to a non-licensed, non-medical "room and board" establishment that could not provide the care he needed. He was not discharged to a "board and care" establishment like the facility staff had indicated). On 10/13/16 at 2 pm, Resident 1's room and board roommate was interviewed. He stated, "It was hell" explaining that Resident 1 was "as big as a house" and pushed him, stole his food, and said he was going to "kick my (his) ass." According to the California Advocates for Nursing Home Reform (CANHR) website, board and care and assisted living facilities are for care and supervision of people who are unable to live by themselves, but who do not need 24 hour nursing care. They are considered non-medical facilities and are not required to have nurses, certified nursing assistants, or physicians on staff. They provide room, meals, housekeeping, supervision, storage and distribution of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 16 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring. Board and care homes typically provide seniors with the same services available in larger assisted living communities; the difference is that these facilities are "regular" houses in residential neighborhoods that are equipped, adapted and staffed to care for a small number of seniors. A review of the Physician Order Report, dated from 7/29/16 through 9/27/16, indicated Resident 1 was taking medications which included: 1. Carvedilol (a medication that lowers blood pressure, adverse reactions include low blood pressure and low heart rate) 3.125 milligrams (mg) twice a day-hold if systolic blood pressure is less than 110. 2. Potassium Chloride (medication used to replace potassium loss with use of furosemide, needs to be taken with food and water to prevent upset stomach) 10 milliequivalents (mEq) daily. 3. Aspirin (used to prevent blood clots in people who have atrial fibrillation, increased risk of bleeding can occur when taking this medication) 81 mg daily. 4. Digoxin (slows heart rate in people with atrial fibrillation, side effects include dizziness and nausea and vomiting, severe toxicity can occur if Digoxin levels not monitored) 125 micrograms (mcg) daily- hold for apical pulse less than 60. 5. Famotidine (treats and prevents irritations in the stomach) 20 mg daily. 6. Furosemide (used to decrease fluid in the body, adverse reactions include severe dehydration and potassium depletion) 20 mg daily. 7. Xarelto (thins the blood to decrease blood clots from forming, adverse reactions include FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 17 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE increased chances of bleeding including bleeding into an important organ resulting in death) 20 mg daily. 8. Cranberry extract (supplement to help prevent urinary tract infections) 425 mg daily. 9. Ativan (medication that decreases anxiety, increased sleepiness can occur when taking this medication and potential for overdose if not taken correctly can lead to injury and death) 0.5 mg twice a day, and Ativan 0.5 mg twice a day, as needed for anxiety. 10. Risperdal (medication used to decrease mood instability, manufacturer warning states use in elderly people with dementia can increase risk of death) 0.5 mg at bedtime. 11. Meclizine (used to treat and prevent dizziness) 25 mg three times a day as needed for vertigo (dizziness). 12. Norco (used to treat pain, side effects include nausea, vomiting, constipation and potential for overdose if not taken correctly) 5325 mg 1 tab every six hours as needed for pain. Review of a physician's order, dated 9/27/16, included, "medications and narcotics" were to go with Resident 1 when discharged. Due to the inappropriate, unsafe discharge that jeopardized the health and welfare of Resident 1 and others, an immediate jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm. On 10/19/16, the Admin involved in the unsafe discharge of Resident 1 was terminated. On 10/20/16 and 10/21/16, the facility presented immediate corrective actions plans which were unacceptable. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 18 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm which included in part: -All residents will have safe and appropriate discharges; -All residents and/or responsible parties will be notified of the physician's discharge plan, involved in the discharge planning process, and included in all decisions made concerning discharges; -Written discharge notice will be provided to all residents and/or RPs, per regulatory requirements; -The IDT (interdisciplinary team, to include nursing staff and the Director of Nursing or RN designee, the administrator, and social services and therapy staff) will evaluate all discharges to ensure appropriateness and safety for all residents; -The facility's Medical Director will evaluate all discharges to ensure appropriateness and safety for all residents; -All staff were educated on appropriate and safe discharge practices and expectations and are empowered to stop any discharge that is not safe or appropriate for a resident; and -Administrative staff are available to staff 24 hours per day, seven days per week, to prevent potentially inappropriate or unsafe resident discharges. During a follow up interview with Hospital Staff A on 11/3/16 at 3:30 pm, she stated Resident 1 was sent to another skilled nursing facility on 11/1/16, with one to one 24 hour supervision and psychiatric care. Hospital Staff A stated there were no locked facilities who could take Resident 1. A review of hospital records indicated Resident 1 was treated with antibiotics at the hospital for LLE cellulitis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 19 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 


F202 SS=D DOCUMENTATION FOR TRANSFER/DISCHARGE OF RES CFR(s): 483.12(a)(3)

F202 12/06/2016 When the facility transfers or discharges a resident under any of the circumstances specified in paragraph (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by the resident's physician when transfer or discharge is necessary under paragraph (a) (2)(i) or paragraph (a)(2)(ii) of this section; and a physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the physician documented in the clinical record an appropriate reason for discharge from the facility for one of 12 sampled residents (Resident 1). This failure resulted in Resident 1's record not being appropriately documented by his physician. Resident 1's record did not indicate his health had improved sufficiently enough to no longer need the services provided by the facility. Resident 1 was discharged to a lower level of care, which was a room and board establishment (unlicensed living arrangement where lodging and food are furnished for a set price, non-medical, landlord tenant situation where resident does not need 24 hour FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 20 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE supervision) where they were unable to meet his needs resulting in his arrest and subsequent hospitalization. Refer to F 203 and F 204. Findings: On 10/10/16, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was discharged to a room and board establishment and the facility did not disclose the resident's behavior. Resident 1 became agitated and threatened to kill his roommate and brought by the police to a hospital for further evaluation and treatment. The complainant alleged that the facility's administrator was involved in the transfer to the room and board and the facility refused to take the resident back indicating Resident 1's functional level was too high for skilled nursing level of care. A review of Resident 1's record on 10/11/16 indicated he was re-admitted to the facility on 7/30/16 with diagnoses of left leg cellulitis (painful, inflamed, infected skin) requiring wound vacuum (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds), cognitive memory deficit (defined as a conditional state between normal aging and dementia), anxiety disorder (worry that interferes with ability to lead a normal life), morbid obesity (100 pounds over ideal body weight), chronic obstructive pulmonary disease (lung condition that makes it difficult to breathe that is not curable), and atrial fibrillation (afib, irregular heartbeat) on coumadin (blood thinning medication used to prevent blood clots caused by atrial fibrillation). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. He had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 21 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resided at a board and care (a licensed 4 to 16 bed non-medical facility that provided room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring)..... for many years prior to being hospitalized and admitted to facility. Resident 1 was a full code (all resuscitative efforts are to be made in the event of cardiopulmonary arrest). A review of Resident 1's physician progress note, dated 8/22/16, indicated, "Resident has tried to elope (run away) several times during skilled nursing facility stay. He is alert and oriented to self. Facility is trying to find placement for him....being followed by wound medical doctor for right ankle wound (wrong ankle documented by medical doctor). Wound vacuum was discontinued due to patient continuously pulling vac out. Resident is on Coumadin (blood thinning medication to prevent clots) for afib and will continue to monitor international normalized ratio (INR, a lab measurement to determine the effects of Coumadin on the body's blood clotting)....continues to work with physical therapy and occupational therapy (PT/OT)......Left ankle wound clean/dry/intact." A review of Resident 1's physician progress note, dated 9/7/16 indicated, "Resident is alert and oriented to self. He is currently on coumadin and INR is monitored...Resident currently on risperdal (an antipsychotic medication used to decrease mood instability) for mood stability after elopement attempts and aggressive behavior towards staff....left ankle wound clean/dry/intact...discontinue coumadin as resident is not a candidate for INR monitoring in an independent living facility. Will start on Xarelto (another medication used to prevent blood clots)...for anticoagulation." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 22 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's physician progress note, dated 9/14/16 indicated, "multiple medical issues including psych issues...has a wound, left ankle...still having behavior issues on and off." A review of Resident 1's physician progress note, dated 9/27/16 (the date he was discharged), indicated, "Resident is alert and oriented to self. He is discharging to a "board and care" in Sacramento...currently on Risperdal....for mood stability after elopement attempts and aggressive behavior towards staff. Left ankle wound clean/dry/intact." A review of Resident 1's nurses notes, dated 7/29/16 through 9/27/16, indicated Resident 1 had multiple episodes of inappropriate behaviors including yelling, shouting, leaving the facility unattended, resident to resident altercations, and undressing himself in public. Resident 1 was administered ativan (medication to decrease anxiety) twice a day and risperdal was started. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated that Resident 1 had a history of a mental disorder and while at facility he stripped his clothes off in public and urinated on cars. She stated that Resident 1 needed constant supervision due to his behaviors. During an interview with NP on 10/12/16 at 12:35 pm, she stated she will never forget Resident 1; he had loud, inappropriate behaviors. She wrote the order to discharge Resident 1 to a "board and care facility." She indicated that a "board and care" facility should be able to provide care to Resident 1 because they could give him his medications and meals. NP asserted that Resident 1 was a candidate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 23 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to be transferred to the "board and care" despite his leg wound requiring wound care, stating, "his wound was healing, his dressing was clean, dry and intact." A concurrent record review of an order dated 9/22/16 stated "cleanse....ankle with normal saline, pat dry, apply Maxorb calcium alginate rope, cover with kerlix and ace wrap, change every other day for 14 days and then re-assess." NP stated she was under the impression assisted living staff could help with wound treatments. In regards to Resident 1's orientation status being acceptable for a "board and care" NP stated he had "good days and bad days depending on his level of agitation." NP stated she thought a psychiatrist had seen Resident 1 about his behaviors. A concurrent record review showed no evidence that a psychiatrist had seen Resident 1 during his stay at the facility. Resident 1 was discharged from facility on 9/27/16. A physician's order, dated 9/27/16 and signed by NP, indicated, "discharge to board and care with medications and narcotics." During an interview with room and board owner (RB) on 10/11/16 at 1:34 pm and continued on 10/13/16 at 1:00 pm, he stated "we are a room and board, not a board and care." RB stated the facility told him Resident 1 was independent, high functioning and did not need help with his medications. During resident 1's record review on 10/11/16 there was no evidence of documentation by his physician or nurse practitioner indicating Resident 1's health status had improved enough to be discharged to a room and board. Once discharged, Resident 1 was responsible for taking his own medications and performing his own wound care, which would have been difficult evidenced by physician progress notes, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 24 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 8/22 through 9/27/16, stating Resident 1 was "oriented to self" only.

F203 SS=D NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE CFR(s): 483.12(a)(4)-(6)

F203 12/06/2016 Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 25 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide notice before discharging one of 12 sampled residents when Resident 1 was not given required written notice, prior to being discharged to a room and board facility. This failure resulted in Resident 1 and his family not being adequately informed of plans to discharge leading to his inappropriate, unsafe discharge to a lower level of care. Refer to F 204. Findings: On 10/10/16, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was discharged to a room and board establishment and the facility did not disclose the resident's behavior. Resident 1 became agitated and threatened to kill his roommate and brought by the police to a hospital for further evaluation and treatment. The facility refused to take the resident back. The complainant alleged that the facility's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 26 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administrator was involved in the transfer to the room and board. A review of Resident 1's record on 10/11/16 indicated he was re-admitted to the facility on 7/30/16 with diagnoses of left leg cellulitis (painful, inflamed, infected skin) requiring wound vac (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds), cognitive memory deficit (defined as a conditional state between normal aging and dementia), anxiety disorder (worry that interferes with ability to lead a normal life), morbid obesity (100 pounds over ideal body weight), chronic obstructive pulmonary disease (lung condition that makes it difficult to breathe that is not curable), and atrial fibrillation (afib, irregular heartbeat) on coumadin (blood thinning medication used to prevent blood clots caused by atrial fibrillation). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. A review of Resident 1's record on 10/11/16 indicated that there was not a written notice given to the resident or to his family prior to his discharge on 9/27/16. During an interview on 10/12/16 at 10:00 am, with Resident 1's daughter, she stated she was not notified of residents discharge in writing or given appeal rights. She stated she was notified that Resident 1 was being discharged to an "assisted living facility" (a licensed 16+ bed, non-medical facility that provides room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring). Resident 1's daughter stated Resident 1 was in need of constant supervision due to his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 27 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE behaviors, which included: wandering outside of the facility, urinating on cars, and stripping in public. During an interview with the Admin on 10/12/16 at 10:25 am, he stated Resident 1 was desperate to leave the facility and his daughter was excited for him to go. The Admin stated, "I didn't give them anything in writing," and indicated he texted the name and address of the accepting facility to the daughter, further stating, "there was no reason to give them the right to appeal."

F204 SS=J PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG CFR(s): 483.12(a)(7)

F204 12/06/2016 A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency the State LTC ombudsman, residents of the facility, and the legal representatives of the residents or other responsible parties, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.75(r). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a safe and orderly discharge for 1 of 12 sampled residents when Resident 1 was inappropriately discharged to a room and board (unlicensed living arrangement where lodging and food are furnished for a set price, non-medical, landlord tenant situation where resident does not need 24 hour supervision) where his physical and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 28 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychosocial needs could not be met, and without proper assessment, evaluation, preparation, ancillary healthcare services referrals (Home health nursing and physical and occupational therapies) and follow up physician appointments. This failure resulted in Resident 1 being discharged to a place that could not provide adequate care for his needs, such as supervision, behavior monitoring, medication administration, and wound care, jeopardizing his health and welfare, placing him at risk for harm. The room and board owners called 9-11 and the police responded and transported Resident 1 to a hospital for further evaluation and treatment, where he required constant hospital staff supervision and psychiatric evaluation and treatment. Immediate Jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm, for the inappropriate, unsafe discharge of Resident 1. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm. Findings: On 10/10/16, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was discharged to a room and board establishment and the facility did not disclose the resident's behavior. Resident 1 became agitated and threatened to kill his roommate and brought by the police to a hospital for further evaluation and treatment. The facility refused to take the resident back. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 29 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The complainant alleged that the facility's administrator was involved in the transfer to the room and board. Review of a nursing progress note, dated 7/29/16 at 10:13 pm, indicated Resident 1 was a new admission to facility with diagnoses of dementia (loss of brain function affecting memory, thinking and behavior) and bipolar disorder (mental problem characterized by mood swings with emotional highs and lows), that Resident 1 was having behaviors of not letting staff assess his leg wound or help him change his urine-soaked clothes, yelling and swinging at staff, and moving about in the hallway and his room, naked. The Director of Nursing (DON) was notified of these behaviors, and due to facility not being able to care for Resident 1 safely, he was sent back to the hospital. A review of Resident 1's record indicated he was re-admitted to the facility on 7/30/16 with diagnoses of left leg cellulitis (painful, inflamed, infected skin) requiring wound vacuum (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds), cognitive memory deficit (defined as a conditional state between normal aging and dementia), anxiety disorder (worry that interferes with ability to lead a normal life), morbid obesity (100 pounds over ideal body weight), chronic obstructive pulmonary disease (COPD, lung condition that makes it difficult to breathe that is not curable), and atrial fibrillation (afib, irregular heartbeat) on Coumadin (blood thinning medication used to prevent blood clots caused by atrial fibrillation). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. Resident 1 was a full code (all resuscitative efforts are to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 30 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE be taken to save life). Review of a nursing progress note, dated 7/30/16 at 5:17 pm, indicated he was readmitted from the hospital, and did not include diagnoses of bipolar disorder or dementia. The facility notified Resident 1's daughter of his admission and she informed the facility that Resident 1 had a history of behaviors including urinating in public, stripping, and "running away" from the facility, when he lived at a board and care facility (a licensed 4 to 16 bed non-medical facility that provided room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring), prior to hospitalization. Resident 1's daughter was informed by hospital staff that Resident 1 needed to be in a "locked down facility." A review of the facility's Interdisciplinary team (IDT, a team of facility staff who meet to review and plan for resident care needs) progress notes, for Resident 1, dated 8/1/16 at 1:10 pm, included the attendees: Director of Staff Development (DSD), the Administrator (Admin), and Director of Nursing (DON). The IDT note indicated Resident 1's discharge plan was for Resident 1 to return to the community, closer to his sister. Resident 1's family, social services, and physician did not attend the IDT meeting. A review of an IDT conference note, dated 8/2/16, conducted by Social Services Director (SSD) with therapy staff present, attended by Resident 1 and Resident 1's sister (via telephone), indicated the family wanted Resident 1 to stay at the facility as a long term resident. Resident 1's sister stated she wanted Resident 1 to be conserved by the County (a legally appointed decision maker), and he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 31 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE already had a payee. Review of a social services progress note, dated 8/9/16 at 6:47 pm, indicated Resident 1 refused wound care and would not wear a wound vacuum (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds). The progress note indicated Resident 1 wanted to return to his previous board and care. According to the California Advocates for Nursing Home Reform (CANHR) website, board and care and assisted living facilities are for care and supervision of people who are unable to live by themselves, but who do not need 24 hour nursing care. They are considered non-medical facilities and are not required to have nurses, certified nursing assistants, or physicians on staff. Review of a nursing progress note, dated 8/15/16, indicated Resident 1 required skilled nursing care related to his chronic lung disease (COPD) and cellulitis (painful, inflamed, infected skin tissue) of left lower extremity (LLE). Resident 1 had a LLE open wound and prescribed wound care treatments, was forgetful, required supervision for all transfers, and received narcotic pain medication for leg pain. Resident 1 was prescribed Coumadin (blood thinning medication to prevent clots) and the dosage was being adjusted due to abnormal laboratory values per a international normalized ratio (INR, a lab measurement to determine the effects of Coumadin on the body's blood clotting) results. Resident 1 required frequent monitoring and redirection by nursing staff for inappropriate behaviors. A review of the facility's minimum data set (MDS, a resident assessment), dated 8/16/16, indicated Resident 1 had a BIMS score of 13 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 32 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE out of 15 (a mental capacity test that determines the ability to think and reason), no identified mood disorder, required limited assistance with bed mobility, transfers, walking, dressing and toileting, limited to extensive assistance with bathing and hygiene, was independent for eating, continent of bowel and bladder, and experienced pain, daily. A social services progress note, dated 8/17/16 at 10:17 am, indicated Resident 1 could not be re-admitted to his previous board and care. Review of a Nurse Practitioner (NP) progress note, dated 8/22/16 at 10:34 am, indicated Resident 1 attempted to elope (leave the facility, undetected) several times. Resident 1 was only oriented to person (himself). Resident 1 was unable to return to previous board and care, due to family problems. NP Stated that his wound vacuum was discontinued due to the resident removing it. A review of the facility's nurses notes, dated from 7/31/16 through 8/31/16 indicated the following: Resident removed his wound vac which had to be replaced by nursing. Laboratory values for Protime and INR were abnormal, requiring blood thinning medication (Coumadin) dosage adjustments. Resident 1 occasionally refused care but was noted to be mostly cooperative, pleasant, alert, confused, forgetful, required redirection and supervision for all transfers. Resident 1's diet included added nutritional supplements, vitamins and snacks twice daily for wound healing. Due to the resident removing the wound vac twice in 24 hours, it was discontinued, and new orders were received for an absorbent dressing to be applied and covered with kerlix and ace wrap. Resident required supervision for all transfers FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 33 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and toileting. Resident 1 had orders for ear drops and lavage and antibiotics for the LLE wound. Resident 1 was occasionally noncompliant with LLE wound dressing changes. Resident 1 exhibited behaviors of repeating himself verbally several times after spoken to and taking his clothes off several times throughout the day and required supervision for basic ADLs, bed mobility, and transferring. Resident 1 expressed having pain by removing LLE wound dressing and picking at his wound to left medial ankle described to have purulent drainage and reddened tissue surrounding the wound, and pain was treated with narcotic medication. Resident 1 required skilled care for his chronic lung disease and LLE cellulitis/wound. Resident 1's LLE wound was open and had deteriorated. Resident 1 had many verbal outbursts daily, pulled his pants down and urinated on a tree outside the facility in the presence of residents and visitors. Became verbally loud and aggressive with staff (treated with Ativan). Required limited one person assistance required with transfers, dressing and hygiene, had multiple anger outbursts, and required supervision for all transfers and toileting. Occasionally refused medications. Required redirection for aggressive behaviors and many inappropriate verbal outbursts. A review of the facility's Discharge and Transfer-Notice of proposed transfer discharge, dated 9/6/16 at 2:46 pm, stated Resident 1 was to be discharged on 9/8/16 to a board and care, due to his health improving, no longer needing services provided by the facility. The document was not signed by Resident's responsible party or physician. There were no physician progress notes or assessments to indicate Resident 1 was improving mentally, rather there was documentation of his inappropriate behaviors. Resident 1 was still requiring FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 34 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wound care to his LLE and INR monitoring for his Coumadin dosage, which was being changed frequently due to his INR not being in a therapeutic range. Review of a NP progress note, dated 9/7/16 at 10:26 am, indicated Resident 1 was only oriented to himself and on Coumadin requiring INR monitoring. Resident 1 was started on Risperdal (an antipsychotic medication used to decrease mood instability) for elopement attempts and aggressive behavior toward staff. Resident 1 was to be discharged to an assisted living facility (a licensed 16+ bed, non-medical facility that provides room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring). The NP recommended Resident 1's Coumadin was to be discontinued because INR monitoring could not be done at an independent living facility, and Xarelto (another medication used to prevent blood clots) was to be started. Review of a social services progress note, dated 9/8/16 at 12:05 pm, indicated Resident 1 was not accepted to the "retirement home" because the owners of the home stated resident was "unstable to go there." Review of a social services progress note, dated 9/12/16 at 10:37 pm, indicated despite receiving denials from two different board and care homes, due to Resident 1's inappropriate behaviors, declining orientation status, unable to make decisions on his own, the facility's plan continued to be "look for lower level placement," for Resident 1. A review of nursing progress notes indicated he continued to have inappropriate behaviors from 9/9/16 through discharge on 9/27/16 despite FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 35 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the start of Risperdal. Review of a Physician's Report for Residential Care Facilities for the Elderly, signed by the physician (MD A) on 9/23/16, indicated residential care level includes primarily nonmedical care and supervision to meet the needs of the person and "DO NOT PROVIDE SKILLED NURSING CARE." The document indicated Resident 1 was examined on 9/23/16, was 6'1" tall and weighed 253 pounds, could not manage his own treatment/medication/ equipment, and had mild cognitive impairment (defined as a conditional state between normal aging and dementia). The document indicated Resident 1 did not have confusion or inappropriate, aggressive or wandering behaviors and was not able to leave the facility unassisted. The document indicated Resident 1 was not able to administer his own medications or oxygen. Physical health status was "Good." A review of the facility's nurses notes, dated from 9/1/16 through 9/27/16 indicated the following: Resident 1 occasionally refused medications, was found walking outside nude, was uncooperative with care, continued to require Coumadin dosage adjustments for abnormal INR levels, his LLE wound measured 2.5 centimeters (cm) by 5.6 cm by 0.3 cm and was draining fluid. Required one person assistance for ADLs and daily skilled nursing care related to chronic lung disease and LLE cellulitis/wound and medicated for pain and anxiety, continued to require daily dressing changes performed by a treatment nurse, exhibited episodes of being verbally aggressive and inappropriate, requiring redirection for inappropriate behaviors and Ativan for increased anxiety, and was started on a new FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 36 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE antipsychotic medication, Risperdal 0.5 mg every bedtime, for mood instability. Coumadin was stopped and a new medication, Xarelto, was started. Resident 1 was educated by the speech therapist to "stop verbal inappropriateness and behavior with the new facility." On 9/7/16 at 5:40 pm, "new order received from NP for OK to discharge to Columbian Retirement Home with meds, HH/PT/OT for strengthening when arrangements made." On 9/8/16, Columbian owner's refused to take Resident 1. On 9/9/16, Ativan medication was increased to 0.5 mg bid and bid prn. On 9/10/16, Resident 1 required one person assist with ADLs and minimal assistance with transfers, and was alert and oriented to himself only. Resident 1 continued to require daily skilled nursing care for COPD and LLE cellulitis/wound. Resident 1 went outside unattended for about 5 minutes, and after unsuccessful attempts to redirect, exhibited verbal outbursts towards staff. Resident 1 continued to receive narcotic pain medication for leg pain, Ativan for anxiety, and wound dressing changes [cleanse with normal saline, pat dry, cover with calcium alginate rope and dry dressing]. On 9/19/16, Resident 1 required redirection for angry outbursts. Review of the facilities September 2016 medication administration record indicated Resident 1 was administered Ativan for inability to relax on 9/1, 9/2, 9/3, 9/4, 9/9, 9/15, 9/16, 9/18, and 9/21/16. A review of the facility's Discharge/Transfer Report indicated Resident 1 was "Discharged home" on 9/27/16. Resident 1's records indicated he was discharged from the facility on 9/27/16 to a room and board establishment. There was no indication of a plan or orientation process in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 37 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE place to smooth Resident 1's transition from one facility to another. The records showed no discharge summary with medications list that provided important information for the new accepting facility to adequately care for Resident 1. During Resident 1's entire stay at the facility there was no IDT note indicating resident was adequately assessed for appropriate discharge to a lower level of care. A written Right of Appeal of Discharge was not in his record for discharge on 9/27/16. During an interview with hospital staff A (a registered nurse) on 10/11/16 at 10:30 am she stated Resident 1 was brought to the hospital by police officers after he was arrested at a room and board establishment. She stated that Resident 1 had a history of Bipolar disorder, a diagnosis of dementia with behaviors, and was not competent to make his own decisions. Resident 1 made multiple attempts to elope from the hospital and numerous threats to kill staff, requiring a one to one sitter (medical professional designated to directly supervise resident at all times). Hospital staff A stated the facility was called about the status of Resident 1 and they refused to take the resident back. Hospital staff A stated Resident 1 was "dumped" by the facility, resulting in an inappropriate discharge. During an interview with room and board (to where the administrator drove Resident 1 in a car) owner (RB) on 10/11/16 at 1:34 pm and continued on 10/13/16 at 1:00 pm, he stated, "we are a room and board, not a board and care". RB stated the facility told him Resident 1 was independent, high functioning and did not need help with his medications. RB stated the plan was to provide Resident 1 with three meals a day, a room to sleep in, and for him to be independent and compliant with normal landlord/tenant rules. The owner stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 38 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 arrived at 3:15 pm on 9/27/16, with a large bag of medications, and no instructions. He did not know anything about Resident 1's wound on his left leg. RB described Resident 1 as having aggressive behaviors towards the other room and board tenants. RB stated Resident 1 was stealing food from others, threatening to hurt them, and shoved his roommate and said "I'll kick your ass... pour this soda in your face." Resident 1 arranged the stolen food in a line and told his roommate not to touch "my food." RB's wife attempted to speak with Resident 1 about his behaviors, he threatened to hurt her. RB stated the resident had been at his room and board for less than 24 hours when they had to call 9-1-1 for assistance with Resident 1. The police arrived and Resident 1 threatened his roommate in front of the police, they arrested him and stated he was not appropriate to stay at the room and board establishment. During an interview with SSD on 10/11/16 at 2:55 pm, she stated she was not involved in Resident 1's discharge, the Admin was involved with arrangement of the discharge. SSD indicated Resident 1 wanted to go back to his original board and care, but they would not take him back due to issues surrounding resident and family. She stated he was originally accepted to another local board and care, but was denied admittance due to his behaviors. SSD stated Resident 1's family wanted resident to go to a locked facility due to his behaviors. SSD described Resident 1 to be loud and stated he would get in people's faces, he liked to "sunbathe" and would get naked outside. SSD stated Resident 1 had improved physically while at the facility because he was able to walk on his own, however, mentally and psychosocially he declined and was not a good candidate for a board and care. The SSD stated she had not made the ordered referrals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 39 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for HH/PT/OT, prior to or on the day of, Resident 1's discharge on 9/27/16. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated the only information given to her in regards to Resident 1's discharge was that he was being transferred to an assisted living place in Sacramento. She stated the facility gave her the name and address and she was not notified in writing or given discharge appeal rights. She stated that Resident 1 had a history of a mental disorder and while at the facility, he stripped his clothes off in public and urinated on cars. She stated that Resident 1 needed constant supervision due to his behaviors and she was under the impression that the assisted living would be able to provide constant supervision to her father. During an interview with the Admin on 10/12/16 at 10:25 am, he stated Resident 1 was desperate to leave the facility and his daughter was excited for him to go. The Admin stated, "I didn't give them anything in writing," and indicated he texted the name and address of the accepting facility to the daughter, further stating, "There was no reason to give them the right to appeal." A review of the facility's Observation Report: Discharge and Transfer-Discharge plan of care, originally created by the SSD on 9/6/16 at 2:40 pm, indicated Resident 1 was to be discharged on 9/8/16. The 9/8/16 date was lined out and replaced with a different hand written discharge date of 9/27/16, and timed 2:00 pm. A new observation report was never generated for Resident 1's actual discharge that occurred on 9/27/16. The report stated the NHA (nursing home administrator, Admin) personally transported Resident 1 to his new living arrangement via car. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 40 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with NP on 10/12/16 at 12:35 pm, she stated she will never forget Resident 1; he had loud, inappropriate behaviors. When asked about the facility's discharge and IDT processes, NP stated she was not part of the IDT. She stated she referenced a facility provided binder that included the facility's recommendations for residents who should be discharged, and wrote the order to discharge Resident 1 to a board and care facility. She indicated that a board and care facility should be able to provide care to Resident 1 because they give him his medications and meals. In regards to Resident 1's orientation status and confusion, NP stated resident was alert and oriented to person and place depending on his level of agitation. Concurrent record review of her progress note, dated 9/27/16 at 2:10 pm, indicated Resident 1 was alert and oriented to self only. NP stated Resident 1 had good days and bad days and his orientation depended on his level of agitation. NP stated she thought a psychiatrist had seen Resident 1 during his stay at the facility and had ordered medication for him. A concurrent record review showed no evidence that Resident 1 had ever been seen by a psychiatrist at the facility. NP asserted that Resident 1 was a candidate to be transferred to the board and care despite his leg wound requiring wound care, stating, "his wound was healing, his dressing was clean, dry and intact." A concurrent record review of an order, dated 9/22/16, indicated "cleanse....ankle with normal saline, pat dry, apply Maxorb calcium alginate rope (a specialized dressing that provides a moist healing environment), cover with kerlix (absorbent cotton) and ace wrap, change every other day for 14 days and then re-assess." NP stated she was under the impression assisted living staff could help with wound treatments. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 41 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of physician orders written by NP, dated 9/27/16, included: discharge to board and care with medications and narcotics, home health (HH), physical therapy/occupational therapy (PT/OT) when arrangements are made and follow up with primary care provider in 7-10 days. On 10/13/16 at 2 pm, Resident 1's room and board roommate was interviewed. He stated "It was hell" explaining that Resident 1 was as "big as a house" and pushed him, stole his food, and said he was going to "kick my (his) ass." A record review conducted on 10/13/16 indicated there was no discharge summary with medication list for Resident 1. The facility's Observation Report: Discharge and TransferDischarge plan of care form, originally dated on 9/6/16, with date lined out and new date of 9/27/16 hand written next to it, indicated, "medications upon discharge: see physician orders." A review of the Physician Order Report, dated from 7/29/16 through 9/27/16, indicated Resident 1 was taking medications which included: 1. Carvedilol (a medication that lowers blood pressure, adverse reactions include low blood pressure and low heart rate) 3.125 milligrams (mg) twice a day-hold if systolic blood pressure is less than 110. 2. Potassium Chloride (medication used to replace potassium loss with use of furosemide, needs to be taken with food and water to prevent upset stomach) 10 milliequivalents (mEq) daily. 3. Aspirin (used to prevent blood clots in people who have atrial fibrillation, increased risk of bleeding can occur when taking this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 42 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication) 81 mg daily. 4. Digoxin (slows heart rate in people with atrial fibrillation, side effects include dizziness and nausea and vomiting, severe toxicity can occur if Digoxin levels not monitored) 125 micrograms (mcg) daily- hold for apical pulse less than 60. 5. Famotidine (treats and prevents irritations in the stomach) 20 mg daily. 6. Furosemide (used to decrease fluid in the body, adverse reactions include severe dehydration and potassium depletion) 20 mg daily. 7. Xarelto (thins the blood to decrease blood clots from forming, adverse reactions include increased chances of bleeding including bleeding into an important organ resulting in death) 20 mg daily. 8. Cranberry extract (supplement to help prevent urinary tract infections) 425 mg daily. 9. Ativan (medication that decreases anxiety, increased sleepiness can occur when taking this medication and potential for overdose if not taken correctly can lead to injury and death) 0.5 mg twice a day, and Ativan 0.5 mg twice a day, as needed for anxiety. 10. Risperdal (medication used to decrease mood instability, manufacturer warning states use in elderly people with dementia can increase risk of death) 0.5 mg at bedtime. 11. Meclizine (used to treat and prevent dizziness) 25 mg three times a day as needed for vertigo (dizziness). 12. Norco (used to treat pain, side effects include nausea, vomiting, constipation and potential for overdose if not taken correctly) 5325 mg 1 tab every six hours as needed for pain. Review of a physician's order, dated 9/27/16, included, "medications and narcotics" were to go with Resident 1 when discharged. Due to the inappropriate, unsafe discharge that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 43 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE jeopardized the health and welfare of Resident 1 and others, an immediate jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm. On 10/19/16, the Admin involved in the unsafe discharge of Resident 1 was terminated. On 10/20/16 and 10/21/16, the facility presented immediate corrective actions plans which were unacceptable. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm which included in part: -All residents will have safe and appropriate discharges; -All residents and/or responsible parties will be notified of the physician's discharge plan, involved in the discharge planning process, and included in all decisions made concerning discharges; -Written discharge notice will be provided to all residents and/or RPs, per regulatory requirements; -The IDT (interdisciplinary team, to include nursing staff and the Director of Nursing or RN designee, the administrator, and social services and therapy staff) will evaluate all discharges to ensure appropriateness and safety for all residents; -The facility's Medical Director will evaluate all discharges to ensure appropriateness and safety for all residents; -All staff were educated on appropriate and safe discharge practices and expectations and are empowered to stop any discharge that is not safe or appropriate for a resident; and -Administrative staff are available to staff 24 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 44 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hours per day, seven days per week, to prevent potentially inappropriate or unsafe resident discharges. During a follow up interview with Hospital Staff A on 11/3/16 at 3:30 pm, she stated Resident 1 was sent to another skilled nursing facility on 11/1/16, with one to one 24 hour supervision and psychiatric care. Hospital Staff A stated there were no locked facilities who could take Resident 1. A review of hospital records indicated Resident 1 was treated with antibiotics at the hospital for LLE cellulitis. 


F240 SS=E CARE AND ENVIRONMENT PROMOTES QUALITY OF LIFE CFR(s): 483.15

F240 12/06/2016 A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to recognize and evaluate the reasons for one of 12 sampled residents (Resident 2) change in psychosocial condition exhibited by new episodes of crying, self-isolation, and decreased participation in activities and socialization, timely. This failure contributed to a decrease in Resident 2's quality of life after visits to home were stopped. Resident 2's psychosocial decline was later determined to be due to not being able to visit with her husband, sister, brother-in-law and dog. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 45 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Resident 2's record was reviewed and indicated Resident 2 was admitted to the facility on 9/23/14 with diagnoses that included stroke, hemiplegia (paralysis of one side of the body), and aphasia (inability to speak). A Minimum Data Set (MDS, a clinical assessment tool), dated 6/29/16, indicated Resident 2's memory was intact and she had some difficulty in new situations and difficulty communicating. The MDS indicated Resident 1 had no behaviors and no signs of depression. A concurrent observation and interview was conducted on 8/4/16 at approximately 11 am with Certified Nurse Assistant (CNA) 1. Resident 2 was observed in bed with the lights off. A privacy curtain was pulled halfway around the bed blocking her view to the door and hallway, and the curtain along the sliding glass door was closed. The TV was on and the volume was too low to hear. Resident 2 was unable to communicate verbally and nodded her head in response to questions. CNA 1 stated she worked at the facility for several years and knew Resident 2 well. CNA 1 stated Resident 2 understood others and used gestures and pointing to communicate her needs. She stated Resident 2 used to participate in activities and go to the dining room for meals. CNA 1 stated Resident 2 had declined to participate in activities for the past couple weeks and had only eaten in the dining room a couple times since she was struck by another resident. CNA 1 stated she thought this incident possibly contributed to her no longer wanting to go to the dining room. An interview was conducted with Registered Nurse (RN) A on 8/4/16 at 11:20 am. RN A stated Resident 2 displayed crying episodes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 46 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which began one month ago and was prescribed Klonopin (a medication used to treat anxiety). RN A stated Resident 2 no longer liked going to the dining room, declined when asked, and stayed in her room. Resident 2's care plans were reviewed. There was no documented evidence a care plan was developed that addressed Resident 2's psychosocial needs related to her new episodes of crying and self-isolation, and decreased activity participation and social interaction. An interview were conducted with the Social Services Director (SSD) on 8/4/16 at 3 pm. The SSD stated she did not know Resident 2 wasn't participating in activities. The SSD stated Resident 2 liked the coffee social, but did not interact and was not engaged. The SSD acknowledged Resident 2 was isolating herself more and that Resident 2 was frustrated with her inability to communicate. The SSD stated Resident 2 used a communication board when she first came to the facility, but was unable to hold it due to her right side being non-functional. The SSD did not recall if Resident 2 was referred for speech therapy services to help identify effective or alternate ways to communicate. The SSD acknowledged Resident 2 had signs of depression and stated they were possibly related to decreased outings with her husband, sister, and brother-in-law, and dog which occurred after returning from a home visit on 6/15/16, possibly under the influence. The SSD stated Resident 2 did not receive counseling services or other support services and acknowledged they weren't considered. The SSD acknowledged the decrease in home visits had a negative effect on Resident 2's quality of life. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 47 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An interview was conducted with the Activities Director (AD) on 8/4/16 at 3:10 pm. The AD stated Resident 2 used to participate in the coffee social, activities that involved music, and pet visits, and that she used to go on outings and spend time with her family. The AD indicated that was something Resident 2 really enjoyed and was no longer doing. When asked if Resident 2 received in-room visits since she was no longer participating in activities, the AD indicated room visits for Resident 2 had not been initiated. An interview was conducted with the SSD on 10/5/16 at approximately 10 am. The SSD stated a care conference was held with Resident 2's family on 8/10/16. The SSD stated Resident 2's isolation and decrease in participation in activities and socialization was related to no longer going home. The SSD stated after the care conference was held, Resident 2 began going home again to visit her family, her husband, sister, and brother-in-law, and her dog. The SSD stated Resident 2 was now back to her old self. An interview was conducted with the Director of Nursing (DON) on 10/13/16 at 4 pm. When asked what was done to support Resident 2 when her home visits stopped, and she experienced episodes of crying and selfisolation and decreased participation in activities and socialization, the DON stated a care conference was held. The DON acknowledged the care conference did not take place until 8/10/16, more than two months after Resident 2 began to display psychosocial changes. The DON confirmed Resident 2's home visits increased following the care conference and stated Resident 2 was now doing well.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d), 483.20(k)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F279 Event ID: 5X4F11 12/06/2016 Facility ID: CA230000278 If continuation sheet 48 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan based on assessment of the resident for two of 12 sampled residents (Residents 2 and 6) when: 1. For Resident 6, there was no care plan initiated for chronic obstructive pulmonary disease (COPD, lung condition that makes it difficult to breathe that is not curable) with use of oxygen. 2. For Resident 2, there was no care plan for a psychosocial condition change, exhibited by new episodes of crying, self-isolation, and decreased participation in activities and socialization. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 49 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE These failures had the potential for Resident 6 to not have appropriate interventions followed for her disease process and oxygen use and contributed to a decrease in Resident 2's quality of life after visits to home were stopped. Resident 2's psychosocial decline was later determined to be due to not being able to visit with her family. Findings: 1. Resident 6 was admitted to facility on 9/24/16 with diagnoses of COPD and acute respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood). A review of the facility's minimum data set (MDS, a resident assessment), dated 8/16/16, indicated Resident 1 had a BIMS score of 13 out of 15 (a mental capacity test that determines the ability to think and reason). During an observation on 10/24/16 at 10:53 am, in Resident 6's room, she was gasping for air and had oxygen running through a tube that started from a concentrator (a device which concentrates the oxygen from a gas supply, typically ambient air, to supply an oxygen enriched gas stream) into her nose, the settings indicated 2 liters. A facility nurse walked into Resident 6's room to give her a respiratory treatment. A record review on 10/24/16 indicated there was no care plan for Resident 6's diagnosed COPD including interventions for oxygen use. During an interview and concurrent record review on 10/24/16 at 12:03 pm with LVN G, she stated, "Resident 6 does not have a care plan for COPD or oxygen use. Normally, a nurse will implement a care plan, I will put one in (care plan in the computer) right now." A review of Resident 6's physician order, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 50 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9/26/16, indicated, "02 at 2 liter/min via nasal cannula continuous for COPD, goal to maintain 02 sats>90%." A review of the facility's minimum data set (MDS, a resident assessment), dated 10/4/16, indicated Resident 6 was admitted with COPD and respiratory treatments included oxygen therapy. A review of the facility's policy and procedure titled, "Care Planning-Interdisciplinary Team," dated November 2010, indicated an individualized comprehensive care plan is developed within 7 days of completion of the resident assessment. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/Interdisciplinary team (IDT, a team of facility staff who meet to review and plan for resident care needs). 2. Resident 2's record was reviewed and indicated Resident 2 was admitted to the facility on 9/23/14 with diagnoses that included stroke, hemiplegia (paralysis of one side of the body), and aphasia (inability to speak). A Minimum Data Set (MDS, a clinical assessment tool), dated 6/29/16, indicated Resident 2's memory was intact and she had some difficulty in new situations and difficulty communicating. The MDS indicated Resident 1 had no behaviors and no signs of depression. A concurrent observation and interview was conducted on 8/4/16 at approximately 11 am with Certified Nurse Assistant (CNA) 1. Resident 2 was observed in bed with the lights off. A privacy curtain was pulled halfway around the bed blocking her view to the door and hallway, and the curtain along the sliding glass door was closed. The TV was on and the volume was too low to hear. Resident 2 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 51 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unable to communicate verbally and nodded her head in response to questions. CNA 1 stated she worked at the facility for several years and knew Resident 2 well. CNA 1 stated Resident 2 understood others and used gestures and pointing to communicate her needs. She stated Resident 2 used to participate in activities and go to the dining room for meals. CNA 1 stated Resident 2 had declined to participate in activities for the past couple weeks and had only eaten in the dining room a couple times since she was struck by another resident. CNA 1 stated she thought this incident possibly contributed to her no longer wanting to go to the dining room. An interview was conducted with Registered Nurse (RN) A on 8/4/16 at 11:20 am. RN A stated Resident 2 displayed crying episodes which began one month ago and was prescribed Klonopin (a medication used to treat anxiety). RN A stated Resident 2 no longer liked going to the dining room, declined when asked, and stayed in her room. An interview were conducted with the Social Services Director (SSD) on 8/4/16 at 3 pm. The SSD stated she did not know Resident 2 wasn't participating in activities. The SSD stated Resident 2 liked the coffee social, but did not interact and was not engaged. The SSD acknowledged Resident 2 was isolating herself more and that Resident 2 was frustrated with her inability to communicate. The SSD stated Resident 2 used a communication board when she first came to the facility, but was unable to hold it due to her right side being non-functional. The SSD did not recall if Resident 2 was referred for speech therapy services to help identify effective or alternate ways to communicate. The SSD acknowledged Resident 2 had signs of depression and stated they were possibly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 52 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE related to decreased outings with her husband, sister, and brother-in-law, and dog which occurred after returning from a home visit on 6/15/16, possibly under the influence. The SSD stated Resident 2 did not receive counseling services or other support services and acknowledged they weren't considered. The SSD acknowledged the decrease in home visits had a negative effect on Resident 2's quality of life. An interview was conducted with the Activities Director (AD) on 8/4/16 at 3:10 pm. The AD stated Resident 2 used to participate in the coffee social, activities that involved music, and pet visits, and that she used to go on outings and spend time with her family. The AD indicated that was something Resident 2 really enjoyed and was no longer doing. When asked if Resident 2 received in-room visits since she was no longer participating in activities, the AD indicated room visits for Resident 2 had not been initiated. An interview was conducted with the SSD on 10/5/16 at approximately 10 am. The SSD stated a care conference was held with Resident 2's family on 8/10/16. The SSD stated Resident 2's isolation and decrease in participation in activities and socialization was related to no longer going home. The SSD stated after the care conference was held, Resident 2 began going home again to visit her family, her husband, sister, and brother-in-law, and her dog. Resident 2's care plans were reviewed. There was no documented evidence a care plan was developed that addressed Resident 2's psychosocial needs related to her new episodes of crying and self-isolation, and decreased activity participation and social interaction. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 53 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An interview was conducted with the Director of Nursing (DON) on 10/13/16 at 4 pm. When asked what was done to support Resident 2 when her home visits stopped, and she experienced episodes of crying and selfisolation and decreased participation in activities and socialization, the DON stated a care conference was held. The DON acknowledged a care conference did not take place until 8/10/16, more than two months after Resident 2 began to display psychosocial changes. The DON confirmed Resident 2's home visits increased following the care conference and stated Resident 2 was now doing well.

F282 SS=E SERVICES BY QUALIFIED PERSONS/PER CARE PLAN CFR(s): 483.20(k)(3)(ii)

F282 12/06/2016 The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the physician's plan of care (prescribed medications, labs, and treatments) was followed for two of 12 sampled residents (Resident 11 and Resident 6) when: 1. a. The physician's plan of care was not followed when Resident 11 did not receive lavage (irrigation)treatment on 10/7/16, 10/11/16 and 10/21/16, as ordered. 1. b. The physician plan of care was not followed when Resident 11 did not receive wound treatments daily, as ordered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 54 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. The physician plan of care was not followed when Resident 6 did not receive a chest X-ray, CBC, BMP (complete blood count and a basic metabolic panel, diagnostic blood work), and Guaifenesin (medication that helps loosen congestion in chest and throat), as ordered. These failures had the potential to negatively impact the residents well being and to experience a decline in their health status. Findings: 1. a. Resident 11's record was reviewed and indicated Resident 11 was admitted to the facility on 9/28/16 with diagnoses that included syncope (temporary loss of consciousness caused by a fall in blood pressure) and collapse, history of falling, Stage III pressure ulcer (injury due to pressure that involves full thickness tissue loss) of right buttock, difficulty walking, muscle weakness, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) without complications, acquired absence of left leg below the knee. During an interview with Resident 11 on 10/21/16 at 4:40 pm, Resident 11 was alert and oriented x 4 (aware of self, place, time and situation) and stated his only issue was his hearing. Resident 11 stated he got some drops for his muffled hearing and was supposed to have his ear cleaned out. Resident 11 stated he felt having his ear cleaned out would help his hearing. During an interview and concurrent record review with Licensed Vocational Nurse (LVN) E, on 10/21/16 at 4:45 pm, LVN E stated Resident 11 was getting some ear drops and they were just changed. A review of the electronic record physician's orders, with LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 55 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE E, dated 10/7/16, included Debrox 6.5% 4 drops in right ear four times daily and on the fifth day lavage. LVN E reviewed the nurses progress notes and was unable to find any documentation Resident 11 received the lavage. LVN D was sitting at the nurses station and stated a lavage would not be charted because it was not a procedure. A review of the physicians orders for Resident 11, indicated on 10/7/16-10/11/16 there was an order for Debrox drops 4 drops in right ear four times a day, on the fifth day lavage. On 10/11/16-10/14/16, there was an order for Debrox drops 4 drops in right ear four times a day, on the fifth day lavage. A review of the medications flowsheet for Resident 11 indicated the Debrox drops were started on 10/11/16 and administered four times a day as ordered but did not indicate a lavage was ever performed. Documentation indicated the last day the drops were administered was on 10/14/16. During an interview with Resident 11 on 10/21/16 at 5:00 pm, Resident 11 discussed that he did have orders to receive a lavage to clean out his ear. When asked if he had any flushing of his ears, Resident 11 stated "no, just some drops that didn't work." During an interview with the Director of Nursing (DON) on 10/21/16 at 5:10 pm., the DON was asked what the expectation was on performing lavages. The DON stated that it would be charted when it was performed. The DON acknowledged it was a procedure and the expectation of staff was to chart them. A physicians order was obtained by LVN D from Nurse Practitioner (NP) for 10/21/16, lavage right ear with warm water using a bulb FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 56 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE syringe, one time. During an interview with Resident 11 on 10/24/16 at 9:35 am, resident reported he had still not had the procedure done to clean out his ear. A review of the Resident 11's Medication Flowsheet had no initials documented on the treatment order for the lavage of right ear to indicate it was done. During an interview with NP, and concurrent record review, on 10/24/16 at 10:29 am, NP stated she ordered drops with lavage on the fifth day. NP stated it was ordered on 10/7/16 but the pharmacy did not have the drops so she reordered it on 10/10/16 and stated she didn't know that he didn't get the lavage. NP stated she was notified on the evening of 10/21/16 that he hadn't received the lavage so she told LVN D to do it that night. NP reviewed Resident 11's progress notes, orders and medication flowsheets. The progress notes did not show that the order was completed and medication flowsheets were not initialed as being completed. NP stated "well, all I can do is order it again." During an interview with the DON and NP on 10/24/16 at 10:36 am, NP wrote a new order for lavage and the DON stated we will make sure it is done. The DON didn't know why it did not get done initially. During an interview with LVN D on 10/24/16 at 3:04 pm, LVN D discussed lavage that was ordered 10/21/16. LVN D stated LVN E was supposed to have done the lavage. LVN D stated she left early that night, around 6:05 pm, and that she gave LVN E the order she had received from NP prior to leaving her shift, with the understanding LVN E would perform the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 57 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE lavage. During an interview with LVN E on 10/25/16 at 5:03 pm, LVN E was asked what happened with regard to the lavage for Resident 11 on 10/21/16. LVN E stated LVN D had given him the order to lavage but when he talked to the resident, the resident told him he had not been getting the drops so LVN E stated he called the on-call MD, but could not remember who that was, and notified him of the order and what the patient had reported. LVN E stated the on-call MD gave orders to do the drops for five days and then lavage on the fifth day so it would be effective. LVN E stated he notified the night shift nurse of the new order and wrote a progress note. A review of physicians orders and progress notes, dated 10/21/16-10/25/16, indicated there was no documentation of the call made to the on-call MD and new orders received. 1. b. A review of Resident 11's physicians orders, with comparison to Treatment Flowsheet for 10/2016, showed the following treatment orders were not completed daily as ordered: Monitor healing abrasions to left elbow daily for changes x 14 days then reassess: Treatment Flowsheets were not initialed to indicate it was completed on 10/1/16, 10/8/16, and 10/9/16. Monitor scabs to left BKA (below the knee amputation) daily for changes x 14 days then reassess: Treatment Flowsheets were not initialed to indicate treatment was completed on 10/1/16, 10/8/16, and 10/9/16. Monitor scattered abrasions to abdomen daily for changes x 14 days then reassess: Treatment Flowsheets were not initialed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 58 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicate treatment was completed on 10/1/16, 10/8/16, and 10/9/16. Monitor scattered abrasions to right lower extremity daily for changes x 14 days then reassess: Treatment Flowsheets were not initialed to indicate treatment was completed on 10/1/16, 10/8/16, and 10/9/16. Monitor scattered bruising to abdomen daily for changes x 14 days then reassess: Treatment Flowsheets were not initialed to indicate treatment was completed on 10/1/16, 10/8/16, and 10/9/16. Abrasion to left BKA. Cleanse with normal saline (NS). Pat dry and apply TAO then cover with dry dressing daily x 14 days then reassess: Treatment Flowsheets were not initialed to indicate treatment was completed on 10/8/16, 10/9/16, 10/15/16, and 10/16/16. Healing stage III to right lower buttock. Cleanse with NS. Pat dry and apply medihoney. Cover with calcium alginate and dry dressing daily x 14 days then reassess: Treatment Flowsheets were not initialed to indicate treatment was completed on 10/15/16. Santyl ointment 250 unit/gram topical, Stage III to right lower buttock. Cleanse with NS. Pat dry and apply Santyl, cover with calcium alginate and foam dressing daily x 14 days then reassess: Treatment Flowsheets were not initialed to indicate treatment was completed on 10/1/16, 10/2/16, 10/8/16, and 10/9/16. During an interview with the Director of Staff Development (DSD) on 10/24/16 at 2:10 pm, regarding missing signatures on treatment flowsheets to indicate the daily treatments were being performed, the DSD stated that currently there was no treatment nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 59 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE coverage over the weekends. The DSD stated they were aware this was a problem and plan to hire someone. 2. A review of the facility's admission records indicated Resident 6 was admitted to the facility on 9/24/16 with diagnoses of COPD (progressive lung disease) and acute respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 6's physicians orders, dated 10/6/16, included a complete blood count (CBC, a blood test used to evaluate overall health), a basic metabolic panel (BMP, a blood test that measures sugar level, fluid and electrolyte balance, and kidney function), chest x-ray (CXR, radiograph of the chest used to diagnose conditions affecting the chest), and Guaifenesin (medication that helps loosen congestion in chest and throat) 600 mg twice a day for cough for 7 days to be done on 10/7/16 for cough and Resident 6's complaint of shortness of breath. A review of the NP's progress note dated 10/6/16 at 1:51 pm indicated, Resident 6 was complaining of shortness of breath and "productive cough with yellow thin mucous on kleenex." NP indicated to order CBC, CMP, and CXR tomorrow (10/7/16) and to continue to monitor for shortness of breath. Resident 6's record contained no documented evidence the medication was started on 10/6/16 as ordered and blood tests and CXR were completed on 10/7/16 as ordered. An interview with LVN D on 10/21/16 at 5:10 pm confirmed that the lab tests, CXR, and medication were not completed as ordered. LVN D stated, "I don't know why orders were missed." Concurrent record review indicated CXR was obtained on 10/10/16, 4 days after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 60 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 6 complained of shortness of breath. Labs were not collected until 10/11/16. . A review of the CXR results, dated 10/10/16, indicated Resident 6 had lower lung infiltrates bilaterally (lung infection of lower lung area). On same document, handwritten by NP is an order that stated, "Start Levaquin (antibiotic) 750mg...daily for 7 days for pneumonia (lung infection)." A review of a nursing progress note by LVN D dated, 10/10/16 at 11:45 am, indicated, Resident 6 was having difficulties breathing with "labored respiration, congestion on bilateral lower lobes, O2 sat 90% on oxygen." Resident 6 was started on an antibiotics and requested to be sent to the emergency room. A review of physicians orders, dated 10/10/16 at 11:20 am, indicated, "Transfer to emergency room for further evaluation and treatment." A review of NP progress notes, dated 10/10/16 at 11:32 am, indicated, "Resident was seen on 10/6/16 with complaints of shortness of breath, wheezing. Labs were ordered 10/6 and chest x-ray, but were never carried out....chest x-ray completed today revealed bilateral pulmonary infiltrates...transfer to emergency room for further evaluation and treatment." A review of NP progress notes, dated 10/11/16 at 2:30 pm, indicated, Resident 6 was transferred to the emergency room on 10/10/16 and came back on the same day with no new orders. NP stated, "no improvement today.....in tripod position with pursed lip breathing..she is on O2, lungs coarse in bilateral lower lobes...heart rate elevated 130's....start metoprolol (medication to slow heart rate), continue levaquin and continue to monitor for respiratory failure." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 61 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with NP on 10/24/16 at 11:06 am she stated, "staff did not make me aware of the missed orders, Resident 6 did go untreated due to missed orders and would have been prescribed antibiotics sooner, but not sure if outcome would have changed."

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 12/06/2016 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide the necessary intervention of bowel care medications as needed (PRN) per physicians orders for one out of 12 sampled residents (Resident 3). This failure led to Resident 3 being admitted to the acute care hospital on 8/14/16 related to probable aspiration pneumonitis (lung infection related to inhaling materials such as vomit, food or liquids), partial small bowel obstruction (blockage) secondary to constipation (difficulty emptying the bowels, usually associated with hardened stools) and obstipation (severe or complete constipation) , acute renal failure (condition in which kidneys suddenly cannot filter waste from the blood) secondary to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 62 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dehydration (more water is moving out of our cells and bodies than what we take in through drinking) with nausea and vomiting. Requiring treatment that included fluid replacement via IV (through the vein), NG tube placement (a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), a diet of nothing by mouth, oxygen therapy and three different antibiotics. Findings: Resident 3's record was reviewed and indicated Resident 3 was admitted to the facility on 7/26/13 with diagnoses that included Alzheimer's disease (a condition that causes problems with memory, thinking and behavior), hypertension (elevated blood pressure), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and muscle weakness. A review of Resident 3's constipation care plan, dated 4/26/16, indicated Resident 3 was identified to be at risk for constipation secondary to decreased mobility with a goal to have continued satisfactory bowel movements every 1 to 3 days, as evidenced by soft formed stools. The facility's approach to achieving this goal included: administer medications per MD order, encourage fluid intake unless contraindicated and notify MD if decreased bowel sounds/abdominal pain/distention/decreased appetite or fever. A review of the nursing progress notes for Resident 3 indicated that on 6/30/16 at 10:17 am "resident was noted to have a bruise and swelling, painful to touch upper left arm." X-ray report, dated 6/30/16 at 2:50 pm, showed "a slightly displaced fracture involving the proximal humerus. The shoulder joint is grossly intact." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 63 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of physicians orders, dated 7/19/16, indicated Resident 3 was prescribed Tylenol with Codeine 300-30 milligrams (mg) 1 tablet twice a day, in addition to Tylenol with Codeine 300-30 mg every 4 hours PRN for pain. Physician's orders, dated 7/29/16-8/19/16 for Milk of Magnesia (MOM) 30 milliliters (ml) once a day as needed for constipation prevention, Dulcolax laxative suppository 10 mg 1 suppository once a day as needed if MOM ineffective, and Fleet enema 1 enema once a day if Dulcolax suppository ineffective. A review of physician's orders indicated, Resident 3 was taking Remeron (medication to help with sleep) 15 mg 1/2 tablet (7.5 mg) at bedtime and Oxybutynin chloride extended release 24 hr (a medication to help with over active bladder), 10 mg once a day. According to Lexi-comp (on-line program that provides drug information modules and clinical databases) "Tylenol with Codeine, Warnings and Precautions: May cause or aggravate constipation; chronic use may result in obstructive bowel disease." "Remeron, Warnings and Precautions: May cause anticholinergic effects constipation, xerostomia, blurred vision, urinary retention; use with caution in patients with decreased gastrointestinal motility." "Oxybutynin, Warnings and Precautions: may aggravate symptoms of decreased GI motility" (Lexicomp Online, retracted 11/2/16.) A review of nursing progress notes, dated 7/21/16 at 10:15 pm, indicated "resident is now on routine pain management, Tylenol codeine [twice daily]. " On 8/01/16 at 3:25 pm, nursing progress note indicated Resident 3's pain is managed with scheduled medications. "Earlier today FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 64 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE [resident] had a hard bowel movement and had some rectal bleeding, treatment nurse aware and monitoring." On 8/3/16 at 4:19 pm, nursing progress note indicated that IDT met to review weight loss of 9 pounds in 31 days. Listed risk factors included lower lip cellulitis, history of UTI, diabetes, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), vitamin B-12 deficiency and depression. IDT review indicated that the resident had a recent decline in activities of daily living (ADL) and was not assessed for a fecal impaction. Interventions implemented were to downgrade diet to mechanical soft diet, Registered Dietitian (RD) referral and weekly weights x 4 weeks. On 8/13/16 at 7:31 pm, nursing progress notes indicated that resident had one episode of vomiting and on 8/14/16 at 10:18 pm, progress notes indicated "resident being sent out to ER for further evaluation. Patient has had vomiting for the past two days." A review of the facility's PRN Medication Flowsheet, dated 8/1/16-8/31/16, indicated Resident 3 received one dose of MOM on 8/8/16 and one dose on 8/9/16. There was no indication that the medication was effective or that Resident 3 received any dose of the Dulcolax suppository or Fleet enema during the dates of 8/1/16-8/31/16, as ordered by MD. A review of the facility's bowel care log records, dated 8/1/16-8/14/16, showed that no bowel movement was documented between the dates of 8/3/16 through 8/11/16 for Resident 3. A review of Resident 3's ADL flow sheet, dated 8/2016, showed no bowel movement was documented between the dates of 8/2/168/11/16. A review of the hospital physician's history and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 65 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physical examination, dated 8/14/16, indicated Resident 3 was sent to the emergency room (ER) due to not eating for the past week. The document indicated at the time of observation the resident was barely able to talk as "her mouth is too dry, unable to understand her." Indicated that per nurse report from the facility, the patient's respiratory rate was 30 and she was not eating much, only 25-30% of meals, and feeling nauseous with a few episodes of vomiting. The facility did not know when her last bowel movement was. The section, Laboratory data, indicated Resident 3 had a BUN level of 63 and creatinine of 1.7 (BUN and creatinine are blood tests to assess how well the kidneys are functioning Normal BUN range is between 7-20 mg/dl (a unit of measurement) and normal creatinine range for women is 0.6-1.1 mg/dl). Chest X-ray showed bilateral coarse infiltrates consistent with aspiration pneumonitis. CT scan of the abdomen showed partial small bowel obstruction. Assessment and planning indicated this is "1) probably aspiration pneumonitis, partial small bowel obstruction secondary to constipation and obstipation... 2) acute renal failure, BUN is very high, consistent with prerenal azotemia (the most common form of kidney failure), secondary to dehydration with nausea and vomiting." Resident 3 was admitted with a diet of nothing by mouth, NG tube (a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), oxygen, fluid replacement via IV (through the vein), and treatment with 3 different antibiotics. A review of Resident 3's facility nursing progress notes, dated 8/19/16 at 8:23 pm, indicated that resident was transferred back to the facility and arrived in stable condition with an admitting diagnosis of partial small bowel obstruction and UTI. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 66 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview and concurrent record review with the Director of Nurses (DON) on 10/13/16 at 3:20 pm, the DON reviewed all records and searched through electronic records and stated he was unable to find documentation indicating Resident 3 had a bowel movement, unable to find any documentation of intervention done to manage constipation other than the two doses of MOM given, one dose on 8/8/16 and one dose on 8/9/16 and he stated he could not find any charting to indicate when or if the physician was notified that Resident 3 had not had a bowel movement for a period of nine days. The DON stated the facility did not have a policy or specific protocol to address bowel care or constipation.

F327 SS=H SUFFICIENT FLUID TO MAINTAIN HYDRATION CFR(s): 483.25(j)

F327 12/06/2016 The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure four of 12 sampled residents (Residents 3, 4, 5, and 12) received sufficient fluid intake based on individual needs to maintain proper hydration and health when: 1. Resident 4's care plan was not comprehensive and individualized to address Resident 4's risk for dehydration. Resident 4's fluid intake was not monitored, his hydration status was not assessed, and his use of Lasix (a diuretic, a medication that removes excess fluid from the body) was not evaluated when he experienced decreased oral intake, weight loss, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 67 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had no edema (excess fluid), and made frequent requests for water. This resulted in Resident 4 being transferred and admitted to the acute care hospital with acute kidney failure and hypotension (low blood pressure) due to dehydration. 2. Resident 5's care plan was not comprehensive and individualized to address Resident 5's risk for dehydration. There was no ongoing assessment of fluid balance and hydration status when Resident 5's fluid intake was less than 1200 cubic centimeters (cc) in 24 hours and was less than her physician ordered fluid restriction parameter, her fluid intake was not monitored per facility policy, and a comprehensive metabolic panel (CMP, a blood test that measures fluid and electrolyte balance and kidney function) and a complete blood count (CBC, a blood test used to evaluate overall health) were not completed timely. This resulted in Resident 5 being transferred to the acute care hospital with critically abnormal (high) BUN (Blood Urea Nitrogen, a test that measures kidney function) level where she was treated with IV (through the vein) fluids and her Lasix was held. Refer to F 502 for additional information. 3. Resident 3's hydration status was not assessed when she developed nausea and vomiting (increasing her risk for dehydration), and her fluid intake was not monitored upon readmission to the facility. This contributed to Resident 3's transfer to the acute care hospital with acute renal failure secondary to dehydration. 4. Resident 12's fluid intake was not monitored, per facility policy, and he exceeded FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 68 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his physician ordered fluid restriction parameter. This potentially contributed to Resident 12 being transferred to the acute care hospital with shortness of breath and wheezing. Findings: 1. The facility admission record was reviewed and indicated Resident 4 was admitted to the facility on 10/25/12 with diagnoses that included diabetes, dysphagia (difficulty swallowing), dementia, polyuria (excessive amount of urination caused by diabetes or overuse of diuretics), and hypotension (low blood pressure). Review of Resident 4's physicians orders, dated 1/13/16, included Lasix (a diuretic) 80 milligrams (mg, a unit of measure) once daily for edema. Resident 4's dehydration care plan, dated 7/2/16, was reviewed and indicated Resident 4 was at risk for dehydration related to altered skin turgor (a sign used to assess degree of dehydration), impaired mobility, need for assistance with eating, swallowing problems, history of weight loss, urinary incontinence (no control over urination), history of dehydration, history of refusing fluids, and thickened liquids. The care plan included dementia, diabetes, edema, history of urinary tract infections (UTI), psychiatric disorder, renal insufficiency, and use of psychotropic medications as contributing factors to Resident 4's dehydration risk. The care plan approaches included Intake and Output (I & O, measurement of fluids that enter the body and the fluids that leave the body) monitoring as indicated, to observe hydration status as indicated (skin turgor, moist mucous membranes), and to offer fluids as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 69 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tolerated or as indicated by diet order. Documentation of Resident 4's Activities of Daily Living (ADLs, basic self-care tasks) for June and July 2016 was reviewed. The documentation did not indicate the amount of fluid Resident 4 was offered or consumed. The documentation indicated Resident 4 was incontinent of urine, but did not include measurements or indicate the number of incontinent episodes per shift. The documentation indicated Resident 4 had a decrease in meal intake beginning on or about 6/19/16. Between 7/1/16 and 7/8/16 Resident 4 refused 7 of 24 meals and consumed only 25% of his meals on three occasions. There was no documentation of food or fluid intake for three meals during the same time period. Resident 4's Progress Notes were reviewed. A note by the Registered Dietician (RD), dated 7/7/16, indicated Resident 4 had a 10 pound (lb) weight loss in 30 days and a 20 lb loss in 90 days, and that his estimated need for fluids was 2215-2658 cc daily. The note indicated Resident 4 was seen by the Nurse Practitioner (NP) on 7/7/16 and that he had no edema. The note indicated Resident 4 was observed on two occasions slumped while eating and that he frequently asked for water. Resident 4's Weekly Nursing Summaries, dated 7/1/16 and 7/8/16, were reviewed. The summaries included a section titled "Clinical Hydration Evaluation" that indicated Resident 4 was not on I & O monitoring and had no signs of dehydration. Resident 4's Progress Notes, dated 6/25/16 through 7/8/16, contained no documented evidence nursing staff or the RD considered Resident 4's weight loss, decreased intake, and frequent requests for water as possible FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 70 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicators for dehydration. There was no documentation Resident 4's Lasix was evaluated or changed when his oral intake decreased and he had no edema. There was no documentation Resident 4's hydration status was assessed daily and that his fluid intake was measured or monitored to ensure sufficient fluids to prevent dehydration. A Progress Note, dated 7/8/16 at 3:15 pm, indicated the NP ordered stat (urgent) laboratory (lab) tests for Resident 4 due to increased weakness and a change in condition. A Progress Note, dated 7/9/16 at 3:22 am, indicated Resident 4 was transferred to the acute care hospital at 1:05 am due to critically abnormal (high) laboratory test levels. A Nephrology Consult from the acute care hospital, dated 7/9/16, was reviewed. The consult included a HISTORY OF PRESENT ILLNESS that indicated, "[Resident] was brought in with altered mental status and he is extremely dry with very severe metabolic abnormalities (abnormal chemical reactions in the body) including severe hypernatremia (high level of sodium in the blood) with a sodium level of 161 (normal range is between 135-146) and he also has severe acute renal failure (kidney failure) with a BUN of 176 and a creatinine of 7.99." (BUN and creatinine are blood tests used to evaluate kidney function. The normal range for BUN is between 7-25 mg/dL, a unit of measure, and the normal range for creatinine is 0.7-1.3 mg/dL.) The PHYSICAL EXAMINATION indicated, "[Resident] is very dry... Very thin with no trace of edema whatsoever." The IMPRESSION AND PLAN indicated, "The patient came in with severe volume depletion and hypernatremia likely secondary to severe free water losses. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 71 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Dehydration occurs when free water losses exceed free water intake.) His water deficit is quite significant and I expect he has at least 56 liter absolute water deficit. He is also in acute renal failure from tubular necrosis (damage to kidneys) and volume depletion and no evidence of obstruction (blockage)." An interview was conducted with the Director of Nursing (DON) on 10/13/16 at 4:20 pm. The DON acknowledged Resident 4 was at risk for dehydration. The DON acknowledged Resident 4's I & O was not monitored, and stated I & O was only monitored when the physician or nursing staff identified the presence of signs/symptoms of dehydration. 2. The facility admission record was reviewed and indicated Resident 5 was admitted to the facility on 6/2/16 with diagnoses that included end-stage kidney disease. A Minimum Data Set (MDS, a clinical assessment tool), dated 6/9/16, indicated Resident 5 was at risk for dehydration due to presence of a wound and use of a diuretic. Review of Resident 5's physicians orders, dated 6/14/16, included to increase Resident 5's Lasix from 40 mg to 80 mg per day, and for a fluid restriction of 1800 cc every 24 hours. Resident 5's dehydration care plan, dated 6/2/16, was reviewed and indicated Resident 5 was at risk for dehydration related to impaired mobility and urinary incontinence. The care plan included diabetes, depression, edema, presence of infection, and use of an antidepressant as contributing factors to Resident 5's dehydration risk. The care plan approaches included fluid restrictions if ordered and I & O as indicated. The care plan did not specify the amount of fluid to be provided by the dietary and nursing departments in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 72 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accordance with facility protocol. Resident 5's I & O records were reviewed. There was no documentation Resident 5's I & O was monitored on 6/14/16, 6/15/16, 6/16/16, and 6/29/16 through 7/6/16 following the implementation of the fluid restriction. The Weekly I & O Evaluation, located at the bottom of the I & O record was incomplete. The I & O records indicated Resident 5's daily fluid intake was less than 1200 cc per day for 14 out of 18 days. Resident 5's record contained no documented evidence the physician was notified when her fluid intake was less than 1200 cc per day, and less than her physician ordered fluid restriction of 1800 cc per day. Resident 5's blood test results were reviewed and indicated an increase in BUN and creatinine levels as follows: 5/29/16 BUN 57, creatinine 2.2 6/6/16 BUN 69, creatinine 2.3 6/17/16 BUN 76, creatinine 2.4 Review of Resident 5's physicians orders, dated 7/7/16, included two orders written the same day for a CMP and a CBC. Resident 5 had a physician's order, dated 7/12/16, for a CMP and CBC. Resident 5's record contained no documented evidence the blood tests were completed on 7/7/16 and 7/12/16, as ordered. Resident 5's Nursing Progress Notes, dated 7/12/16 through 7/14/16, were reviewed. The notes indicated Resident 5 was being monitored for a decrease in blood pressure and situational awareness. The notes indicated Resident 5 had increased confusion, weakness, lethargy, difficulty standing to ambulate to the toilet, and presence of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 73 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hallucinations. A Progress Note, dated 7/13/16, indicated the Interdisciplinary Team (IDT, a team of facility staff who meet to review and plan for resident care needs) met to discuss Resident 5's functional decline, including unsteady gait, weakness, and increase in hallucinations. The Progress Notes contained no documented evidence the team considered Resident 5's behavioral changes as possible indicators for dehydration. There was no documented evidence the RD completed an initial evaluation to determine Resident 5's estimated need for fluids. There was no documentation Resident 5's hydration status was reassessed and her care plan revised following an increase in her Lasix dose and when she was placed on fluid restrictions. There was no documented evidence Resident 5's fluid intake was accurately measured or monitored to ensure sufficient fluids to prevent dehydration. A Progress Note, dated 7/14/16 at 3:23 pm, indicated Resident 5 had been declining over the past week and was sent to the acute care hospital due to "critically high" labs with a BUN of 107. A review of the hospital physicians history and physical examination, dated 7/14/16, indicated Resident 5 had an elevated BUN level of 114, a creatinine level of 3.35, was treated with IV fluids, and her Lasix held. An interview was conducted with the DON on 8/4/16 at 3:20 pm. The DON acknowledged Resident 5 was at risk for dehydration. The DON stated Resident 5's I & O was monitored when she was placed on a fluid restriction, but was unable to provide a complete accounting of I & O documentation upon request. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 74 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A second interview was conducted with the DON on 10/13/16 at 5 pm. The DON acknowledged Resident 5 had three orders for the same blood tests and that the tests were not completed until 7/14/16, seven days after the original order. The DON was unable to provide documentation or identify why the tests were not done timely. (Refer to F 502). 3. Resident 3 was admitted to the facility on 7/26/13 with diagnoses that included Alzheimer's disease (a condition that causes problems with memory, thinking, and behavior), hypertension (elevated blood pressure), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and muscle weakness. A review of Resident 3's Dehydration Care Plan, dated 4/26/16, indicated Resident 3 was at risk for dehydration related to impaired mobility, history of weight loss, dehydration, poor appetite and urinary tract infections (UTIs). Resident 3's goal indicated will have evidence of adequate hydration as evidenced by: stable vital signs, good skin turgor within normal limits of age, and moist mucous membranes. The facility approach to achieving the goal included to observe hydration status as indicated, observe resident for swallowing problems, refer to speech therapy as appropriate, and to offer fluids as tolerated or as indicated per diet. A review of progress notes, dated 8/3/16 at 4:19 pm, indicated the IDT met to review Resident 3's weight loss of 9 lbs in 31 days. The listed risk factors included lower lip cellulitis, history of UTI, diabetes, hypothyroidism (abnormally low thyroid function), Vitamin B-12 deficiency, and depression. IDT review indicated Resident 3 had a recent decline in ADLs. The IDT note did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 75 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not indicate Resident 3 was assessed for hydration. Interventions implemented were to downgrade diet to a mechanical soft diet, an RD referral, and weekly weights x 4 weeks. A review of Resident 3's ADL log for 8/2016 indicated fluids were offered, but did not show the amount of fluids offered or consumed. The record indicated Resident 3 was incontinent of urine, but did not show a measurement of urine output or indicate the number of incontinent episodes per shift. A review of a weekly summary report, dated 7/28/16, indicated Resident 3's weight was 116 lbs and average meal intake was 1-25%. Resident 3 was not on I &O monitoring and no signs/symptoms of dehydration were identified. A weekly summary report, dated 8/11/16, indicated Resident 3's weight was 106 lbs, average intake was 26-50%, I & O was not being monitored, and indicated no signs/symptoms of dehydration. A review of Resident 3's progress notes, dated 8/8/16 at 5:53 pm, indicated an RD evaluation was done and estimated resident needs per RD note on 7/21/16 to be 1100-1210 calories, 53-63 grams of protein, and 1318-1581 cc of fluid. The note indicated Resident 3's intake was less than 25% with 9 refusals out of 22 meals and her needs were not being met. The note indicated to monitor oral intake and weight trends, but did not indicate any monitoring of fluid intake and output to ensure that hydration needs were being met. A progress note, dated 8/13/16 at 7:31 pm, indicated resident had one episode of vomiting and on 8/14/16 at 10:18 pm, a progress note indicated, "Resident being sent out to emergency room (ER) for further evaluation. Patient has had vomiting for the past two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 76 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE days." A review of the hospital physician's history and physical examination, dated 8/14/16, indicated Resident 3 was sent to the ER due to not eating for the past week. The report indicated at the time of observation the resident was barely able to talk as "her mouth is too dry, unable to understand her," per nurse report from the facility, the patient's respiratory rate was 30 and she was not eating much, only 2530% of meals, and feeling nauseous with a few episodes of vomiting. The facility did not know when her last bowel movement was. The section "Laboratory Data," indicated Resident 3 had a BUN level of 63 and a creatinine of 1.7. "Assessment and Planning" indicated this is "1) probable aspiration pneumonitis, partial small bowel obstruction secondary to constipation and obstipation...2) acute renal failure, BUN is very high, consistent with prerenal azotemia (the most common form of kidney failure), secondary to dehydration with nausea and vomiting. The report indicated Resident 3 was admitted to hospital with a diet of nothing by mouth, NG tube( a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), oxygen, fluids via IV, and treatment with three different antibiotics. A review of Resident 3's nursing progress notes indicated Resident 3 was readmitted to the facility on 8/19/16 at 8:23 pm. An weekly summary report, dated 8/25/16, indicated Resident 3 had no signs/symptoms of dehydration and I & O was to be monitored due to being newly admitted. An interview was conducted with Registered Nurse (RN) B on 10/13/16 at 5:30 pm. RN B confirmed, according to facility policy, staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 77 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE monitored the I & O for all new admissions, residents with a urinary catheter, and residents with signs and symptoms of dehydration. During a telephone interview with Medical Records staff (MR) on 10/14/16 at 1 pm, MR stated she was unable to locate any records of I & O documentation for Resident 3. 4. Resident 12's record was reviewed and indicated he was admitted to the facility on 10/11/16 with diagnoses that included heart failure, kidney disease, and UTI. Review of physician's orders, dated 10/11/16, included a fluid restriction, 1500 cc every 24 hours; morning 700 cc, evening 600 cc and night 200 cc. A review of the 10/2016 medication administration record indicated licensed nurses documented a checkmark for fluid restriction monitoring, but did not indicate fluid amounts. An I & O record, dated from 10/12 through 10/18/16, was reviewed. The record included night, morning, and evening fluid intake sections for "Med Pass," "Meals, "Other" and "Total" and indicated Resident 13 exceeded his physician ordered fluid restriction parameters on 10/13 and 10/17/16. The record indicated fluid intake was not completed on 10/18/16 for the evening shift and there was no total documented for the 24 hour period. A review of a physician's history and physical examination, dated 10/16/16, indicated Resident 12's shortness of breath was improved, and he had congestive heart failure. The physician's plan was to obtain a repeat chest X-ray and restrict fluid intake. The physician indicated Resident 12 may go home in "a few days." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 78 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of a nurses note, dated 10/18/16, indicated Resident 12 was noted to have had a significant drop (low 80's %) in oxygen saturation when walking to the restroom. Review of a nurses note, dated 10/19/16, timed 4:39 pm, indicated Resident 12 complained of shortness of breath after walking to the restroom, his oxygen saturation was low (82%), he was assisted to bed and oxygen was placed back on him, and he had a temperature of 101.2 degrees Fahrenheit. The physician was notified of the change in condition and Resident 12 was transferred to the hospital on 10/19/16 for shortness of breath and wheezing. The facility policy titled "Hydration - Clinical Protocol," revised 9/12, was reviewed. The policy included the following, in part: "Assessment and Recognition: The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example those with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well. Treatment/Management: If medications are contributing to fluid and electrolyte imbalance, they should be tapered or stopped (at least temporarily), or the physician should provide clinically valid reasons why they cannot or should not be changed, even temporarily. Monitoring and Follow-Up: The physician will help monitor for the development... of fluid and electrolyte imbalance in at risk individuals." The facility protocol for "Resident FLUID INTAKE DAILY CHARTING GUIDELINES," undated, was reviewed. The protocol included the following, in part: "2. All residents to have a nursing order: Notify MD for fluid intake less than 1200 cc/day FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 79 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unless contraindicated. 3. RD to calculate fluid needs on Initial, Annual, [Significant Change of Condition] or [Clostridium difficile] diagnosis... 4. For Patients on FLUID RESTRICTION (FR): Fluid restriction order to include cc provided by nursing and dietary. This should also be in the care plan... (To total all fluids [Licensed Vocational Nurse] must print report from Facility Reports: Resident Info... Intake & Output report. EVERY SHIFT)."

F329 SS=E DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l)

F329 12/06/2016 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 80 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to ensure the medication regimen was managed effectively for one of 12 sampled residents (Resident 2) when Resident 2 was prescribed and administered duplicate, unnecessary medications (Cymbalta and Klonopin) without clinical justification for use and nonpharmacological approaches were not considered, prior to the use of the medications. This resulted in Resident 2 receiving unnecessary medications that had the potential to adversely affect her quality of life and physical and psychosocial well-being. Findings: The facility admission record was reviewed and indicated Resident 2 was admitted to the facility on 9/23/14 with diagnoses that included stroke and hemiplegia (paralysis of one side of the body). A Minimum Data Set (MDS, a clinical assessment tool), dated 6/29/16, indicated Resident 2's memory was intact and she had some difficulty in new situations and aphasia (inability to speak). The MDS indicated Resident 1 had no behaviors and no signs of depression. A concurrent observation and interview was conducted on 8/4/16 at approximately 11 am with Certified Nurse Assistant (CNA) 1. Resident 2 was observed in bed with the lights off. A privacy curtain was pulled halfway around the bed blocking her view to the door and hallway, and the curtain along the sliding glass door was closed. CNA 1 stated she worked at the facility for several years and knew Resident 2 well. She stated Resident 2 used to participate in activities and go to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 81 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dining room for meals. CNA 1 stated Resident 2 had declined to participate in activities for the past couple weeks and had only eaten in the dining room a couple times since she was struck by another resident. CNA 1 stated she thought this incident possibly contributed to her no longer wanting to go to the dining room. An interview was conducted with Registered Nurse (RN) A on 8/4/16 at 11:20 am. RN A stated Resident 2 displayed crying episodes which began one month ago and was prescribed Klonopin (a medication used to treat anxiety). RN A stated Resident 2 no longer liked going to the dining room, declined when asked, and stayed in her room. RN A stated Resident 2's family felt her crying episodes were likely related to changes at the facility. An interview was conducted with the Social Services Director (SSD) on 8/4/16 at 3 pm. The SSD stated she did not know Resident 2 wasn't participating in activities. The SSD stated Resident 2 liked the coffee social, but did not interact and was not engaged. The SSD acknowledged Resident 2 was isolating herself more and that Resident 2 was frustrated with her inability to communicate. The SSD stated Resident 2 used a communication board when she first came to the facility, but was unable to hold it due to her right side being non-functional. The SSD did not recall if Resident 2 was referred for speech therapy services to help identify effective or alternate ways to communicate. The SSD acknowledged Resident 2 had signs of depression and stated they were possibly related to decreased outings with her family, after returning from a home visit on 6/15/16, possibly under the influence. The SSD acknowledged counseling and other support services were not considered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 82 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An interview was conducted with the Activities Director (AD) on 8/4/16 at 3:10 pm. The AD stated Resident 2 used to participate in the coffee social, activities that involved music, and pet visits, and that she used to go on outings and spend time with her family. The AD indicated that was something Resident 2 really enjoyed and was no longer doing. When asked if Resident 2 received in-room visits since she was no longer participating in activities, the AD indicated room visits had not been initiated An interview was conducted with the Director of Nursing (DON) on 10/13/16 at 4 pm. When asked what was done to support Resident 2 when her home visits stopped, and she experienced increased isolation and decreased participation in activities, the DON stated a care conference was held. The DON acknowledged the care conference did not take place until 8/10/16, more than two months after Resident 2 began to display behavioral changes. Review of Resident 2's physician's orders, dated 6/26/16, included "psych to [evaluate] and treat for depression," and for Cymbalta (a medication used to treat depression) 30 milligrams (mg) daily. During a concurrent interview on 10/12/16 at 3 pm, the NP stated Resident 2's Cymbalta was ordered for excessive crying and social isolation. Resident 2's record contained an evaluation by the psychologist dated 7/1/16. The evaluation indicated, "Takes Cymbalta but should likely be taking an antianxiety/mood stabilizer such as Klonopin." Resident 2's record indicated Klonopin 0.25 mg was ordered on 7/15/16 for anxiety manifested by crying episodes. The Klonopin was ordered 19 days after the Cymbalta was ordered for the same effect. There were no changes made to Resident 2's Cymbalta when the order for Klonopin was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 83 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE initiated. A follow-up interview was conducted with the psychologist on 10/25/16 at 11:45 am. The psychologist stated he provided evaluations and made suggestions regarding psychopharmacological treatment. The psychologist stated he suggested the use of Klonopin as a mood stabilizer. The psychologist indicated concurrent use of Cymbalta and Klonopin was not intended. Further review of Resident 2's record revealed no documented evidence an Interdisciplinary Team (a team of facility staff who meet to review and plan for resident care needs) meeting was held to discuss and identify the underlying cause(s) and/or potential psychological stressors (altercation with another resident, changes in facility staffing and environment, disruption in home visits, and difficulty with communication) that led to Resident 2's crying episodes and isolation. There was no documented evidence the use of non-pharmacological approaches were implemented prior to or in addition to the use of medication. There was no documentation regarding the rationale and benefits for the concurrent use of Cymbalta and Klonopin for crying episodes or self-isolating.

F497 SS=E NURSE AIDE PERFORM REVIEW-12 HR/YR INSERVICE CFR(s): 483.75(e)(8)

F497 12/06/2016 The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; address areas of weakness as determined in nurse aides' performance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 84 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reviews and may address the special needs of residents as determined by the facility staff; and for nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to complete annual performance evaluations for every Certified Nurse Assistant (CNA) who worked in the facility over the past year, to ensure CNAs were provided the necessary education and were proficient in providing residnet care to meet the needs of the residents. This had the potential for residents to receive substandard care which could adversely affect their health and well-being. Findings: On 10/20/16 at 2:32 pm, during a concurrent interview and record review the Director of Staff Development (DSD) stated that she had been working in this position for the last 10 months. The DSD stated that all staff were considered new employees as of 4/1/16 when a new company purchased the facility. An employee list with hire dates documented 36 CNA's remained with the facility. The DSD stated that she did not have the original hire dates for these CNA's and was unsure of when an annual competencies would be due. The DSD provided a calendar and confirmed that she created the schedule from general regulatory required in-service. The DSD stated if facility concerns are brought to her attention she adds them to the in-service schedule. The DSD confirmed that there were no specific inservices scheduled that addressed nutritional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 85 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or hydration needs of patients or related nursing interventions.

F498 SS=E NURSE AIDE DEMONSTRATE COMPETENCY/CARE NEEDS CFR(s): 483.75(f)

F498 12/06/2016 The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to perform skills checks for newly hired Certified Nurse Assistants (CNA) and annual competency assessments on CNAs who had a history of working in the facility. This had the potential for residents to receive substandard care which could adversely affect their health and well-being. Findings: On 10/20/16 at 2:32 pm, during a concurrent interview and record review, the Director of Staff Development (DSD) stated that she took the DSD position in 12/2015. The DSD stated that all staff were considered new employees as of 4/1/16, when a new company purchased the facility. An employee list with hire dates documented 36 CNAs remained with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 86 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility. The DSD stated there had not been any skills checks completed or annual competencies done for these CNAs. The DSD stated that she did not have the original hire dates for these CNAs. The DSD confirmed that there had not been skills checks completed on CNAs that were hired between 4/1/16 and 10/20/16. The DSD stated she was unsure what the policy instructed. The facility's policy was requested for review, but was not provided by end of survey.

F502 SS=E ADMINISTRATION CFR(s): 483.75(j)(1)

F502 12/06/2016 The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure laboratory (lab) tests were completed, as ordered, for three of 12 sampled residents (Residents 2, 5, and 6). This failure had the potential for Residents 2, 5, and 6 and other residents who have ordered labs to have incomplete evaluations of their current health statuses. Findings: 1. The facility admission record was reviewed and indicated Resident 2 was admitted to the facility on 9/23/14 with diagnoses that included heart failure, diabetes, and hyperlipidemia (elevated cholesterol). Review of Resident 2's physician's orders, dated 11/19/15, included a lipid panel (a blood test that measures cholesterol levels) and liver FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 87 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE function tests (blood tests used to help diagnose and monitor liver disease or damage) the first Monday of May and November. Resident 2's record contained no documented evidence the blood tests were completed in May, as ordered. An interview was conducted with the Medical Records Director (MRD) on 8/4/16 at 1:50 pm. The MRD reviewed Resident 2's record and confirmed the blood tests were not done in May, as ordered. The MRD acknowledged there was no documentation Resident 2 refused to have the blood tests done and stated lab services denied coming out to the facility. 2. The facility admission record was reviewed and indicated Resident 5 was admitted to the facility on 6/2/16 with diagnoses that included end-stage kidney disease. Review of Resident 5's physician's orders, dated 7/7/16, included two orders written the same day for a comprehensive metabolic panel (CMP, a blood test that measures sugar level, fluid and electrolyte balance, and kidney and liver function) and a complete blood count (CBC, a blood test used to evaluate overall health). Resident 5 also had a physician's order, dated 7/12/16, for a CMP and CBC. Resident 5's record contained no documented evidence the blood tests were completed on 7/7/16 and 7/12/16, as ordered. An interview was conducted with the Director of Nursing (DON) on 10/13/16 at 5 pm. The DON acknowledged Resident 5 had three orders for the same blood tests and that the tests were not completed until 7/14/16, seven days after the original order. The DON was unable to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 88 of 89 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555682 (X3) DATE SURVEY COMPLETED 10/24/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE POST-ACUTE 1617 Ramirez St Marysville, CA 95901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provide documentation or identify why the tests were not done timely. 3. A review of the facility's admission orders indicated Resident 6 was admitted to the facility on 9/24/16 with diagnoses of COPD (a progressive lung disease) and acute respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood). Review of Resident 6's physician's orders, dated 10/6/16, included a basic metabolic panel (BMP, a blood test that measures sugar level, electrolyte and fluid balance, and kidney function) and a CBC to be done on 10/7/16 for cough and Resident 6's complaint of shortness of breath. Resident 6's record contained no documented evidence the blood tests were completed on 10/7/16, as ordered. An interview with Licensed Vocational Nurse (LVN) D on 10/21/16 at 5:10 pm confirmed that the lab tests were not done on 10/7/16, as ordered. LVN D stated, "I don't know why orders were missed." Concurrent record review indicated labs were collected on 10/11/16 and Resident 6 had to be treated for a high potassium level with kayexalate (medication that helps the body get rid of too much potassium). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5X4F11 Facility ID: CA230000278 If continuation sheet 89 of 89