Inspection·March 4, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to assess for self-administration of medication for 1 of 15 sampled residents (Resident 36) when Resident 36 was allowed to self-administer her oral inhaler. This failure had the potential for Resident 36 to develop medication side effects if medication was self-administered inappropriately. Residents Affected - Few Findings: During a clinical record review for Resident 36, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with a diagnosis that include Chronic Obstructive Pulmonary disease (COPD - diseases that cause airflow blockage and breathing-related problems). During a clinical record review for Resident 36, the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems) dated 1/28/22 indicated Resident 36 had a BIMS score of 11/15 (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). During an observation on 2/28/22 at 10:15 a.m. in Resident 36's room, Resident 36 self-administered 2 puffs of the Budenoside Formoterol inhaler (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma) that was on top of her overbed table, removed the mouthpiece from her mouth with no wait time and did not rinse her mouth with water after use. Resident 36 nodded her head when asked if she would normally self-administer her own oral inhaler,. During an observation, interview, and concurrent record review with Licensed Nurse D on 2/28/22 at 4:14 p.m., Licensed Nurse D verified the Budesonide Formoterol inhaler was still at Resident 36's overbed table. Asked Licensed Nurse D reason for Resident 36 keeping the inhaler at bedside, Licensed Nurse D stated, morning nurse must have forgotten to take it back. Licensed Nurse D verified Resident 36 had an order for Budesonide Formoterol inhaler to give 2 puffs with special instruction to rinse mouth with water after use. He stated Resident 36 self-administers her own oral inhaler and knew how to do it. Licensed Nurse D verified there was no care plan for self-administration of medication for Resident 36. During an interview and concurrent record review with Licensed Nurse C on 3/2/22 at 3:56 p.m. Asked Licensed Nurse C what the process was for allowing Resident 36 to self-administer her own oral inhaler, Licensed Nurse C stated she educated Resident 36 to rinse her mouth, but it was hard for Resident 36 to follow instructions. When asked should Resident 36 self-administer her inhaler if she was hard to follow instructions, she stated, No. Asked Licensed Nurse C about the risk for Resident 36 not rinsing her mouth after administration of Budesonide oral inhaler, Licensed Nurse C stated, because Budesonide is steroid, [Resident 36] could have gum sore, or patches on her tongue. Licensed Nurse C verified there was no care plan for self-administration of medication for Resident 36. During an interview and concurrent record review with the Director of Nursing (DON) on 3/3/22 at 2:25 p.m. Asked DON about the process when resident could self-administer his/ her own medication. DON stated resident would normally request to self-administer her own medication, the Interdisciplinary Team (IDT health care professionals who work together toward the goals of the resident) would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 2 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meet to discuss if resident was appropriate to self-administer, then the nurse would go in and assess the resident to see if resident was appropriate for self-administration. Asked DON if Resident 36 requested to self-administer her oral inhaler, DON stated Resident 36 recently requested if she could self-administer her own inhaler. DON stated the self-administration of medication assessment was initiated on 3/1/22 but was not completed and Resident 36 did not receive health teachings for self-administration due to Resident 36 was sent out to the acute hospital. Review of the Facility policy and procedure titled Self-Administration of Medications revised in February 2021 indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that is clinically appropriate and safe for resident to do so. Review of the Budesonide and Formoterol insert from Resident 36's medication box indicated, Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol may cause serious side effects including Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol to help reduce your chance of getting Thrush (an infectious disease, caused fungus) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 3 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a record review on 2/28/22 at 4:45 p.m., Resident 145's electronic medical record (eMR) indicated she was [AGE] years old and had been admitted [DATE] with diagnoses including dysphagia (difficulty chewing or swallowing), protein-calorie malnutrition, dementia, gastrostomy (insertion of a feeding tube directly into the stomach through the wall of the abdomen), and failure to thrive. Resident 145's registered dietician note dated 2/16/22 indicated Resident 145's body mass index was 13 and she was severely underweight. Resident 145's Braden scale (a tool used for determining risk for pressure ulcers (bed sores)) dated 1/16/22, indicated Resident 145 was at moderate risk for pressure ulcers. An Interdisciplinary Team Skin Note dated 2/3/22 indicated Resident 145 had a deep tissue injury (an injury to skin caused by prolonged pressure) to her coccyx (tailbone area) that was 5 centimeters long and 0.5 centimeters wide. Resident 145's MDS (minimum data set, an assessment tool), Section M, with a reference date of 1/11/22 indicated Resident 145 was not at risk for developing pressure ulcers. Residents Affected - Some During a record review and concurrent interview on 3/3/22 at 2:01 a.m., MDS Nurse reviewed Resident 145's MDS Section M with reference date 1/11/22. MDS Nurse stated, She (Resident 145) is at risk, it was a typo. I will do a modification. Based on observation, interview and record review the facility failed to ensure accurate MDS assessments (The Minimum Data Set is a tool for implementing standardized assessment and for facilitating care management in nursing homes) were submitted for two of two sampled residents (Residents 46 and 145) when they: 1.Failed to document the correct discharge disposition for one Resident, Resident 46. This failure led to an incorrect discharge disposition submitted on Resident 46 MDS which indicated Resident 46 was discharged to a hospital. 2. Failed to identify risk for pressure ulcers on one Resident, Resident 145. This failure could have potentially lead to Resident 145 not getting the pressure ulcer prevention she needs. Findings: 1. Review of the closed record/progress notes and care plan for Resident 46 on 03/03/22 at 11:00 am, indicated that Resident 46 did not get discharged to a hospital from the facility. Resident 46 was discharged to home with Home Health. During an observation and concurrent interview on 03/03/22 at 11:51 am, the MDS Nurse stated she was still learning [MDS]. the MDS nurse stated she had been the MDS nurse since September 2021. Resident 46 was admitted on [DATE]. When asked if Resident 46 was discharged to the hospital from the facility, the MDS nurse stated I'm thinking no. When asked where Resident 46 discharged to, the MDS nurse looked at the MDS record and stated, the notes say [Resident 46] discharged home with husband and home health. When the MDS nurse was shown the discharge disposition, from Part A on the MDS, dated [DATE], which indicated Resident 46 was discharged to a hospital, the MDS nurse stated, that was probably a mistake. I did make a mistake . I can do a modification. The facility policy and procedure titled Resident Assessments dated 2001 (Revised November 2019) indicated A comprehensive assessment of every resident's needs is made at intervals designated by OBRA(Omnibus Budget Reconciliation Act) and PPS (SNF Prospective Payment System) requirements. 1. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 4 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident Assessment coordinator is responsible to ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments-conducted for all residents in the facility. PPS required assessments-conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits. (7.) emergence of a new pressure ulcer at stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening pressure ulcer status. Event ID: Facility ID: 555127 If continuation sheet Page 5 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan for 1 of 15 sampled residents (Resident 36) when: 1. The facility did not develop a care plan for weight gain to indicate how the facility would monitor and maintain Resident 36's weight. 2. The facility did not develop a Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs) care plan to indicate what symptoms to expect, how often and what to monitor. (Reference F684) This failure resulted to Resident 36's continued weight-gain due to worsening bilateral leg edema and subsequently was transferred to the acute hospital due to shortness of breath. Findings: 1. During a clinical record review for Resident 36, the Face sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with a multiple diagnosis that include Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs), Cardiomyopathy (heart loses its ability to pump blood effectively). During a clinical record review for Resident 36, the Care Plan created on 2/1/22 indicated, BLE (bilateral lower extremity) +4 pitting edema (swollen part of your body has a dimple (or pit) after pressing it for a few seconds) worsening. During a clinical record review for Resident 36, the Weight and Vitals Summary record indicated Resident 36 had an 11 lbs. (5.54%) weight gain from 1/26/22 to 3/1/22. During a clinical record review for Resident 36, the Dietary Note dated 2/2/22 at 3:36 p.m. indicated Resident 36 weighed 205 lbs. with a significant weight gain of 5.4 lbs. in one week. During a clinical record review for Resident 36, the Doctor's Note dated 3/1/22 indicated, Patient had been gaining weight, refusing to be weighed intermittently, noted with worsening leg edema and weight gain. Doctor's lung assessment indicated Resident 36 had crackles (occur if the small air sacs in the lungs fill with fluid) to her bilateral lung fields. During an interview with Licensed Nurse J on 3/4/22 10:41 a.m., Asked Licensed Nurse J what to monitor for residents with CHF, Licensed Staff J stated she would monitor for edema, monitor resident's weight, notify the doctor for any changes, and initiate a care plan. Licensed Nurse J verified there was no weight gain care plan for Resident 36. During an interview and concurrent record review with the DON on 3/4/22 at 11:16 a.m., the DON was asked about their process in tracking weight changes for residents, the DON stated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) with the Registered Dietician would meet to identify residents who had a significant weight change. She stated the IDT met on 2/2/22 to discuss Resident 36's weight. The DON verified there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 6 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 care plan for Resident 36's weight gain. Level of Harm - Minimal harm or potential for actual harm Review of the Facility policy and procedure titled Weight Assessment and intervention revised in September 2008 indicated, the threshold for significant unplanned and undesired weight loss/ gain will be based on the following: 1 month - 5% weight loss/ gain is significant; greater that 5% is severe Residents Affected - Few 2. During a clinical record review for Resident 36, the Care Plan created on 2/1/22 indicated, BLE (bilateral lower extremity) +4 pitting edema (swollen part of your body has a dimple (or pit) after pressing it for a few seconds) worsening. Ongoing fluctuations in fluid/ hydration status, CHF, cardiomyopathy. The care plan interventions did not indicate to monitor for signs of shortness of breath or to assess lung sounds for congestion. During an interview with Physician L on 3/3/22 at 10:55 a.m., Physician L stated Resident 36 was admitted to the acute hospital for CHF exacerbation (worsening of a disease). During an interview with Physician L on 3/4/22 10:34 a.m., Asked Physician L what his expectation from the nurses on what to monitor for residents with CHF, he stated he had a protocol for nurses on what to monitor for residents with CHF. He stated he expected the nurses to monitor for resident's weights, to maintain fluid and salt restrictions, monitor vital signs and perform respiratory assessments. During an interview with Licensed Nurse J on 3/4/22 10:41 a.m., Asked Licensed Nurse J what to monitor for residents with CHF, Licensed Staff J stated she would monitor for edema shortness of breath, presence of cough, perform lung assessment and notify the doctor for any changes. Licensed Nurse J verified there was no care plan specific to CHF to indicate what licensed nurses should monitor and when to report to the doctor. Review of the Facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised in December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plan are revised as information about the residents and the residents' condition change. Review of the Facility policy and procedure titled Heart Failure - Clinical Protocol revised in November 2018 indicated, The nurses will assess and document/report the following: Vital signs; General physical assessment. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 7 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, one of 15 sampled residents (Resident 21's): 1. Fall Risk care plan and 2. Risk for Constipation care plan were not adequately updated with interventions to prevent falls from occurring and constipation. These failures contributed to Resident 21: 1. falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death and 2. Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized . Findings: 1. A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone) and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical/Telemedicine Visit, dated 5/18/21, indicated Resident 21 had diagnosis including Alzheimer's Disease and lumbar 2/thoracic 3 fracture, status post fall resulted in inability to walk and decrease mobility, had no decision-making capacity, and was admitted on Fall Precautions. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/25/21, indicated Resident 21's BIM (Brief Interview of Mental Status) of 5 (severely cognitively impaired). Resident 21 needed one person physical assist with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), and personal hygiene. Resident 21 needed two plus persons physical assist to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Resident 21 was total dependent on bathing. Resident 21 was not steady and needed assistance when moving from seating and standing position, walking with assistive device, moving on/off the toilet, and transferring between bed and chair or wheelchair. A review of Resident 21's admission Assessment V4-V3, dated 5/18/21, indicated Resident 21's primary diagnosis was fall. Resident 21 was a fall risk. Resident 21 was alert with forgetfulness, not a reliable historian, could stand, but unsteady. A review of Resident 21's document, Risk for Falls WH, dated 5/18/21, indicated Resident 21 had a fall in the last thirty days prior to admission, cognitive skills were moderately impaired (decisions poor/supervision required), gait: balance problems when standing, and while walking, and needed assistive devices, such as a walker and wheelchair. Resident 21 was a High Risk for falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 8 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 21's Risk for Fall care plan, initiated 5/18/21, indicated fall risk interventions included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure that the resident is wearing appropriate footwear (shoes with non-slip sole or non-skid socks) when ambulating or mobilized in wheelchair, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team - professional disciplines, such as physician, case manager, nurse, social services, etc. work together to provide the greatest benefit for the resident/family/responsible party), the resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position, handrails on walls, and personal items within reach. Fall One: A review of Resident 21's Change of Condition Assessment/SBAR (Situation, Background, Assessment and Recommendation), dated 5/20/21, indicated Resident 21 had an unwitnessed fall on 5/20/21 at approximently 6 p.m. Resident 21 was found on the floor laying on her back perpendicular to her bed. A review of the Fall IDT note, dated 5/21/2021, indicated Resident 21 stated, I was just trying to get over here from there. The IDT plan was to have Resident 21 will be up in her wheelchair at the nurse's station when awake. A review of Resident 21's short term Actual Fall with No Injury, created 5/20/21 and initiated 5/21/21, indicated to continue interventions on the At Risk Fall care plan, for no apparent acute injury. New interventions included: determine and address causative factors (Resolved 7/9/21), monitor/document/report to physician for sign/symptoms: pain, and change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation (Resolved 7/9/21), and Resident 21 to participate in activities daily (Initiated 5/24/21 and Resolved 7/9/21). Resident 21's Risk for Falls care plan was not updated specifying the IDT plan for Resident 21 to be up in her wheelchair at the nurse's station when awake. The facility Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. Fall Two: A review of Resident 21's Change of Condition Assessment/SBAR, dated 5/25/21, and Nurses Progress Notes, dated 5/25/21, indicated Resident 21 had an unwitnessed fall on 5/25/21 at 4:20 a.m. Resident 21 was found by staff sitting down on her roommates fall mat. When Resident 21 was asked what she was trying to do, Resident 21 stated, This is my house and my business. Nurse noted redness to Resident 21's right hand/wrist. A review of Resident 21's short term Actual Fall with Minor Injury: Poor Balance, Unsteady Gait, created 5/25/21 and initiated 5/25/21, indicated to continue interventions on the At Risk Fall care plan. New interventions included: ensure resident has a floor sensor pad in place while resident is in bed to alert staff that Resident 21 is trying to get out of bed alone (Resolved 7/20/21), and plan is to have an up in wheelchair schedule for the resident throughout the day (Resolved 7/20/21). Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 9 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Fall Three and Four: Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's Change of Condition Assessment/SBAR, dated 6/6/21, and Nurses Progress Notes, dated 6/6/21, indicated Resident 21 had two witnessed falls on 6/6/21 at 4:30 p.m. and 5:20 p.m., while Resident 21 was up in her wheelchair near Nurse's Station Two. Resident 21's Nurse's Progress Note, indicated Resident 21 had a behavior of inability to relax and kept propelling back and forth in her wheelchair, which led to her sliding out of her wheelchair and landing on her buttocks two times within a one-hour period while near Nursing Station Two. There was no documentation Resident 21 was being monitored/supervised closely when falls occurred. Resident 21 told nurse she was attempting to see her daughter. Residents Affected - Some Aa review of Resident 21's IDT Progress Note, dated 6/9/21, indicated: IDT recommends placing sensor pad on wheelchair to alert staff when Resident 21 is attempting to standup. The IDT recommendation was not initiated on Resident 21's Fall care plan until 7/7/21 and no other interventions were initiated after Resident 21's two witnessed falls on 6/9/21. Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day. Fall Five: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/3/21, Nurse's Progress Note, dated 7/3/21, and Post Fall Evaluation, dated 7/3/21, indicated Resident 21 was found in the lying on the floor the bathroom floor at 4 p.m. on her right side with her head up. A review of Resident 21's short term Fall care plan for 7/3/21 fall, included the following short-term interventions: added floor mat, initiated 7/6/21 and resolved 8/23/21, monitor frequently for safety, initiated 7/3/21 and resolved 8/23/21, and provide redirection frequently, initiated 7/3/21 and resolved 8/23/21, During an observation on 2/28/22 at 4:08 p.m., Resident 21 was propelling self in hallway with no supervision and propelled self to the Physical Therapy (PT) room. During an interview on 3/3/22 at 8:48 a.m., Licensed Nurse A stated most of the time the Health Care Personal (HCP) kept Resident 21 out by the Nurse's Station. Licensed Nurse A stated Resident 21 had no alarm on her bed and wheelchair. When Licensed Nurse A was asked how often Resident 21 was checked, Licensed Nurse A stated HCP checked on Resident 21 every two hours. Licensed Nurse A stated the Night shift probably checked on Resident 21 every two hours and frequently while awake. Licensed Nurse A could not explain what he meant by frequently except for Resident 21 was checked on every two hours. Fall Six: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/20/21, and Nurse's Progress Note, dated 7/20/21, indicated Resident 21 had an unwitnessed fall on 7/20/21at 11:45 a.m. Resident 21 was found on floor mat at bedside. Resident 21 stated to nurse she was trying to go to the bathroom. Resident 21 was assisted back to bed with one person assist. A review of Resident 21's short term Fall care plan for 7/20/21 fall, included one new short term intervention: Scheduled toileting every two hours while up in wheel, initiated 7/21/21 and resolved 8/23/21. Resident 21's Fall care plan did not specify scheduled toileting while in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 10 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Fall Seven: Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's Change of Condition Assessment/SBAR, dated 8/5/21, and Post Fall Evaluation, dated 8/5/21, indicated Resident 21 was trying to stand from her wheelchair on her own and walk to the bathroom when she had an unwitnessed fall on 8/5/21 at 3:45 p.m. Residents Affected - Some A review of Resident 21's Post Fall Evaluation, dated 8/6/21, indicated Resident 21's wheelchair alarm was going off, so a Certified Nursing Assistant (CNA) went to check on Resident 21. The CNA saw Resident 21 had fallen from her wheelchair in front of her bathroom. A review of Resident 21's Risk for Falls had no new interventions and there was no short term Fall care plan initiated for Resident 21's 8/6/21 unwitnessed fall. A review of Resident 21's Fall IDT Progress Note, dated 8/12/21, indicated IDT reviewed Resident 21's fall history with a plan to provide a wedge cushion for her wheelchair and anti-roll back wheel locks for the prevention of falls. Resident 21 continued with physical therapy for safety and functional mobility. The interventions addressed were not added to Resident 21's Fall Risk care plan. Fall Eight: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/2/21, Post Fall Evaluation, dated 11/2/21, and Nurse's Progress Notes, dated 11/2/21, indicated Resident 21 had a witnessed fall on 11/2/21 at 5:30 p.m. while up in her wheelchair in the hallway. Resident 21 was pulling herself down the hallway using the hall siderail while her wheelchair wheels were against the side of the wall. Resident 21 pulled herself forward causing Resident 21 to lose her body balance and fell forward out of her wheelchair whereby Resident 21 landed on the floor on her right side. Resident 21, who had poor safety awareness, had no HCP nearby monitoring Resident 21 to prevent her from falling out of her wheelchair. Nurse who witnessed fall was coming from the opposite direction. A review of Resident 21's short term Fall care plan, date initiated 11/2/21, indicated interventions included educate resident/family/caregivers about safety reminders and what to do if a fall occurs, continue PT, and plan was to have resident up in wheelchair at nursing station when awake. Resident 21 has fallen three times while up in hallway near nurse's station. There were no new recommendations to prevent further falls such as how staff was going to provide and monitor for supervision. Fall Nine: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/3/21, Post Fall Evaluation, dated 11/3/21 and Nurse's Progress Notes, dated 11/3/21, indicated Resident 21's chair alarm went off around 8:10 a.m. The CNA and nurse quickly went to Resident 21's room where Resident 21 was noted to have an unwitnessed fall. Resident 21 was found near the doorway and sink, laying on her left side facing the sink. Resident 21 withstood a small bump/redness to left forehead and back of right hand was discolored. A review of Resident 21's short term Fall care plan, date initiated 11/3/21, indicated one new intervention: Provide activities that promote exercise and strength building where possible Provide 1:1 activities if bed bound, which was resolved 11/18/21. A review of Resident 21's Quarterly MDS ), 11/24/22, indicated Resident 21's BIM (Brief Interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 11 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm of Mental Status) of 3 (severely cognitively impaired) and Resident 21 was not steady, only could stabilize with staff assistance when moving from seating and standing position, moving on/off toilet, and transferring between bed and chair or wheelchair. Ambulation did not happen. Fall Ten: Residents Affected - Some A review of Resident 21's Nurse's Progress Note dated 1/13/22 indicated and an IDT Note, dated 1/14/21, indicated Resident 21 had a witnessed fall on 1/13/21 around 4:15 p.m. right after room change. Resident 21 was in her new room in her wheelchair and attempting to stand. Resident 21 lost her balance and fell to her knees and then chest. Resident 21's roommate and activities were in the room and saw the fall. Resident 21 told the nurses she was trying to mess with her socks. A review of Resident 21's short term Fall care plan, date initiated 1/13/22, and short-term care plan for Recent Room Change, initiated 1/14/22 indicated three new short-term interventions: resident will be introduced to new staff that will be working with her, resident will be oriented to room and roommate and resident will be monitored closely times seventy-two hours after fall (Note: monitoring happened after each fall for seventy-two hours) and concerns related to new room. Monitor for confusion, disorientation more than normal and room move. The monitoring did not specify how staff was going to provide and monitor for supervision nor did the care plans define closely. The care plans did not specify how frequently staff would be checking on Resident 21. Both short term care plans were resolved on 1/20/22. Fall Eleven: A review of Resident 21's Change of Condition Assessment/SBAR, dated 2/8/22, Post Fall Evaluation, dated 2/8/22 and IDT Progress Notes, dated 2/9/22, indicated Resident 21 had an unwitnessed fall around 6:45 p.m. Resident 21 was in her room and found sitting on her bottom. Resident 21 was attempting to transfer from her wheelchair to bed. A review of Resident 21's short term Fall care plan, initiated 2/8/22, indicated one new intervention: offer resident to lie down after dinner to prevent further falls. Resident 21's fall risk care plan indicated call light and personal items were in easy reach but did not specify: 1. How the facility would provide reminders so Resident 21, who was severely cognitively impaired, would remember to ask for assistance with transferring, and 2. How often the facility would do visual checks/supervision. A review of Resident 21's Impaired Cognitive Function/Dementia or Impaired Thought Process related to Alzheimer's, care plan, initiated on 5/18/21, one intervention included and initiated on 5/18/21, indicated: Cue, reorient and supervise as needed, but the intervention did not indicate how staff was going to provide and monitor for supervision and how often. A review of Resident 21'sCommunication Problem care plan initiated 5/28/21, one intervention initiated 8/16/21, indicated: 'Resident is not able to initiate needs request and requires staff support to have needs care and concrete addressed and met by staff. During an interview on 3/3/22 at 9:56 a.m., Physical Therapy (PT) Manager T stated Resident 21 was back on PT until 2/11/22 mainly to work on a safe transfer with assistance. PT Manager T stated Resident 21 should never be by herself when transferring from bed to wheelchair, wheelchair to bed . Resident 21 has always needed assistance with transfers, not steady. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 12 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/3/22 at 11:49 a.m., the Infection Preventionist Nurse (IPN) stated Resident 21 should not get up on her own. When the IPN was asked how Resident 21 was monitored closely to prevent her from falling, the IPN stated Resident 21 was out and about often in the hallways propelling herself in her wheelchair where she was watched because staff were out and about in the hallways. During an interview on 3/3/22 at 11:50 a.m., the Director of Nursing (DON) stated Resident 21 was monitored at least every two hours. When the DON was asked if six falls was too much, the DON did not answer. The DON stated a short term Fall care plan was started for Resident 21 after each fall, but the interventions were short term. Resident 21 was monitored frequently for three days after each fall. The frequent monitoring was not a long-term intervention. When the DON was asked how Resident 21 was monitored to prevent her from falling, the DON stated Resident 21 was cognitively impaired and she was out and about propelling herself in the hallways often, whereby Resident 21 was watched. The DON stated Resident 21 did not have an alarm on her bed, wheelchair and/or no floor sensory pad anymore. During an interview on 3/3/22 at 3:25 p.m., Licensed Nurse C stated Resident 21 should be monitored every 15 to 30 min. Licensed Nurse C stated Resident 21 usually was propelling self in wheelchair in hallway after 2 p.m. During an observation on 3/3/22 at 4:05 p.m., Resident 21 was up in wheelchair in hallway propelling self and no staff was around supervising/monitoring Resident 21. Resident 21 was holding on to siderail across from Nurse's Station One and then crossed over into the hallway where her room was located. During an interview on 3/3/22 at 4:30 p.m., Staff P stated she checked on Resident 21 every two hours. Staff P stated Resident 21 was out in the hall a lot and people were around to watch her. Staff P stated Resident 21 could not get up on her own, Resident 21 needed assistance. During an observation on 3/3/22 at 4:45 p.m., while two surveyors were at Nurse's Station One, Resident 21 was observed propelling self in wheelchair nearby. There was no staff around supervising/monitoring Resident 21 who was majorly cognitively impaired, had poor safety awareness, impulsive, and had fallen eleven times within a nine month period. No one had checked on Resident 21`in the past 15 minutes. Fall Twelve: A review of Resident 21's Nurse's Progress Notes, dated 3/4/21, and Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM (Bowel Movement) from 1/28/22 through 2/2/22 (six days), so on 3/4/21 at 12 a.m., Resident 21 was given a Dulcolax Suppository 10 mg (milligrams) for constipation. Nursing Progress Notes indicated safety fall precautions were maintained, but at 1:50 a.m. Resident 21 was found laying on the floor by her bedside. Resident 21 had an extra-large BM in her brief. Note: Nurse's Progress Note indicated the nurse did not go back to check on Resident 21, who was severely cognitively impaired and had poor safety awareness for almost 2 hours after Resident 21 was given a suppository to stimulate a BM. During a concurrent observation and interview on 3/4/22 at 9 a.m., Surveyor went into Resident 21's room along with Staff K, who showed where Resident 21's drop mat was kept. Staff K stated it was placed on the floor next to Resident 21's bed when she was in bed. Resident 21 was up in her wheelchair next to her bed. Staff K stated Resident 21 did not have a bed alarm and/or a wheelchair alarm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 13 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/4/22 at 9:03 a.m., Staff Q stated she checked on Resident 21 every two hours. Staff Q stated Resident 21 was walking when Resident 21 was first admitted , but with assistance. When Staff Q was asked what frequently monitoring meant, she could not answer. Staff Q stated she checked on Resident 21 every time she passed by Resident 21's room because Resident 21's door was always opened. Staff Q stated another CNA was passing by Resident 21's opened door and saw Resident 21 was trying to get up, so Staff K told Staff Q, who went to check on Resident 21 right away. Staff Q stated if she was not available, Staff K would have assisted Resident 21. Staff Q was asked again what frequent monitoring meant and Staff Q could not define. Staff Q stated Resident 21 could not get up on her own, unsafe. During an interview on 3/4/22 at 9:45 a.m. the DON stated Resident 21 went to Activities as much as possible. The DON stated Resident 21 could not stand on her own. The DON stated Resident 21 was using a four-wheel walker with seat when Resident 21 was first admitted , but the walker was not safe. The DON stated Resident 21 was cognitively impaired and it was impossible to watch her all the time. The DON stated none of the residents had a one-on-one sitter. The DON stated a one-on-one sitter would be impossible because of lack of staff. The DON stated no residents had alarms and Resident 21's was discontinued on 11/20/21. The DON stated the facility did not use any alarms anymore because the alarms were found not to worked and scared the resident. During an interview on 3/4/22 at 11:41 a.m., Activities Assistant R stated she only worked Friday and Saturdays. Activities Assistant R stated Resident 21 would come to activities occasionally. We would encourage her to come. Activities Assistant R stated today Resident 21 was at the sensory awareness activity the entire time. During an interview on 3/4/22 at 11:48 a.m., Interim Activities Director S stated Resident 21 would come to activities sometimes. Interim Activities Director S stated Resident 21 was encourage to come to activities, but often Resident 21 wanted to stay in her room. Interim Activities Director S stated Resident 21 would come to activities two to three times during the week, just depended on her mood. Interim Activities Director S stated Resident 21 liked the social coffee activity; Resident 21 really came to be around other residents though often did not engage. The Facility Policy/Procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated: Policy heading: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors: . 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment . e. lower extremity weakness . i. functional impairments . k. incontinence, 3. Medical factors that contribute to the risk of falls include: . e. balance and gait disorders, etc. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Monitoring Subsequent Falls and Fall Risk: . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 14 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone)and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical/Telemedicine Visit, dated 5/18/21, indicated facility was to follow Bowel Care per Facility Protocol for Resident 21. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), 5/25/21, indicated Resident 21's BIM (Brief Interview of Mental Status) of 5 (severely cognitively impaired). Resident 21 needed one person physical assist with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), personal hygiene, two plus persons physical assist to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, and standing position (excludes to/from bath/toilet, total dependent on bathing and frequently incontinent of urine/bowel movement. During an interview on 3/1/22 at 11:15 a.m., Confidential Family Member stated Resident 21 was having diarrhea prior to being admitted to the facility and it was not like Resident 21 to not have BM daily or at least every other day. 1/2022: A review of Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), from 1/22/22 through 1/26/22 (5 days), and from 1/28/22 through 2/2/22 (six days). A review of Resident 21's Physician L's Protocol for Constipation, related to decreased mobility. indicated: If No BM in three days begin: MOM (Milk of Magnesia) Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn (as needed) for bowel care. Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if MOM is ineffective. Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if suppository is ineffective. If no results, contact MD (Doctor of Medicine). A review of Resident 21's Risk for Constipation care plan, initialed 5/18/21, indicated constipations interventions included : Follow facility bowel protocol for bowel management, MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for constipation daily, Dulcolax Suppository 10 mg Insert 10 mg suppository rectally every twenty-four hours prn for constipation if no results from oral laxative, and Fleet Enema 7-19 gm /118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for constipation if no results from suppository. If no results from enema, call MD. The licensed nurses were not following Resident 21's Risk for Constipation care plan per review of Resident 21's MARs, (Medication Administration Record), dated 1/2022, 2/2022, and 3/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 15 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 21's Order Summary Report, dated 1/2022, and MAR, dated 1/2022, indicated Resident 21 was administered Senna 8.6 mg (milligrams) give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. Resident 21 had an order for MOM Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if no BM times three days, start date 5/18/21. Per Resident 21's MAR, dated 1/2022, Licensed Nurses did not start Physician L's Protocol for Constipation on Resident 21, who did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), and from 1/22/22 through 1/26/22 (5 days). Resident 21 was administered MOM on 2/1/22 at 11:59 a.m. after no BM from 1/28/22 through 2/1/22 (five days). Licensed Nurse did not follow Resident 21's Physician L's Protocol for Constipation when Resident 21 was not given the ordered Dulcolax Suppository after twenty-four hours of no BM the following day, 2/2/22. Resident 21 had a large, formed BM on 2/3/22 at 12:56 p.m. 2/2022: A review of Resident 21's Bowel Movement task, dated 2/2022, indicated Resident 21 did not have a BM from 2/6/22 through 2/10/22 (five days), from 2/12/221 to 2/15/22 (four days), and from 2/26/22 through 3/2/22 (five days). A review of Resident 21's Order Summary Report, dated 2/2022, and MAR, dated 2/2022, indicated Resident 21 was administered Senna 8.6 mg, give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. On 2/24/21, Docusate Calcium 240 mg was discontinued and Resident 21 started on DSS (Docusate Calcium) capsule 250 mg by mouth two times a day for constipation, start date 2/24/21 at 5 p.m. Resident 21 continued to have the Protocol for Constipation: MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm /118 ml - Insert one application rectally every twenty-four hours prn for bowel care if no BM ti[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 16 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician's Protocol for Constipation and Resident 21's Risk for Constipation care plan for one of 15 sampled residents (Resident 21) causing Resident 21 to not have a bowel movement (BM) anywhere from four to seven days in a row. This had the potential for Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized . Residents Affected - Some Findings: A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone)and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical/Telemedicine Visit, dated 5/18/21, indicated the facility was to follow Bowel Care per Facility Protocol for Resident 21. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), 5/25/21, indicated Resident 21's BIM (Brief Interview of Mental Status) of 5 (severely cognitively impaired). Resident 21 needed one person physical assist with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), personal hygiene, two plus persons physical assist to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, and standing position (excludes to/from bath/toilet, total dependent on bathing and frequently incontinent of urine/bowel movement. During an interview on 3/1/22 at 11:15 a.m., Confidential Family Member stated Resident 21 was having diarrhea prior to being admitted to the facility and it was not like Resident 21 to not have a BM daily or at least every other day. 1/2022: A review of Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), from 1/22/22 through 1/26/22 (5 days), and from 1/28/22 through 2/2/22 (six days). A review of Resident 21's Physician L's Protocol for Constipation, indicated: If No BM in three days begin: MOM (Milk of Magnesia) Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn (as needed) for bowel care. Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if MOM is ineffective. Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 17 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 bowel care if suppository is ineffective. If no results, contact MD (Doctor of Medicine). Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's Risk for Constipation care plan, initialed 5/18/21, indicated constipations interventions included : Follow facility bowel protocol for bowel management, MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for constipation daily, Dulcolax Suppository 10 mg Insert 10 mg suppository rectally every twenty-four hours prn for constipation if no results from oral laxative, and Fleet Enema 7-19 gm /118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for constipation if no results from suppository. If no results from enema, call MD. The licensed nurses were not following Resident 21's Risk for Constipation care plan per review of Resident 21's MARs, (Medication Administration Record), dated 1/2022, 2/2022, and 3/2022. Residents Affected - Some A review of Resident 21's Order Summary Report, dated 1/2022, and MAR, dated 1/2022, indicated Resident 21 was administered Senna 8.6 mg (milligrams) give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. Resident 21 had an order for MOM Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if no BM times three days, start date 5/18/21. Per Resident 21's MAR, dated 1/2022, Licensed Nurses did not start Physician L's Protocol for Constipation on Resident 21, who did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), and from 1/22/22 through 1/26/22 (5 days). Resident 21 was administered MOM on 2/1/22 at 11:59 a.m. after no BM from 1/28/22 through 2/1/22 (five days). Licensed Staff did not follow Resident 21's Physician L's Protocol for Constipation when Resident 21 was not given the ordered Dulcolax Suppository after twenty-four hours of no BM the following day, 2/2/22. Resident 21 had a large, formed BM on 2/3/22 at 12:56 p.m. 2/2022: A review of Resident 21's Bowel Movement task, dated 2/2022, indicated Resident 21 did not have a BM from 2/6/22 through 2/10/22 (five days), from 2/12/221 to 2/15/22 (four days), and from 2/26/22 through 3/2/22 (five days). A review of Resident 21's Order Summary Report, dated 2/2022, and MAR, dated 2/2022, indicated Resident 21 was administered Senna 8.6 mg, give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. On 2/24/21, Docusate Calcium 240 mg was discontinued and Resident 21 started on DSS (Docusate Calcium) capsule 250 mg by mouth two times a day for constipation, start date 2/24/21 at 5 p.m. Resident 21 continued to have the Protocol for Constipation: MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm /118 ml - Insert one application rectally every twenty-four hours prn for bowel care if no BM times three days, start date 5/18/21. Per Resident 21's MAR, dated 2/2022, Licensed Nurses did not start Physician L's Protocol for Constipation for Resident 21, who did not have a BM from 2/6/22 through 2/10/22 (five days), from 2/12/221 to 2/15/22 (four days), and from 2/26/22 through 3/2/22 (five days). During an interview on 3/2/22 at 4:29 p.m. when it was brought to Licensed Nurse N's attention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 18 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 21 had not had a BM from 2/26/22 through 3/2/22 (five days), Licensed Nurse N stated Resident 21 should have been started on Physician L's Protocol for Constipation after three days of not having a BM. During an interview on 3/3/22 at 8:48 a.m., Licensed Nurse A stated Resident 21 should not go six days (2/26/22 to 3/3/22) before having a BM. Licensed Nurse A stated Resident 21's constipation was addressed to him at the change of shift this morning. Licensed Nurse A stated the Night shift nurse was responsibility to try to start the ordered Protocol for Constipation for Resident 21 if she has not gone for three days. Licensed Nurse A stated Resident 21 was non-compliant with the Night shift nurse; Resident 21 has severe dimension/cognitively impaired. Licensed Nurse A stated he was going to attempt to start Physician L's Protocol for Constipation today. When Licensed Nurse A was asked why Resident 21's Risk for Constipation care plan was not updated to address Resident 21 not being compliant with Physician L's Protocol for Constipation and why Physician L was not notified regarding Resident 21 being non-compliant. Licensed Nurse A could not answer. During an interview on 3/4/22 at 10:13 a.m., the Director of Nursing (DON) was asked why Resident 21's nurses did not follow Physician L's Protocol for Constipation when on multiple occasions Resident 21 went longer than three days before she had a BM. The DON stated Resident 21 had routine bowel care, softeners. The DON stated Physician L's Protocol for Constipation should occur after three days of no BM, and if the resident was non-compliant, the nurse should notify the resident's physician. During an interview on 3/3/22 at 3:25 p.m., Licensed Nurse C stated Resident 21 had routine stool softeners, but if Resident 21 did not have a BM within a forty-eight-to-seventy-two-hour period, the nurse should start addressing the issue with prn bowel care orders for constipation. Licensed Nurse C stated if a resident was having continuous issues with having a BM, their Risk for Constipation care plan should be update with new interventions to address lack of BMS and non-compliant with bowel care, and their physician should be notified as well as their responsible party. Licensed Nurse C stated Yes, I have had issues understanding the Certified Nursing Assistant's (CNA's) coding under the BM task because the CNAs were not always consistent with their coding, making it difficult to understanding if the resident had a BM or not. Licensed Nurse C stated if the resident was cognitively intact, she would ask the resident if they had a BM. During an interview on 3/3/22 at 3:36 p.m., Staff O stated how the BM task electronic charting should be answered was as follows: 1. Incontinent/Continent or none, 2. Size of BM: small, medium or large or none and 3. consistency: loose, soft, formed. Staff O stated all questions should be answered. Both Licensed Nurse C and Staff O stated to understand if the resident had a BM would depend on how the CNA completed the documentation under the BM task. Licensed Nurse C stated she found the CNAs' BM documentation incorrect at times. The facility policy/procedure titled, (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised 9/2017, indicated Assessment and Recognition: . 2. Examples of lower gastrointestinal tract conditions and symptoms include: a. Residents with history of diarrhea, b. Fecal incontinence . f. Alteration in bowel movements . 3. In addition, the nurse shall assess and document/report the following: . f. Abdominal assessment . h. Onset, duration, frequency, severity of signs and symptoms . Monitoring and Follow-up: 1. The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc . The facility job description titled, LVN - Charge Nurse, dated 2003, indicated: Duties and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 19 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Responsibilities: Administrative Functions: Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility . Ensure that all nursing service personnel are in compliance with their respective job description . Charting and documentation: . Report all discrepancies noted concerning . charting errors , to the Nurse Supervisor . Personnel Functions: . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services . Nursing Care Function: .Review the resident's chart for specific treatments, medication orders . Ensure that personnel providing direct care to the residents are providing such care in accordance with the resident's care plan and wishes . The facility job description titled, RN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Administrative Functions: Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility . Ensure that all nursing service personnel are in compliance with their respective job description . Charting and documentation: . Report all discrepancies noted concerning . charting errors , to the Nurse Supervisor . Personnel Functions: . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services . Nursing Care Function: .Review the resident's chart for specific treatments, medication orders . Nursing Care Function: .Review the resident's chart for specific treatments, medication orders . Ensure that personnel providing direct care to the residents are providing such care in accordance with the resident's care plan and wishes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 20 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to do a respiratory assessment and identify a large fluid filled blister approximately 8 cm in diameter for 1 of 15 sampled residents (Resident 36) when Resident 36 had bilateral (both sides) leg edema (swelling caused by fluid). This failure resulted in Resident 36 to experience discomfort and was subsequently sent to the acute hospital for shortness of breath and worsening of leg edema. Residents Affected - Few Findings: During a clinical record review for Resident 36, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with multiple diagnoses that included Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs), Cardiomyopathy (heart loses its ability to pump blood effectively), and Chronic Obstructive Pulmonary Disease (COPD - lung diseases that make it hard to breathe and gets worse over time). During a clinical record review Resident 36's Care Plan, created on 2/1/22, indicated, BLE (bilateral lower extremity) +4 pitting edema (swollen part of your body becomes indented (or pitted) after pressing it for a few seconds) worsening. Ongoing fluctuations in fluid/ hydration status, CHF, cardiomyopathy. The care plan interventions did not indicate to monitor for signs of shortness of breath or to assess lung sounds for congestion. During a clinical record review for Resident 36, the Nurse's Note dated 2/28/22 at 6:22 a.m. indicated, [Resident 36] wanted to sit on the edge of the bed several times but reminded her that her legs needed to be elevated due to increased swelling and they need to be wrapped, resident refused suggestions. During an observation on 2/28/22 at 10:15 a.m., Resident 36 was lying in bed with head of bed slightly elevated with no blanket. Both of her legs were swollen with clear fluid leaking from the left leg and a large fluid filled blister on top of her left foot. Resident 36 also had a moist cough during the initial encounter. During a concurrent interview with Resident 36, observation, and record review on 2/28/22 at 3:38 p.m., Resident 36 stated she had pain everywhere and requested to be assisted to sit up. A Certified Nurse Assistant (CNA) assisted Resident 36 to sit at the edge of the bed and during the process, Resident 36 had facial grimacing. She was catching her breath and her lips were slightly cyanotic (bluish). Resident 36 shook her head side to side and refused to talk when asked how she felt. Review of the Nurses Notes dated 2/27/22 to 2/28/22, did not indicate the staff were monitoring for signs and symptoms of respiratory distress. There was no documentation of the blister on the left foot. During an interview on 2/28/22 at 4:14 p.m., Licensed Nurse D stated there was no blister on Resident 36's left foot last time he worked two days ago. He verified the morning nurse made a change of condition report on 2/28/22 regarding a fluid filled blister on Resident 36 left foot. Licensed Nurse D verified a care plan for left lower extremity blister was also created on 2/28/22. Licensed Nurse D stated he had not observed Resident 36 showing signs of difficulty breathing. During a clinical record review for Resident 36, the nurse's progress note dated 2/28/22 at 11:29 p.m. indicated the blister on Resident 36 left foot measured 9X9 popped. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 21 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and concurrent record review on 3/1/22 at 8:53 a.m., Resident 36 was sitting at the edge of the bed. Her left leg was wrapped with white gauze, and a moist cough observed. During a clinical record review for Resident 36, Physician L's Note dated 3/1/22 indicated, Patient had been gaining weight, refusing to be weighed intermittently, noted with worsening leg edema and weight gain. Physician L's note indicated Resident 36's lung sounds had crackles (occur if the small air sacs in the lungs fill with fluid) to her bilateral lung fields. During a clinical record review for Resident 36, the Weight and Vitals Summary record indicated Resident 36 had an 11 pound (5.54%) weight gain from 1/26/22 to 3/1/22. During an observation on 3/2/22 at 12:35 p.m., Resident 36 was partially in bed, part of upper body was in bed, right foot resting on the floor and left foot was resting on the floor with a pillow. A Certified Nurse Assistant (CNA) was inside the room passing Resident 36's lunch tray. Resident 36 was moaning and grimacing while she was assisted to sit at the edge of the bed and breathed through her mouth rapidly with audible wheezing (whistling sound). Resident 36 had a hard time responding to CNA when asked how she felt. She was not able to hold herself in a sitting position and fell back to her bed. During an interview with Licensed Nurse C on 3/2/22 at 3:52 p.m. Licensed Nurse C stated Resident 36 was sent out to the acute hospital due to shortness of breath and increased swelling of her legs. Licensed Nurse C stated Resident 36's vital signs (V/S - clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) was checked and was given oxygen (life-supporting component of the air) for shortness of breath prior to transfer to the acute hospital. Licensed Nurse stated she did not perform respiratory assessment for Resident 36. During an interview with Licensed Nurse C on 3/2/22 at 3:53 a.m., Licensed Nurse C stated she did not receive a report from night shift on 2/28/2022 regarding Resident 36's blister on her left foot. During an interview with Physician L on 3/3/22 at 10:55 a.m., Physician L stated Resident 36 was admitted to the acute hospital for CHF exacerbation (worsening of a disease). During an interview on 3/4/22 10:34 a.m., Physician L was asked what his expectation was from the nurses regarding monitoring for residents with CHF, and he stated he had a protocol for nurses on what to monitor for residents with CHF that included a respiratory assessment. During an interview on 3/4/22 10:41 a.m., when asked what to monitor for residents with CHF, Licensed Staff J stated she would monitor for shortness of breath, presence of cough, perform a lung assessment and notify the doctor of any changes. Licensed Nurse J stated she was not aware Physician L had a protocol on what to monitor for residents with CHF. During an interview on 3/4/22 at 11:03 a.m., Licensed Nurse A was asked what to monitor for residents with CHF, and Licensed Nurse A stated he would monitor for signs of respiratory distress. During an interview and concurrent record review with the DON on 3/4/22 at 11:16 a.m., the DON was asked what her expectation was from the nurses on what to assess for residents with CHF, and she stated she expected the nurses to monitor resident for signs of respiratory distress. When asked what risks the resident may have if not assessed timely, the DON stated, CHF exacerbation is pretty common, and the resident could have respiratory distress if their lungs were to fill fluids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 22 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the Facility policy and procedure titled Heart Failure - Clinical Protocol revised in November 2018 indicated, The nurses will assess and document/report the following: Vital signs; General physical assessment.The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 23 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident safety when staff did not evaluate, develop, and implement adequate interventions for 1 of 15 sampled residents (Resident 21), who had poor safety awareness and a history of falls, to prevent multiple falls. This failure contributed to Resident 21 falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death. Findings: A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with diagnoses including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone) and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical, dated 5/18/21, indicated Resident 21 had diagnosis including Alzheimer's Disease and lumbar 2/thoracic 3 fracture, status post fall resulted in inability to walk and decrease mobility, had no decision making capacity, and was admitted on Fall Precautions. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/25/21, indicated Resident 21's BIMS score (Brief Interview of Mental Status) was 5 (severely cognitively impaired). Resident 21 needed one person physical assistance with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), and personal hygiene. Resident 21 needed two plus persons physical assistance to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Resident 21 was total dependent on bathing. Resident 21 was not steady and needed assistance when moving from seating and standing position, walking with assistive device, moving on/off the toilet, and transferring between bed and chair or wheelchair. A review of Resident 21's admission Assessment V4-V3, dated 5/18/21, indicated Resident 21's primary diagnosis was fall. Resident 21 was a fall risk. Resident 21 was alert with forgetfulness, not a reliable historian, could stand, but unsteady. A review of Resident 21's document, Risk for Falls, dated 5/18/21, indicated Resident 21 had a fall in the last thirty days prior to admission, cognitive skills were moderately impaired (decisions poor/supervision required), gait: balance problems when standing, and while walking, and needed assistive devices, such as a walker and wheelchair. The document indicated Resident 21 was a High Risk for falls. A review of Resident 21's Risk for Fall care plan, initiated 5/18/21, indicated fall risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 24 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interventions included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure that the resident is wearing appropriate footwear (shoes with non-slip sole or non-skid socks) when ambulating or mobilized in wheelchair, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team - professional disciplines, such as physician, case manager, nurse, social services, etc. work together to provide the greatest benefit for the resident/family/responsible party), the resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position, handrails on walls, and personal items within reach. Fall One: A review of Resident 21's Change of Condition Assessment/SBAR (Situation, Background, Assessment and Recommendation), dated 5/20/21, indicated Resident 21 had an unwitnessed fall on 5/20/21 at approximently 6 p.m. Resident 21 was found on the floor laying on her back perpendicular to her bed. A review of the Fall IDT note, dated 5/21/2021, indicated Resident 21 stated, I was just trying to get over here from there. The IDT plan was to have Resident 21 up in her wheelchair at the nurse's station when awake. A review of Resident 21's short term Actual Fall with No Injury, created 5/20/21 and initiated 5/21/21, indicated to continue interventions on the At Risk Fall care plan, for no apparent acute injury. New interventions included: determine and address causative factors (Resolved 7/9/21), monitor/document/report to physician for sign/symptoms: pain, and change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation (Resolved 7/9/21), and Resident 21 to participate in activities daily (Initiated 5/24/21 and Resolved 7/9/21). Resident 21's Risk for Falls care plan was not updated specifying the IDT plan for Resident 21 to be up in her wheelchair at the nurse's station when awake. The facility Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. Fall Two: A review of Resident 21's Change of Condition Assessment/SBAR, dated 5/25/21, and Nurses Progress Notes, dated 5/25/21, indicated Resident 21 had an unwitnessed fall on 5/25/21 at 4:20 a.m. Resident 21 was found by staff sitting down on her roommates fall mat. When Resident 21 was asked what she was trying to do, Resident 21 stated, This is my house and my business. Nurse noted redness to Resident 21's right hand/wrist. A review of Resident 21's short term Actual Fall with Minor Injury: Poor Balance, Unsteady Gait, created 5/25/21 and initiated 5/25/21, indicated to continue interventions on the At Risk Fall care plan. New interventions included: ensure resident has a floor sensor pad in place while resident is in bed to alert staff that Resident 21 is trying to get out of bed alone (Resolved 7/20/21), and plan is to have an up in wheelchair schedule for the resident throughout the day (Resolved 7/20/21). Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 25 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Fall Three and Four: Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's Change of Condition Assessment/SBAR, dated 6/6/21, and Nurses Progress Notes, dated 6/6/21, indicated Resident 21 had two witnessed falls on 6/6/21 at 4:30 p.m. and 5:20 p.m., while Resident 21 was up in her wheelchair near Nurse's Station Two. Resident 21's Nurse's Progress Note, indicated Resident 21 had a behavior of inability to relax and kept propelling back and forth in her wheelchair, which led to her sliding out of her wheelchair and landing on her buttocks two times within a one-hour period while near Nursing Station Two. There was no documentation Resident 21 was being monitored/supervised closely when falls occurred. Resident 21 told nurse she was attempting to see her daughter. Residents Affected - Some Aa review of Resident 21's IDT Progress Note, dated 6/9/21, indicated: IDT recommends placing sensor pad on wheelchair to alert staff when Resident 21 is attempting to standup. The IDT recommendation was not initiated on Resident 21's Fall care plan until 7/7/21 and no other interventions were initiated after Resident 21's two witnessed falls on 6/9/21. Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day. Fall Five: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/3/21, Nurse's Progress Note, dated 7/3/21, and Post Fall Evaluation, dated 7/3/21, indicated Resident 21 was found in the lying on the floor the bathroom floor at 4 p.m. on her right side with her head up. A review of Resident 21's short term Fall care plan for 7/3/21 fall, included the following short-term interventions: added floor mat, initiated 7/6/21 and resolved 8/23/21, monitor frequently for safety, initiated 7/3/21 and resolved 8/23/21, and provide redirection frequently, initiated 7/3/21 and resolved 8/23/21, During an observation on 2/28/22 at 4:08 p.m., Resident 21 was propelling self in hallway with no supervision and propelled self to the Physical Therapy (PT) room. During an interview on 3/3/22 at 8:48 a.m., Licensed Nurse A stated most of the time the Health Care Personal (HCP) kept Resident 21 out by the Nurse's Station. Licensed Nurse A stated Resident 21 had no alarm on her bed and wheelchair. When Licensed Nurse A was asked how often Resident 21 was checked, Licensed Nurse A stated HCP checked on Resident 21 every two hours. Licensed Nurse A stated Night shift probably checked on Resident 21 every two hours and frequently while awake. Licensed Nurse A could not explain what he meant by frequently except for Resident 21 was checked on every two hours. Fall Six: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/20/21, and Nurse's Progress Note, dated 7/20/21, indicated Resident 21 had an unwitnessed fall on 7/20/21at 11:45 a.m. Resident 21 was found on floor mat at bedside. Resident 21 stated to nurse she was trying to go to the bathroom. Resident 21 was assisted back to bed with one person assist. A review of Resident 21's short term Fall care plan for 7/20/21 fall, included one new short term intervention: Scheduled toileting every two hours while up in wheel, initiated 7/21/21 and resolved 8/23/21. Resident 21's Fall care plan did not specify scheduled toileting while in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 26 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Fall Seven: Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's Change of Condition Assessment/SBAR, dated 8/5/21, and Post Fall Evaluation, dated 8/5/21, indicated Resident 21 was trying to stand from her wheelchair on her own and walk to the bathroom when she had an unwitnessed fall on 8/5/21 at 3:45 p.m. Residents Affected - Some A review of Resident 21's Post Fall Evaluation, dated 8/6/21, indicated Resident 21's wheelchair alarm was going off, so a Certified Nursing Assistant (CNA) went to check on Resident 21. The CNA saw Resident 21 had fallen from her wheelchair in front of her bathroom. A review of Resident 21's Risk for Falls had no new interventions and there was no short term Fall care plan initiated for Resident 21's 8/6/21 unwitnessed fall. A review of Resident 21's Fall IDT Progress Note, dated 8/12/21, indicated IDT reviewed Resident 21's fall history with a plan to provide a wedge cushion for her wheelchair and anti-roll back wheel locks for the prevention of falls. Resident 21 continued with physical therapy for safety and functional mobility. The interventions addressed were not added to Resident 21's Fall Risk care plan. Fall Eight: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/2/21, Post Fall Evaluation, dated 11/2/21, and Nurse's Progress Notes, dated 11/2/21, indicated Resident 21 had a witnessed fall on 11/2/21 at 5:30 p.m. while up in her wheelchair in the hallway. Resident 21 was pulling herself down the hallway using the hall siderail while her wheelchair wheels were against the side of the wall. Resident 21 pulled herself forward causing Resident 21 to lose her body balance and fell forward out of her wheelchair whereby Resident 21 landed on the floor on her right side. Resident 21, who had poor safety awareness, had no HCP nearby monitoring Resident 21 to prevent her from falling out of her wheelchair. Nurse who witnessed fall was coming from the opposite direction. A review of Resident 21's short term Fall care plan, date initiated 11/2/21, indicated interventions included educate resident/family/caregivers about safety reminders and what to do if a fall occurs, continue PT, and plan was to have resident up in wheelchair at nursing station when awake. Resident 21 has fallen three times while up in hallway near nurse's station. There were no new recommendations to prevent further falls such as how staff was going to provide and monitor for supervision. Fall Nine: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/3/21, Post Fall Evaluation, dated 11/3/21 and Nurse's Progress Notes, dated 11/3/21, indicated Resident 21's chair alarm went off around 8:10 a.m. The CNA and nurse quickly went to Resident 21's room where Resident 21 was noted to have an unwitnessed fall. Resident 21 was found near the doorway and sink, laying on her left side facing the sink. Resident 21 withstood a small bump/redness to left forehead and back of right hand was discolored. Aa review of Resident 21's short term Fall care plan, date initiated 11/3/21, indicated one new intervention: Provide activities that promote exercise and strength building where possible Provide 1:1 activities if bed bound, which was resolved 11/18/21. A review of Resident 21's Quarterly MDS), 11/24/22, indicated Resident 21's BIM (Brief Interview of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 27 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Mental Status) of 3 (severely cognitively impaired) and Resident 21 was not steady, only could stabilize with staff assistance when moving from seating and standing position, moving on/off toilet, and transferring between bed and chair or wheelchair. Ambulation did not happen. Fall Ten: Residents Affected - Some A review of Resident 21's Nurse's Progress Note dated 1/13/22 indicated and an IDT Note, dated 1/14/21, indicated Resident 21 had a witnessed fall on 1/13/21 around 4:15 p.m. right after room change. Resident 21 was in her new room in her wheelchair and attempting to stand. Resident 21 lost her balance and fell to her knees and then chest. Resident 21's roommate and activities were in the room and saw the fall. Resident 21 told the nurses she was trying to mess with her socks. A review of Resident 21's short term Fall care plan, date initiated 1/13/22, and short-term care plan for Recent Room Change, initiated 1/14/22 indicated three new short-term interventions: resident will be introduced to new staff that will be working with her, resident will be oriented to room and roommate and resident will be monitored closely times seventy-two hours after fall (Note: monitoring happened after each fall for seventy-two hours) and concerns related to new room. Monitor for confusion, disorientation more than normal and room move. The monitoring did not specify how staff was going to provide and monitor for supervision nor did the care plans define closely. The care plans did not specify how frequently staff would be checking on Resident 21. Both short term care plans were resolved on 1/20/22. Fall Eleven: A review of Resident 21's Change of Condition Assessment/SBAR, dated 2/8/22, Post Fall Evaluation, dated 2/8/22 and IDT Progress Notes, dated 2/9/22, indicated Resident 21 had an unwitnessed fall around 6:45 p.m. Resident 21 was in her room and found sitting on her bottom. Resident 21 was attempting to transfer from her wheelchair to bed. A review of Resident 21's short term Fall care plan, initiated 2/8/22, indicated one new intervention: offer resident to lie down after dinner to prevent further falls. Resident 21's fall risk care plan indicated call light and personal items were in easy reach but did not specify: 1. How the facility would provide reminders so Resident 21, who was severely cognitively impaired, would remember to ask for assistance with transferring, and 2. How often the facility would do visual checks/supervision. A review of Resident 21's Impaired Cognitive Function/Dementia or Impaired Thought Process related to Alzheimer's, care plan, initiated on 5/18/21, one intervention included and initiated on 5/18/21, indicated: Cue, reorient and supervise as needed, but the intervention did not indicate how staff was going to provide and monitor for supervision and how often. A review of Resident 21'sCommunication Problem care plan initiated 5/28/21, one intervention initiated 8/16/21, indicated: 'Resident is not able to initiate needs request and requires staff support to have needs care and concrete addressed and met by staff. During an interview on 3/3/22 at 9:56 a.m., Physical Therapy (PT) Manager T stated Resident 21 was back on PT until 2/11/22 mainly to work on a safe transfer with assistance. PT Manager T stated Resident 21 should never be by herself when transferring from bed to wheelchair, wheelchair to bed . Resident 21 has always need assistance with transfers, not steady. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 28 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/3/22 at 11:49 a.m., the Infection Preventionist Nurse (IPN) stated Resident 21 should not get up on her own. When the IPN was asked how Resident 21 was monitored closely to prevent her from falling, the IPN stated Resident 21 was out and about often in the hallways propelling herself in her wheelchair where she was watched because staff were out and about in the hallways. During an interview on 3/3/22 at 11:50 a.m., the Director of Nursing (DON) stated Resident 21 was monitored at least every two hours. When the DON was asked if six falls was too much, the DON did not answer. The DON stated a short term Fall care plan was started for Resident 21 after each fall, but the interventions were short term. Resident 21 was monitored frequently for three days after each fall. The frequent monitoring was not a long-term intervention. When the DON was asked how Resident 21 was monitored to prevent her from falling, the DON stated Resident 21 was cognitively impaired and she was out and about propelling herself in the hallways often, whereby Resident 21 was watched. The DON stated Resident 21 did not have an alarm on her bed, wheelchair and/or no floor sensory pad anymore. During an interview on 3/3/22 at 3:25 p.m., Licensed Nurse C stated Resident 21 should be monitored every 15 to 30 min. Licensed Nurse C stated Resident 21 usually was propelling self in wheelchair in hallway after 2 p.m. Licensed Nurse C stated the CNAs started work at 6 a.m. to 2 p.m. and nurses started work at 7 a.m. to 3 p.m. During an observation on 3/3/22 at 4:05 p.m., Resident 21 was up in wheelchair in hallway propelling self and no staff was around supervising/monitoring Resident 21. Resident 21 was holding on to siderail across from Nurse's Station One and then crossed over into the hallway where her room was located. During an interview on 3/3/22 at 4:30 p.m., Staff P stated she checked on Resident 21 every two hours. Staff P stated Resident 21 was out in the hall a lot and people were around to watch her. Staff P stated Resident 21 could not get up on her own, Resident 21 needed assistance. During an observation on 3/3/22 at 4:45 p.m., while two surveyors were at Nurse's Station One, Resident 21 was observed propelling self in wheelchair nearby. There was no staff around supervising/monitoring Resident 21 who was cognitively impaired, had poor safety awareness, impulsive, and had fallen eleven times within a nine month period. No one had checked on Resident 21 in the past 15 minutes. Fall Twelve: A review of Resident 21's Nurse's Progress Notes, dated 3/4/21, and Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM (Bowel Movement) from 1/28/22 through 2/2/22 (six days), so on 3/4/21 at 12 a.m., Resident 21 was given a Dulcolax Suppository 10 mg (milligrams) for constipation. Nursing Progress Notes indicated safety fall precautions were maintained, but at 1:50 a.m. Resident 21 was found laying on the floor by her bedside. Resident 21 had an extra-large BM in her brief. Note: Nurse's Progress Note indicated the nurse did not go back to check on Resident 21, who was severely cognitively impaired and had poor safety awareness for almost two hours after Resident 21 was given a suppository to stimulate a BM. During a concurrent observation and interview on 3/4/22 at 9 a.m., Surveyor went into Resident 21's room along with Staff K, who showed where Resident 21's drop mat was kept. Staff K stated it was placed on the floor next to Resident 21's bed when she was in bed. Resident 21 was up in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 29 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 wheelchair next to her bed. Staff K stated Resident 21 did not have a bed alarm and/or a wheelchair alarm. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/4/22 at 9:03 a.m., Staff Q stated she checked on Resident 21 every two hours. Staff Q stated Resident 21 was walking when Resident 21 was first admitted , but with assistance. When Staff Q was asked what frequently monitoring meant, she could not answer. Staff Q stated she checked on Resident 21 every time she passed by Resident 21's room because Resident 21's door was always opened. Staff Q stated another CNA was passing by Resident 21's opened door and saw Resident 21 was trying to get up, so Staff K told Staff Q, who went to check on Resident 21 right away. Staff Q stated if she was not available, Staff K would have assisted Resident 21. Staff Q was asked again what frequent monitoring meant and Staff Q could not define. Staff Q stated Resident 21 could not get up on her own, unsafe. Residents Affected - Some During an interview on 3/4/22 at 9:45 a.m. the DON stated Resident 21 went to Activities as much as possible. The DON stated Resident 21 could not stand on her own. The DON stated Resident 21 was using a four-wheel walker with seat when Resident 21 was first admitted , but the walker was not safe. The DON stated Resident 21 was cognitively impaired and it was impossible to watch her all the time. The DON stated none of the residents had a one-on-one sitter. The DON stated a one-on-one sitter would be impossible because of lack of staff. The DON stated no residents had alarms and Resident 21's was discontinued on 11/20/21. The DON stated the facility did not use any alarms anymore because the alarms were found not to worked and scared the resident. During an interview on 3/4/22 at 11:41 a.m., Activities Assistant R stated she only worked Friday and Saturdays. Activities Assistant R stated Resident 21 would come to activities occasionally. We would encourage her to come. Activities Assistant R stated today Resident 21 was at the sensory awareness activity the entire time. During an interview on 3/4/22 at 11:48 a.m., Interim Activities Director S stated Resident 21 would come to activities sometimes. Interim Activities Director S stated Resident 21 was encourage to come to activities, but often Resident 21 wanted to stay in her room. Interim Activities Director S stated Resident 21 would come to activities two to three times during the week, just depended on her mood. Interim Activities Director S stated Resident 21 liked the social coffee activity; Resident 21 really came to be around other residents though often did not engage. The Facility Policy/Procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated: Policy heading: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors: . 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment . e. lower extremity weakness . i. functional impairments . k. incontinence, 3. Medical factors that contribute to the risk of falls include: . e. balance and gait disorders, etc. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Monitoring Subsequent Falls and Fall Risk: . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 4. The staff and/or physician will document the basis for conclusions that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 30 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Level of Harm - Minimal harm or potential for actual harm The facility job description titled, RN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Nursing Care Functions: . Ensure that residents who are unable to call for help are checked frequently. Residents Affected - Some The facility job description titled, LVN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Nursing Care Functions: . Ensure that residents who are unable to call for help are checked frequently. The facility job description titled, Director of Nursing Services, dated 2003, indicated: Duties and Responsibilities: Nursing Care Functions: . Ensure that residents who are unable to call for help are checked frequently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 31 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to re-order one Resident's (Resident 95) blood thinner medication in a timely manner to ensure there were no missed doses. This failure caused Resident 95 to miss two doses of his blood thinner and had the potential to cause Resident 95 to develop a blood clot. Findings: During a review of the clinical record for Resident 95, Physician L ordered Enoxaparin (blood thinner) on 2/23/2022. The physician's order read: Inject 100mg/ml (milligrams per milliliter) subcutaneously (under the skin) two times a day for deep vein thrombosis (blood clot) prophylaxis (prevention of). During a medication administration observation on 3/2/2022 at 8:18 a.m., the day shift Licensed nurse A asked the night shift Licensed nurse B if the Enoxaparin for Resident 95 had come from the Pharmacy. The night shift Licensed nurse B stated No. During a medication administration observation on 3/2/22 at 8:29 a.m., Licensed nurse A stated he did not have the Enoxaparin for Resident 95. He stated the Enoxaparin was re-ordered from the Pharmacy on 3/1/22. Licensed nurse A called the Pharmacy on 3/2/22 at 8:29 a.m. and was told the medicine was delivered. Licensed nurse A checked the other two medication carts for the Enoxaparin, and it was not there. Licensed nurse A called the Pharmacy again on 3/2/22 at 8:38 a.m. to ask who received the medication at the facility. The Pharmacy then stated the medication was on the way. While Licensed Nurse A was on the telephone with the Pharmacy, the D.O.N. asked if she could help Licensed Nurse A. The D.O.N. stated she thought the medicine had been discontinued. The D.O.N. checked the paper chart for the MD order which indicated, continue the Enoxaparin. During an interview with Licensed nurse A on 3/2/2022 at 3:50 p.m. he stated the medicine had not arrived yet. At this point, two doses of Enoxaparin were missed, the a.m. dose and the p.m. dose. During an interview with the D.O.N. on 3/3/2022 at 10:00 a.m. when asked what her expectation was regarding the missed doses of Enoxaparin for Resident 95, the D.O.N. stated she reached out to the Pharmacy account manager yesterday (3/2/22), and they could not tell her what happened with the order for Enoxaparin. When asked what could happen if a Resident did not get his/her blood thinner? The D.O.N. stated they can develop a blood clot. When asked what actions the nurse should have taken, the D.O.N. stated, the nurse should report to Physician L and Physician U (the cardiologist), and the nurse faxes the lab results (PT/INR -A prothrombin time (PT) measures the time it takes for a clot to form in a blood sample. An INR is a calculation based on the results) range- to the cardiologist. The DON stated, they ordered the enoxaparin when they were on the last syringe. During an interview on 3/3/2022 at 10:15 a.m., with Licensed Nurse C, when asked what she would do if she found the facility was out of Enoxaparin for a resident, she stated, I would check the PT/INR. Licensed Nurse C stated she would check the medicine order and check the supply of the medicine, and re-order it if needed, and follow up to make sure the pharmacy sent the supply. During an interview with Licensed Nurse A on 3/3/2022 at 11:00 a.m., he stated Licensed nurse B told him the medication was delivered this morning at 2 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 32 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Licensed Nurse A on 3/3/2022 at 11:20 a.m., when asked why he charted in the MAR, on 3/2/2022, that the Enoxaparin was given, Licensed nurse A stated, it was a mistake, an error A record review of a progress note dated 3/2/2022 at 11:00 a.m., written by Licensed nurse A, indicated the MD was notified that Lovenox 100/ml had not been delivered and will arrive later today and the a.m. dose would be missed. A record review of progress note dated 3/2/2022 at 11:53 a.m., written by Licensed nurse A, indicated [Resident 95's] Enoxaparin not given charted given by mistake notified the oncoming nurse to give upon arrival. Notified MD INR ordered stat. During an interview with the D.O.N. on 3/3/2022 at 3:04 p.m., when asked what her expectation was regarding ordering Enoxaparin, she stated It shouldn't take more than one day. It's twice a day, that's two days, so I will now say four syringes. If you get the call in (to the pharmacy) by 1p.m., you should have it by the next run(delivery) . between 3-4 p.m. During a record review titled, Encounter-Office Visit, dated 3/3/2022 at 3:12 p.m., Physician L entered a note that indicated, [Resident 95] missed a dose of Lovenox (brand name for Enoxaparin), given today after supply available. Patient denies any bleeding, SOB (shortness of breath), CP (chest pain), HA (headache) (Potential symptoms of a blood clot formation). No fever. Plan: Check INR CBC (Complete Blood Count) CMP(Complete Metabolic Panel) today. Continue meds and rehab. No injury or observable side effects from related to missed dose of Lovenox. The facility policy and procedure titled Administering Medications dated 2001, (Revised April 2019), indicated 4. Medications are administered in accordance with prescriber orders, including any required timeframe. 6. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 33 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide proper monitoring of drug adverse effects when one of five residents sampled for unnecessary medication review (Resident 27) did not have ordered monitoring for signs and symptoms of bleeding while taking a blood thinner. This failure could potentially lead to Resident 27 having undetected bleeding. Residents Affected - Few Findings: During a record review on 3/1/22 at 4:45 p.m., Resident 27's electronic medical record revealed Resident 27 was admitted on [DATE] and her medical diagnoses included chronic embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in the right leg). Resident 27's physician orders indicated she was taking Eliquis (a blood thinner) 2.5 milligrams (a unit of measure) twice a day for deep vein thrombosis (a blood clot). Further review of Resident 27's physician orders and medication administration record (MAR) revealed there was no order or documentation for nurses monitoring Resident 27 for signs or symptoms of bleeding. During an interview on 3/2/22 at 11:22 a.m., when asked what side effects he was monitoring for Resident 27's use of Eliquis, Licensed Nurse A stated he monitored her for excessive bleeding. When asked where he documented this monitoring, Licensed Nurse A stated he only documented a progress note if she had any bleeding. During a record review and concurrent interview on 3/4/22 at 9:41 a.m., Director of Nursing (DON) reviewed Resident 27's chart, and stated she was not seeing an order to monitor Resident 27 for side effects of Eliquis. DON stated the omission of monitoring got missed by pharmacy and us, and stated she was putting in the order. DON confirmed there should be an order for monitoring for side effects of blood thinners. Review of website dailymed.nlm.nih.gov revealed the drug label information for Eliquis, last updated 6/16/21, included the warning, ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. Review of facility policy and procedure Medication Therapy, last revised 4/2007, indicated, Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: . potential or suspected side effects are present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 34 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly secure residents' medications when two of 15 sampled residents, Residents 28 and 36, had inhalers stored on their bedside tables. This failure had the potential to result in other residents misusing the inhalers when they had unrestricted access to prescription medications. Findings: Resident 28 During an observation and concurrent interview on 2/28/22 at 11:08 a.m., Resident 28 had two inhalers on her bedside table. One was a puffer-style inhaler and one was a flat, purple, disk-shaped inhaler. Resident 28 stated she did not need help to use the inhalers. During a medical record review, Resident 28's physician orders indicated Advair Diskus 500-50 mcg (micrograms, a unit of measure)/act (activation) 1 inhalation orally two times a day for COPD (chronic obstructive pulmonary disease) and Albuterol Sulfate aerosol solution 108 mcg/act 2 puffs inhale orally every 4 hours related to COPD. Resident 28's Interdisciplinary Team (IDT) Progress note dated 3/2/22 at 5:26 p.m. indicated, Spoke to [Resident 28] about locking her inhaler in individual lock box kept at her bed side and the key given to nursing. She declines to have this done, in her opinion this will not work for her and would rather the nurse keep her inhalers for her. During an interview on 3/4/22 at 9:41 a.m., when asked about the IDT progress note written on 3/2/22, DON stated the note was written after they realized Resident 28 had her inhalers out on her table. DON stated they bought her a lock box, and the nurse would have to get Resident 28 the key when Resident 28 needed her inhalers. DON stated the inhalers were not supposed to be out on Resident 28's table unsecured. When queried, DON stated she did not know how the inhalers got there. Resident 36 During an observation on 2/28/22 at 10:15 a.m. in Resident 36's room, Resident 36 self-administered 2 puffs of the Budenoside Formoterol inhaler (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma) that was on top of her overbed table, removed the mouthpiece from her mouth with no wait time and did not rinse her mouth with water after use. Asked Resident 36 if she would normally self-administer her own oral inhaler, Resident 36 nodded her head. During an observation, interview, and concurrent record review with Licensed Nurse D on 2/28/22 at 4:14 p.m., Licensed Nurse D verified the Budesonide Formoterol inhaler was still on Resident 36's overbed table. Licensed Nurse D was asked the reason for Resident 36 keeping the inhaler at bedside, and Licensed Nurse D stated, morning nurse must have forgotten to take it back. Licensed Nurse D verified Resident 36 had an order for Budesonide Formoterol inhaler to give 2 puffs with special instruction to rinse mouth with water after use. He stated Resident 36 self-administers her own oral inhaler and knew how to do it. Licensed Nurse D verified there was no care plan for self-administration of medication for Resident 36. During an interview with the DON on 3/3/22 at 2:25 p.m., when asked how licensed staff would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 35 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete monitor Resident 36 for proper administration of inhaler, the DON stated Resident 36 was provided with a locked box, nurses keep the key and would give the key to Resident when it's time for her take the medication. Licensed staff would be present during self-administration to monitor resident if she was doing it correctly. Review of facility policy Storage of Medications, last revised 11/2020, revealed, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Event ID: Facility ID: 555127 If continuation sheet Page 36 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: Residents Affected - Some 1. Foods were not stored in the refrigerator per facility storage guidelines including bread, premade cheese sandwiches, and gelatin, tomatoes had brown spots and felt mushy, and Romaine lettuce was not sealed and no open date, and 2. Test tray evaluation of lunch on 3/2/2022 at 12:57 p.m., found pureed Risotto tasted bland and had a gluey texture causing pureed risotto difficult to swallow, broccoli mushy and gray/green in color, and test tray evaluation of dinner on 3/2/2022 at 5:10 p.m., found the bottom bun of the grilled hamburger bun was hard, dry, and over cooked. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise resident medical status. Findings: 1. During the initial tour of the kitchen on 2/28/22 at 9:15 a.m., the walk-in refrigerator nearest the kitchen entrance had stored hot dog buns and hamburger buns, premade cheese sandwiches, which were wrapped and dated 2/22/22 and premade peanut butter and jelly sandwiches, which were wrapped and dated 2/26/22. The Dietary Director stated the date on the premade sandwiches indicated the date the sandwiches were made, and the Dietary Director stated all bread was stored in the refrigerator. The walk-in refrigerator nearest the prep sink had loaves of white and wheat bread, a large box of [NAME] tomatoes, which had brown spots and felt meshy, a large opened bag of Romaine lettuce, with no received or opened date, and diet Jell-O, dated 2/18/22. During an interview on 2/28/22 at 10:46 a.m., Resident 28 stated, The food is horrible, it's slop, it's awful, it should be thrown to the pigs. In the cauliflower chowder, the milk was curdled, I was looking forward to it. It's awful tasting, no spices. The meat is unrecognizable, gravy on everything . mystery meat. During a meeting with the Resident Council on 3/1/22 at 11:08 a.m., one out of seven residents stated the facility was using air bread, cheapest bread the facility could buy. Two out of seven residents stated they never ate the bread being served. Four out of seven residents stated bread was okay. Resident's stated vegetables were over cooked causing lack of flavor in the vegetables. Food was not good, all nutrients go down the drain. No seasoning. A lot of carbohydrates. During a concurrent observation and interview on 3/2/22 8:45 a.m., the walk-in refrigerator nearest the kitchen entrance had premade turkey on wheat bread with Mayonnaise sandwiches, dated 2/28/22, hot dog buns, dated 10/14/21 and 10/21/21, hamburger buns, dated 2/24/22, and the premade peanut butter and jelly sandwiches, dated 2/26/22, were still in the refrigerator. The Dietary Director stated the hamburger buns were going to be used for the residents' evening meal, which included smokey beef hamburger on a bun. The walk-in refrigerator nearest the prep sink had stored loaves of white bread, receive date 2/17/22, and loaves of wheat bread, receive date 2/22/22, the [NAME] tomatoes, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 37 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had brown spots and felt meshy, dated 2/14/22, were still in the refrigerator and the Romaine lettuce was tied, receive date 2/17/22. The Dietary Director stated today was when she cleaned outdated/old fruits/vegetables. The facility dietary document titled, Refrigerator Storage Guide, dated 2019, indicated: .gelatin, prepared, plain or with fruit, maximum refrigerator time of five days . The facility dietary document titled, Produce Storage Guidelines, dated 2018, indicated: . May use longer if no signs of spoilage are visible. lettuce, salad greens . refrigerator seven to ten days, tomatoes one to two weeks (at room temperature - preferably cool . The facility dietary document titled, Dried Goods Storage Guidelines, dated 2018, indicated: . bread unopened and opened on shelf five-seven days and three months frozen . The facility policy/procedure titled, Storage of Food and Supplies, dated 2018, indicated: Policy: Food and supplies will be stored properly and in a safe manner. Procedures For Dry Storage: . 13. Bread will be delivered frequently and used in the order that is delivered to assure freshness. Bread products not used within five days can be frozen. Some breads do last five-seven days. Check manufactures recommendations. Do not store bread in the refrigerator . The facility policy/procedure titled, Labeling and Dating of Foods, dated 2019, indicated: Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Procedure: . Produce is to be dated with a receive dated . 2. On 3/2/22 at 1:15 p.m., a lunch test tray was completed. It was noted by surveyors and Registered Dietician, while the food temperatures were 131º F or greater, the pureed Risotto was bland and had a gluey [NAME], which caused the Risotto to stick to one's palate (the roof of mouth) and difficult to swallow. The surveyor noted broccoli was bland, mushy, and grayish/green. During an interview on 3/2/22 at 2:45 p.m., Resident 28 stated the broccoli served at lunch was mushy and overcooked. On 3/2/22 at 5:10 p.m., a dinner test tray was completed. It was noted by surveyors the hamburger bun tasted dry. The Dietary Director stated the bun was grilled on the outside not inside. The bottom part of the hamburger bun was hard to touch. The dietary document titled: Recipe: Pureed Starch (Rice, Pasta, Potatoes), undated, indicated: Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk . If starch is already moist after pureed, you may not need much added milk. 4. Puree should reach a consistency slightly softer than whipping topping. May add more liquid if needed to reach this consistency. The dietary document titled, Recipe: Smokey Hamburger on a Bun, undated, indicated: Directions: . Special Diets: .Mechanical Soft: . Serve on bun . Note: There was no indication on the recipe to grill the outside of the hamburger buns. The facility policy/procedure titled, Meal Service, dated 2018, indicated: Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 38 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 at the appropriate temperatures . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 39 of 40 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Post Acute 450 Hayes Lane Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, one resident's urinary catheter bag and tubing (a device that drains urine from the bladder through a tube to a collection bag) were on the floor. This could potentially lead to the resident developing a urinary tract infection (UTI). Residents Affected - Few Finding: During an observation and concurrent interview on 3/3/22 at 4 p.m., Resident 27 was in bed watching TV. Resident 27's urinary catheter bag and tubing were on the floor next to the bed. Infection Preventionist Nurse (IPN) came to Resident 27's room. When asked if the catheter bag was touching the floor, IPN stated it was covered with the bag (dignity bag, covers the collection bag so the resident's urine is not visible). When asked if the catheter tubing was on the floor, IPN stated, Yes. IPN stated the tubing should not be on the floor because it can cause an infection. During an interview on 3/4/22 at 11:58 a.m., when asked what measures she took to prevent a urinary tract infection for a resident with a urinary catheter, Staff M stated she checked the collection bag every two hours and measured how many cc's (cubic centimeters, a unit of measure), noted the color of the urine, and let the nurse know if it was smelly. Staff M stated she would encourage the resident to drink water. When asked if there were any other interventions, Staff M stated, No. Review of Resident 27's care plan revealed a focus area of The resident has (Suprapubic) Catheter . dated 5/21/21, with a goal of, The resident will show no [signs or symptoms] of Urinary infection through review date . The interventions on the care plan included monitoring for signs and symptoms of UTI, but did not include using clean technique in handling of the catheter device. Review of facility procedure Catheter Care, Urinary, last revised 9/2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 40 of 40