Inspection·April 22, 2024

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 interviews and records review, the facility failed to assess and monitor for signs of after surgery complications for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure had the potential for Resident 20 to develop an unidentified bacterial eye infection which could result in Resident 20's discomfort. Residents Affected - Some Findings: A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., when Licensed Staff D was asked about the facility policy for resident's who had a change of condition (COC), Licensed Staff D stated nurses would monitor the resident for any complications from the COC. Licensed Staff D concurred that Resident 20's left eye surgery was considered a COC. When Licensed Staff D was asked what should the nurses monitor after Resident 20's eye surgery, Licensed Staff D stated nurses would monitor for signs of eye infection like eye discharges, redness, itching and eye discomfort. During an interview with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about her expectation from the nurses after Resident 20 had eye surgery, the DON stated she expected the nurses to assess and monitor for any signs of complications from the eye surgery, like eye infection and pain every shift for seventy two (72) hours as standard practice and document their observations. After review of the nurses' progress notes from 4/9/24 to 4/19/24 with the DON, the DON stated there was no documentation from the nurses to show Resident 20 was assessed and monitored for signs of complications after the eye surgery. Review of the Facility policy and procedure titled Acute Condition Changes - Clinical Protocol revised on March 2018 under Monitoring and Follow-up indicated, The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 2 of 12 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 04/22/2024 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the posted daily staffing schedule had an additional required information such as census (number of residents in the facility), the total numbers of Licensed and Unlicensed staff and the actual hours worked individually, reflect staff absences on that shift due to call-outs and illness, and clearly identify the staff's name in a clear and readable format. Residents Affected - Many This failure had the potential to result in poor and inadequate care that compromised the health and safety of residents. Findings: During a concurrent observation and interview on 4/18/24 at 4 p.m. with the Administrator (ADM), during a tour to the nurses' station where the daily staffing was located, the daily staffing for Licensed and Unlicensed nurse was located inside a binder. ADM stated that the daily staffing was readily available to read to all visitors, staff, and residents. During a concurrent interview and record review on 4/18/24 at 4 p.m. at the nurses' station, when Administrator (ADM) was asked do you have the census written on the daily staffing, ADM answered no. When asked ADM, how do you differentiate the staff's name listed on the daily staff list as there were no last name or last name initial, since you have multiple staff with the same first name, ADM answered, yes, she does not see the last name. ADM stated, she would change the format of the posting for daily staff assignments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 3 of 12 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 04/22/2024 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure Ophthalmic (pertaining to the eye) medications were administered according to the doctor's order for two of 15 sampled residents (Resident 20 and Resident 41) when: 1. a. Resident 20 who had left eye surgery did not receive the ordered Ofloxacin Ophthalmic Solution 0.3%, (an antibiotic used to treat bacterial infections of the eye) three days after the medication was ordered, and (b) Resident 20 did not receive the medication according to the ordered administration time. These failures had the potential risk for Resident 20 to develop bacterial eye infection and eye discomfort. (Cross reference F684) 2. Resident 41 who had a diagnosis of Glaucoma (an eye diseases that can cause vision loss and blindness) did not receive his eye medications according to the ordered administration time. These failure had the potential risk for Resident 41 to experience eye pain and deterioration of visual function. Findings: Resident 20 During an interview with Resident 20 on 4/15/24 at 4:02 p.m., Resident 20 stated he had a new order for eyedrop after his eye surgery and did not get the medication until after two days. Resident 20 stated he was supposed to have the eyedrops at 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; and 8:00 p.m. but the nurses were late in giving his eye drops. A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. A review of the document titled Order Summary Report indicated a Physician's Order written on 4/10/24 for Ofloxacin Ophthalmic Solution 0.3%, to give one drop in left eye four times a day. a. A review of the document titled Pharmaceuticals Shipping Manifest dated 4/14/24 indicated the Ofloxacin 0.3% eye drop was received on 4/14/24 at 10:53 p.m. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., Licensed Staff D stated Resident 20 had left eye surgery and currently receiving antibiotic eye drops. A review of the Medication Administration Record (MAR) for Resident 20 with Licensed Staff D from 4/10/24 to 4/13/24 indicated 3 with the nurse's initials under the Ofloxacin order. When Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 4 of 12 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 04/22/2024 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 - Some Staff D was asked what 3 stand for, she stated to hold (an order to suspend the medication administration under specific conditions) the medication and to see nurses' notes for reason of holding the medication. However, after review of the nurses' progress note with Licensed Staff D, Licensed Staff D stated the progress note did not indicate reason for holding the medication. She stated the medicine could be unavailable. When Licensed Staff D was asked about the risks for Resident 20 for the delayed administration of eye antibiotic after his eye surgery, she stated Resident 20 could be at risk for eye infection and eye pain. During a review of the MAR for Resident 20 and concurrent interview with Licensed Staff C on 4/19/24 at 10:31 a.m., Licensed Staff C verified the order for Ofloxacin was written on 4/10/24 and that nurses documented 3 from 4/10/24 to 4/13/24. When Licensed Staff C was asked why was the eye antibiotic not given for three days, Licensed Staff C stated she called the pharmacy and was told the medicine won't be delivered until 4/16/24 due to Resident 20's medical insurance. When Licensed Staff C was asked if Resident 20's physician was notified that the medicine won't be delivered until 4/16/24, she stated she was not sure if Resident 20's physician was notified. When Licensed Staff C was asked about the risks for Resident 20 for the delayed administration of the eye antibiotic, Licensed Staff C stated Resident 20 had the potential risk for eye infection, swelling, redness, pain and burning sensation. During an interview with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about the facility's medication administration policy for new ordered antibiotic, the DON stated antibiotic medications should be given as soon as possible, within 4 hours. When the DON was asked if she was aware that the Ofloxacin delivery was delayed due to Resident 20's medical insurance, the DON stated no. She stated if she was notified that the medicine could not be delivered on time, she could fill up an authorization form to expedite the process to avoid the delay. The DON stated risks for delayed treatment would be eye infection. b. A review of the document titled Medication Administration Audit Report indicated Resident 20 received Ofloxacin Ophthalmic Solution 0.3% one drop to his left eye on the following dates and times: - On 4/15/24, Resident 20 received the medication at 12:22 p.m. for the scheduled 8:00 a.m. dose. - On 4/16/24, Resident 20 received the medication at 10:15 a.m. for the scheduled 8:00 a.m. dose; and 6:00 p.m. for the scheduled 4:00 p.m. dose. - On 4/17/24, Resident 20 received the medication at 11:04 a.m. for the scheduled 8:00 a.m. dose; and 6:28 p.m. for the scheduled 4:00 p.m. dose. - On 4/19/24, Resident 20 received the medication at 1:57 p.m. for the scheduled 8:00 a.m. dose; and 6:14 p.m. for the scheduled 4:00 p.m. dose. - On 4/20/24, Resident 20 received the medication at 10:04 a.m. for the scheduled 8:00 a.m. dose; 6:31 p.m. for the scheduled 4:00 p.m. dose; and 10:55 p.m. for the scheduled 8:00 p.m. dose. - On 4/21/24, Resident 20 received the medication at 4:40 p.m. for the scheduled 12:00 p.m. dose. During an interview with Licensed Staff D on 4/22/24 at 1:34 p.m., when asked about the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 5 of 12 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 04/22/2024 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 policy for medication administration, Licensed Staff D stated nurses could administer scheduled medications an hour early or an hour late and expected to document on the resident's MAR immediately after administering the medications. Resident 41 Residents Affected - Some During an interview with Resident 41 on 4/15/24 at 3:38 p.m., Resident 41 stated he often gets his medicines including his eye drops a couple of hours late. He stated he was supposed to get the eyedrops three times a day in the morning, at noon and at night. A review of the document titled admission Record indicated Resident 41 was admitted on [DATE] with diagnosis including but not limited to Glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight) and Hypertension (High Blood Pressure). A review of the document titled Order Summary Report indicated a Physician's Order written on 2/26/24 for Prolensa Ophthalmic Solution 0.07% (used to treat pain or swelling of the eye following cataract surgery [a procedure to remove the lens of the eye] to give one drop in right eye two times a day for Glaucoma; a Physician's Order written on 3/19/24 for Brinzolamide-Brimonidine Ophthalmic Suspension 1-0.2% (used to treat increased pressure in the eye caused by glaucoma) to give one drop in right eye two times a day for Glaucoma, and Timolol Maleate Ophthalmic Solution 0.5% (used to treat high pressure inside the eye due to glaucoma) to give one drop in right eye two times a day for Glaucoma. A review of the document titled Medication Administration Audit Report indicated Resident 41 received Brinzolamide-Brimonidine Ophthalmic Suspension 1-0.2%; Timolol Maleate Ophthalmic Solution 0.5%; and Prolensa Ophthalmic Solution 0.07% on the following dates and times: - On 4/16/24, Resident 41 received the medications at 10:19 a.m. for the scheduled 8:00 a.m. dose. - On 4/17/24, Resident 41 received the medications at 11:45 a.m. for the scheduled 8:00 a.m. dose. - On 4/20/24, Resident 41 received the medications at 10:13 a.m. for the scheduled 8:00 a.m. dose. - On 4/21/24, Resident 41 received the medications at 4:40 p.m. for the scheduled 12:00 p.m. dose. During an interview with the DON on 4/23/24 at 1:41 p.m., when the DON was asked about the facility's policy for medication administration, she stated nurses have one hour before and one hour after the scheduled time to give the medications and nurses were expected to document as soon as the medications were given to the residents. Review of the Facility policy and procedure titled Medication Administration General Guidelines dated 9/2018 indicated, Medications are administered in accordance with written orders of the prescriber . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 6 of 12 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 04/22/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to follow their Medication Storage Policy, when 3 expired COVID 19 Vaccines and 1 box of Arginaid (wound healing nutrition) were found in the facility's Medication Storage room and another expired box of Arginaid was found in Medication Cart 1. This failure had the potential to result in Residents being injected with an expired ineffective COVID 19 vaccine resulting in an unvaccinated status as well as expired deteriorated Arginaid being ineffective for wound healing. Findings: During an observation on [DATE] at 12:55 p.m., in Medication Cart 1, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 12:59 p.m., in the Medication Storage room, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 1 p.m., in the Medication Storage room, 3 expired Covid 19 vaccines were observed with an expiration date of [DATE] in the medication refrigerator as well as 1 box of expired Arginaid found on the shelf with an expiration of [DATE]. During an interview with Licensed Staff C on [DATE] at 1:10 p.m., Licensed Staff C queried as to the risk to Resident safety if the Resident were to receive an expired Covid 19 vaccine. Licensed Staff C stated, she thinks the risks would be the Resident would not be effectively vaccinated due to the deterioration of the COVID 19 medication in the vial. Licensed Staff C queried as to what the risks would be to Resident safety if the Resident were to receive expired Arginaid for their wound. Licensed Staff C responded, she doesn't believe the expired Arginaid would be beneficial to support wound healing and the wound could get larger. During a review of the facility's policy and procedure titled, Medication Storage dated, 2007, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Medication storage conditions are monitored on a regular basis as a random quality assurance check. During a review of the Infection Preventionist Job Description, Revised [DATE], indicated, monitor the designated shelf life of sterizlied and packaged supplies; reprocess as necessary. Order inventories of vaccines to be adminsitered to staff and residents in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 7 of 12 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 04/22/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure two of two residents, Resident 9 and Resident 19, received action, obtain feedback, and conduct systematic investigations to improve quality of care, quality of life and resident's safety during Quality Assurance and Performance Improvement (QAPI) meetings when: Residents Affected - Some 1) The Director of Staff Development (DSD) did not report an incident reported by an Ombudsman of verbal abuse and mocking (imitating behavior) towards Resident 9 by Unlicensed Staff L. DSD did not inform the Administrator of the abuse allegation. ADM was the abuse coordinator. 2) Resident 19 attempted to complain to DSD regarding an alleged verbal abuse by Unlicensed Staff M & Unlicensed Staff N . DSD did not follow up with Resident 19 about the allegation and did not inform ADM nor the Inter Department team (IDT) during their daily IDT meeting & monthly meetings of QAPI. Findings: (1) During a concurrent interview and record review on 4/19/24 at 9:39 a.m. the Director of Staff Development (DSD) stated that she was the supervisors for the Certified Nursing Assistance (CNA). When asked the DSD if an Ombudsman reported to her about a CNA who was verbally aggressive to a resident, DSD answered yes. DSD stated that the Ombudsman reported to her about a staff who was imitating a resident. DSD filled out a form titled Employee warning/coaching documentation for Unlicensed Staff L (CNA). A review of the form dated 2/26/24 indicated that Ombudsman notified DSD/DON (Director of Nursing) Under Action taken verbal warning, corrective action by employee was an in-service title residents/patients' rights and will not imitate noise of resident's voice/sound. When asked DSD, did you inform the Administrator (ADM) regarding the alleged verbal abuse incident, DSD answered not sure, maybe I have. DSD stated she knew that the Director of Nursing (DON) was aware of this alleged abuse. When asked DSD, did you notify a law enforcement and State Agency, DSD answered No. During an interview on 4/1824 at 11:32 a.m., the administrator (ADM) stated that she was the Abuse Coordinator. ADM stated her managers made rounds once per week, talked with residents, report any type of abuse to social worker, managers, to reach out to family or conservator. ADM stated that all types of abuse was to be reported to her. ADM stated that once she received any allegation of abuse that she would investigate, interview resident, staff to determine if abuse occurred. ADM stated that part of the abuse was to report to State Agency, Ombudsman, Law enforcement, and Medical Doctor. When asked ADM, did you know about an incident happened between Unlicensed staff L allegedly imitating the noise that Resident 9 made, ADM stated, she was not aware of that incident. ADM stated that no one had informed her. When asked ADM, what was your expectation from your management when there was an alleged abuse, DM stated that she expected her management to inform her of alleged abuse. ADM stated that they meet Monday thru Friday in the morning for management meeting. When asked ADM if she recalled any report about this incident between Unlicensed Staff L and Resident 19 during the daily meeting, ADM stated No. (2) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 8 of 12 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 04/22/2024 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 0868 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 4/17/24 at 12:44 p.m., in Resident 19's room, Resident 19 stated that Unlicensed Staff M and N scolded her saying you are stressing me out. Resident 19 stated that she was upset from being scolded, so she said that she yelled at them back. Resident 19 stated that she informed the DSD briefly and DSD said that she would be back, it happened approximately last week, not sure of the exact date. Resident 19 stated that she did not hear back from DSD. Resident 19 stated that Unlicensed Staff M & N were not assigned to her anymore. During an interview on 4/18/24 at 11:32 a.m. ADM stated that she was not aware that Resident 19 had a verbal altercation with the Unlicensed Staff M & N. ADM stated that DSD did not mention it to her. ADM stated that she met with the Management Team (IDT) from Monday through Friday to discussed new issues. When asked ADM, do you recall when your Management Team discussed these verbal altercations between Unlicensed nurses L, M & N and Residents 9 and Resident 19, ADM stated No, she was not aware. During an interview on 4/19/24 at 10:30 a.m. with the DSD, DSD stated Resident 19 requested to speak to her for an alleged verbal altercation between resident and staff. DSD stated, she recalled that Resident 19 wanted to speak to her, but she was not able to go back to Resident 19's room. When asked DSD, did you inform another management or ADM that Resident 19 would like to report a verbal altercation, DSD stated No. During a concurrent interview and record review on 4/22/24 at 1:19 p.m. ADM stated that if a resident complains, it would be discussed in management (IDT) meeting. ADM stated that during IDT meeting daily, the abuse events were discussed or reported. ADM stated that the Ombudsman never informed her regarding abuse that involved Resident 9 and Unlicensed Staff L. ADM stated that the Ombudsman asked her about a specific last name of an Unlicensed Staff, but she never told her why. ADM stated that the topic or issues discussed during QAPI, personnel improvement plan and employee health files. When asked ADM, during your QAPI meeting, had any of your management mentioned anything about alleged verbal altercation or abuse, ADM stated, No, there were no discussion. A review of the facility's Policy & Procedure titled Quality Assurance and Performance Improvement (QAPI) Plan revised 4/2014 indicated This facility shall develop, implement and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolved identified problems Under objectives, 1) Provide a means to identify and resolve present and potential naive outcomes related to resident care and services: 3) Provide structure and processes to correct identified utility and/or safety deficiencies: 4) Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5) Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively ad to delineate lines of authority, responsibility and accountability. Under Authority: 1) The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI Program. 2) The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 9 of 12 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 04/22/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observation, interview and record review, the facility failed to provide a fully credentialed Infection Preventionist (nurse who surveys and monitors infection prevention and control). This failure had the potential for Residents to obtain infections and be placed on unnecessary medications due to lack of infection control surveillance. During an interview with the DON on 4/16/24 at 10:30 a.m., DON queried as to who the Infection Preventionist is for the facility. DON stated, the nurse who has been working as the Infection Preventionist (Licensed Staff H) resigned 12/29/23. DON stated, Licensed Staff H and Licensed Staff I have been filling in. DON queried for the facility's staffing sign in sheets for Licensed Staff H and Licensed Staff I from 1/3/24 to 4/15/24. DON also queried for the timecard accounting for License Staff H and Licensed Staff I from 1/3/24 to 4/15/24. During a record review of Licensed Staff H's timecard for the time frame 1/3/24 to 4/15/24. License Staff H's worked day shift on 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, and 2/29/24. During a record review of Licensed Staff H's Staffing Sign in sheets for 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, and 2/29/24, Licensed Staff H's timecard revealed that none of these dates was Licensed Staff H signed in to work as the Infection Preventionist. During a record review of Licensed Staff H's HR File, Certificate of Training for Infection Prevention 2-Day Course from CDPH (California Department of Public Health), dated, 9/12/19. No other Infection Preventionist training was found in Licensed Staff H's file as well as no annual continuing education CEU's. During a record review of Licensed Staff I's timecard for the time frame of 1/3/24 to 4/15/24, Licensed Staff I worked day shift on 1/4/24, 1/11/,24, 1/12/24, 1/16/24, 1/17/24, 1/25/24, 2/1/24, 2/5/24, 2/6/24, 2/12/24, 2/18/24, 2/20/24, 2/22/24, 2/26/24, 3/26/24 and was signed in on the Staffing Sign In sheets as the Infection Preventionist. Licensed Staff I worked as an Infection Preventionist from 1/3/24 -4/15/24 for a total of 15 shifts. During a record review of Licensed Staff I's HR File, Certificate of Training for infection Prevention 2-Day Course from CDPH, dated, March 1, 2024. This Certificate was 2.5 months after License Staff H resigned. Licensed Staff I started working as an Infection Preventionist on 1/4/23 without Infection Preventionist certification. No other credentialing prior to March 1, 2024, was found in Licensed Staff I's HR File. During an interview with the DON on 4/15/24 at 10:30 a.m., DON queried for the facility's policy for Infection Preventionist. No policy received. DON queried if both the DON position and the DSD position required a full-time nurse. DON responded, yes. During a review of the CDPH's Entrance Conference Worksheet, dated 4/15/24, Line 21, indicated, Name of facility's infection preventionist (IP). Documentation of the IP's primary professional training and evidence of completion of specialized training in infection prevention and control. This information was requested in writing from the ADM but no name or certification was received for the facility's Infection Preventionist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 10 of 12 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 04/22/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure titled, Antibiotic Stewardship - Staff and Clinician Training and Roles Revised 2016, indicated, The facility will educate and train staff and practitioners about the facility Antibiotic Stewardship Program, including appropriate prescribing, monitoring and surveillance of antibiotic use and outcomes. Nursing and Direct Care Licensed Staff - Nurses will receive initial orientation and ongoing training on: The facility's Antibiotic Stewardship Program, including the need for judicious use of antibiotics; how to utilize the standardized assessment and communication tool for resident suspected of having an infection; How to communicate with resident and family about the need for appropriate use of antibiotic; specific information that should be reported to the physician or provider upon identifying sign and symptoms of possible infection and specific information that should be obtained when an order for an antibiotic is received. Director of Nursing and the Infection Preventionist - Administration and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on: the facility's antibiotic Stewardship Program; the rationale for judicious use of antibiotics; how to use surveillance tools to monitor infection rates, antibiotic usage patterns and outcomes; how and when to gather data to present to the Infection Prevention and Control Committee for scheduled meetings; and individual roles and responsibilities in maintain antibiotic stewardship. The DON will monitor individual resident antibiotic regimens, including reviewing clinical documentation supporting antibiotic orders; and compliance with start/stop dates and/or days of therapy. The IP will audit, and the DON will provide feedback to providers on antibiotic prescribing practices. IP will monitor over time and report to the IPCC. a) measures of antibiotic start, resident days, and days of therapy. b) antibiotic susceptibility patterns (antibiogram data for specific timeframe) and c) negative outcomes or events related to antibiotic use for example C difficile infections, adverse drug event and antibiotic resistance rates. The IP will obtain, and the DON will provide to healthcare practitioners, educational resources and materials about antibiotic resistance and opportunities for improved antibiotic use. During a review of the facility's policy and procedure titled, Facility Assessment revised, April 2023, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The team responsible for conducting, reviewing, and updating the facility assessment includes the following: Administrator, A representative of the governing body, Medical Director, DON, and Infection Preventionist. Once the reviews of the resident needs and the facility resources are conducted, the facility assessment consists of systematically evaluating how well aligned these are. Each department provides input on current or potential gaps in care or services due to possible misalignment or lack of appropriate resources. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. This assessment is based on information acquired during a facility-based infection control risk assessment, as well as a community-based risk assessment. During a review of the facility's policy and procedure titled, Administrative Management (Governing Board) Revised April 2023, indicated, The governing board shall be responsible for the management and operation of the facility. The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The administrator is appointed by and accountable to the governing board. The governing board is responsible for but is not limited to: Oversight of facility care and services in accordance with professional standards of practice and principles. Establishment and ongoing review of all administrative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 11 of 12 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 04/22/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many programs governing facility management and operations, including Corporate Compliance Program .Quality Assurance and Performance Improvement program, and Staff orientation, training and development programs. Creation of and participation in the annual facility-wide assessment: Provision of a safe physical environment equipped and staffed to maintain the facility and services. During a review of the DON's job description, revised October 2020, indicated, Safety and Sanitation Ensure that nursing services personnel follow established infection prevention and control procedures. During a review of the Infection Preventionists job description, revised October 2020, indicated, Primary Purpose of this position is to plan, organize develop, coordinate, and direct the facility infection prevention and control program and its activities in accordance with the current federal, state, and local standards, guidelines and regulations that govern such programs and as directed by the Administrator and the infection Prevention and Control Committee. Administrative Functions: Plan develop, implement, evaluate and oversee the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities. Establish and maintain an infection surveillance program that is based on standardized definitions of infections. Review, summarize and report data relative to key infection prevention and control initiatives including antibiotic stewardship, healthcare acquired infections, immunization programs and outbreaks. Present findings from special investigations and make recommendations to the Infection Prevention and Control Committee. Participate in the annual facility assessment, perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 12 of 12