Inspection·September 11, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of five Certified Nursing Assistants (CNA) underwent a background check prior to employment. This failure had the potential to result in the facility not preventing individuals with a criminal history of abuse, neglect and exploitation to provide care to a medically vulnerable population of 56 residents.Findings:During a concurrent interview and record review on 9/10/25 at 3:26 p.m. with the Administrator (Admin), CNA 1's employee file was reviewed. CNA 1's employee file was missing a background check. The Admin confirmed with HR (human resources) that CNA 1 did not have a background check completed. The Admin stated all employees were supposed to go through the background check process to ensure the facility did not hire an individual that had a criminal history because it could impact the resident's safety.During a review of the facility's policy and procedure (P&P) titled, Background Screening Investigations, dated March 2019, the P&P indicated, Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 2 of 11 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 09/11/2025 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 Based on interview and record review, the facility failed to assess and submit accurate data for one of 14 sampled residents (Resident 27) when the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 27's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).Findings: During a concurrent interview and record review on 9/11/25 at 11:20 a.m. with Minimum Data Set Coordinator (MDSC), Resident 27's MDS 3.0 Section I- Active Diagnoses, dated 8/1/25, and Active Orders, undated, were reviewed. Resident 27's MDS 3.0 Section I- Active Diagnoses indicated under infections Resident 27 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 27's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 27 was admitted to the facility with a previous diagnosis of Chronic Viral Hepatitis C and confirmed Resident 27 had not received any treatment or medication for Chronic Viral Hepatitis C. During an interview on 9/11/25 at 11:40 a.m. with the Administrator (ADMIN), the ADMIN stated Resident 27's Chronic Viral Hepatitis C should not have been coded in MDS under active diagnoses because he was not receiving any treatment or medication for that diagnosis. During a review of CMS Long-Term Care Facility [LTCF] Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2024, CMS LTCF RAI 3.0 User's Manual indicated, Code disease that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Example of inactive Diagnoses . the resident has recovered . with no residual effects and no continued treatment . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 3 of 11 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 09/11/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 43) received a shower or bed bath for 16 days. This failure resulted in Resident 43 expressing a level of dissatisfaction with grooming and wanting to be groomed more often.Findings:During a review of Resident 43's admission Record, dated 9/11/25, the admission Record indicated Resident 43 was admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting right dominant side (loss of ability to move the right side of the body due to loss of oxygen to the brain).During a review of Resident 43's Minimum Data Set (MDS- an assessment tool used to guide resident care) Section GGFunctional Abilities, dated 9/5/25, the MDS Section GG indicated Resident 43 required maximal assistance (when a resident requires 50-75% of help from staff) for showering/bathing.During a concurrent observation and interview on 9/8/25 at 4:08 p.m. with Resident 43, Resident 43 had an accumulation of dirt underneath her fingernails and dry flaky skin to the palm of her right hand. Resident 43 stated she only received a couple of bed baths in the past month. Resident 43 further stated she did not receive consistent showers and would like to shower more.During a concurrent interview and record review on 9/11/25 at 9:45 a.m. with the Director of Nursing (DON) the following documents were reviewed:-the facility's Shower Schedule, undated, the facility Shower Schedule indicated Resident 43 was scheduled to be showered on Wednesday's and Sunday's PM (evening) shift.-Resident 43's Task: Shower, dated 8/13/25 to 9/11/25, the Task: Shower indicated Resident 43 did not receive a shower or bed bath for 16 days, during the period of 8/18/25 to 9/2/25.The DON confirmed there was no documentation of Resident 43 refusing a shower or bed bath. The DON stated Resident 43 should have received four showers or bed baths within the 16-day period.During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Dignity, dated February 2020, the P&P indicated, Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction . residents are groomed as they wish to be groomed . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 4 of 11 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 09/11/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the prescribed left hand roll (rolled up wash cloth or towel used to support and position the hand and wrist to prevent contractures-permanent shortening or tightening of muscles resulting in limited range of motion and stiffness in the hand) was applied as ordered by the physician for one of 14 sampled residents (Resident 54). This failure had the potential to result in Resident 54's decline in functional abilities.Findings:During a review of Resident 54's admission Record, dated 9/11/25, Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE] with a diagnosis of left-hand contracture.During a review of Resident 54's Care Plan Report, dated 3/4/18, the Care Plan Report indicated, [Resident 54] has an ADL [Activities of Daily Living-basic personal tasks] self-care performance deficit r/t [related to] limited mobility, Dementia [progressive decline in cognitive abilities], contracture of left hand (admitted with). Requires total care with all ADLs . is not able to initiate needs request and requires staff support to have needs are and concrete addressed and met by staff . CONTRACTURES: has contracture of the left hand . Left Hand roll on in AM and off in PM .During multiple observations on 9/8/25 between 1:39 p.m. to 2:52 p.m. in Resident 54's room, Resident 54 was sitting in a Geri-chair (specialized recliner designed for individuals with limited mobility) with left wrist bent at a downward angle. Resident 54's left hand did not contain a brace, splint or hand roll.During multiple observations on 9/9/25 between 8:45 a.m. to 4:21 p.m. in Resident 54's room, Resident 54 was sitting in a Geri-chair with left wrist bent at a downward angle. Resident 54's left hand did not contain a brace, splint or hand roll.During a concurrent observation and interview on 9/9/25 at 4:21 p.m. with the Infection Preventionist (IP), in Resident 54's room, Resident 54 was sitting in her Geri-chair with left wrist bent downward at an angle and did not contain a brace, splint or hand roll. IP stated Resident 54 should have had a hand roll in her left hand.During a concurrent interview and record review on 9/9/25 at 4:30 p.m. with the Director of Nursing (DON), Resident 54's Physician Order, dated 4/5/21 was reviewed. Resident 54's Physician Order indicated Place Hand Roll in Left Hand, On in the Morning and off at Night. Approximately 8 hours. The DON stated Resident 54 should have had a hand roll applied to her left hand.During an interview on 9/10/25 at 10:03 a.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 54's preventative measure for worsening of the contracture was to follow the physician order and apply the hand roll daily.Facility did not provide a policy and procedure for following physician orders. Event ID: Facility ID: 555127 If continuation sheet Page 5 of 11 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 09/11/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent when one of two licensed nurses were observed and made the following medication errors:1. Resident 74 did not receive the correct dosage of Baclofen (muscle relaxant medication used to treat muscle stiffness, spasms and pain) in accordance with the physician order.2. Metformin (medication used to treat type 2 diabetes- chronic condition when the body does not regulate blood sugars) was not given with breakfast in accordance with the physician order for Resident 12.These failures resulted in two identified medication errors out of 30 opportunities for medication administration. The facility's overall medication error rate was 6%.Findings:1.During a review of Resident 74's admission Record, dated 9/11/25, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome (consistent pain that significantly interferes with daily life).During a concurrent observation and interview on 9/9/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 removed 1 tablet of baclofen 10mg (milligram- unit of measurement) from the blister pack (packaging of medication that is individually sealed in plastic with cardboard backing), cut the tablet in half and added it to a medicine cup containing eight pills. LVN 1 counted all medications in the medicine cup and stated there was a total of ten pills, including the medication that was cut in half. LVN 1 then administered all medications to Resident 74.During a concurrent interview and record review on 9/9/25 at 12:38 p.m. with LVN 1, Resident 74's Physician Order, dated 9/3/25 was reviewed. The Physician Order indicated, Baclofen Oral Tablet 15 MG, Give 1 tablet by mouth three times a day for muscle spasms. LVN 1 confirmed he administered only 10 mg of Baclofen to Resident 74 and stated he should have given an additional half tablet of baclofen to equal the physician order of 15 mg.During an interview on 9/9/25 at 3:29 p.m. with the Director of Nursing (DON), the DON stated the expectation for nurses administering medication, was to confirm the dosage given with the physician order.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated November 2017, the P&P indicated, Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medication. Pour the correct number of tablets or capsules into the medication cup.2.During a review of Resident 12's admission Record, dated 9/11/25, admission Record indicated Resident 12 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes.During an observation on 9/9/25 at 9:43 a.m., Resident 12 was in her room and no breakfast tray was observed. LVN 1 removed 1 tablet of Metformin 500 mg from the blister pack that had a label Give 1 tablet by mouth with Breakfast and Dinner. LVN 1 then administered the Metformin to Resident 12 without breakfast.During a concurrent interview and record review on 9/9/25 at 12:26 p.m. with LVN 1, Resident 12's Physician Order, dated 12/11/23 was reviewed. The Physician Order indicated, metFORMIN. Give 500 mg by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA with breakfast and dinner. LVN 1 confirmed Resident 12 ate breakfast prior to medication administration and stated breakfast meal trays were distributed at 7 a.m. LVN 1 further stated Resident 12's Metformin should have been given within 30 minutes of eating breakfast.During an interview on 9/9/25 at 3:31 p.m. with the DON, the DON stated when medication was ordered to be administered with breakfast, the medication was expected to be administered while eating breakfast.During an interview on 9/11/25 at 11:14 a.m. with the Pharmacist (Pharm), the Pharm stated manufacturer recommends to administer Metformin with food to prevent GI (gastrointestinalstomach) discomfort.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated November 2017, the P&P indicated, Medications that require specific instructions for administration are Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 6 of 11 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 09/11/2025 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 0759 administered in a way that complies with manufacturer's recommendations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 7 of 11 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 09/11/2025 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 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 safely store drugs in accordance with acceptable standards of practice when Resident 30's Naloxone (fast-acting medication that reverses an opioid [pain medication] overdose) had an expiration date of [DATE] and stored in a medication cart. This failure had the potential for Resident 30 to be administered an expired medication.Findings:During a review of Resident 30's admission Record, dated [DATE], admission Record indicated Resident 30 was admitted to the facility on [DATE] with a diagnosis of diverticulitis (inflammation and/or infection of the large intestines that can cause sudden or intense pain).During a concurrent observation and interview on [DATE] at 5:05 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 30's naloxone nasal spray had an expiration date of 7/2025 in a medication cart. LVN 2 stated the naloxone should have been discarded.During an interview on [DATE] at 4:21 p.m. with the DON, the DON stated all medications that were expired should have been discarded.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Event ID: Facility ID: 555127 If continuation sheet Page 8 of 11 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 09/11/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three of four outside dumpsters' were covered. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 56 residents.Findings:During a concurrent observation and interview on 9/8/25 at 1:30 p.m. with the Dietary Manager (DM) outside of the building near the kitchen, there were three dumpsters with overflowing garbage that were uncovered. There was foul odor and many flies coming from the dumpsters. The DM stated the dumpsters should have been covered.During a follow up interview on 9/11/25 at 10:37 a.m. with the DM, the DM stated the maintenance department was responsible for ensuring the dumpsters were maintained and closed. The DM further stated dumpsters needed to remain closed to prevent an attraction of pests that could lead to contamination of food. During a review of the facility's policy and procedure (P&P) titled Food-Related Garbage and Refuse Disposal dated October 2017, the P&P indicated, .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 9 of 11 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 09/11/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement an infection prevention and control program when:Personal Protective Equipment (PPE-specialized clothing or equipment used to provide a barrier and reduce exposure to hazards or infections) was not disposed correctly outside of Resident 67's room.Seven of seven residents (Resident 18, 24, 32, 45, 52, 66, and 73) were on Enhanced Barrier Precaution (EBP-infection control intervention used to prevent the spread of MDROs- bacteria that is resistant to most antibiotics) and did not have PPE available immediately outside the resident's room in accordance with The Center for Disease Control and Prevention (CDC) guidelines.These failures had the potential to place residents at risk for cross contamination that could lead to illness.Findings: Residents Affected - Many 1.During a review of Resident 67’s “admission Record,” dated 9/10/25, the “admission Record” indicated Resident 67 was admitted to the facility on [DATE] with a diagnosis of COVID-19. During an observation on 9/8/25 at 2:16 p.m. outside of Resident 67's room (room [ROOM NUMBER]), there was a face shield hanging on the back side of the resident’s door, facing towards the inside of the room. The face shield had unlabeled and undated. Resident 67's room did not have a sign indicating the resident was on any isolation precautions (preventative measures used to prevent the spread of germs by creating barriers and implementing safe practices). During an interview on 9/10/25 at 2:55 p.m. with the Licensed Vocation Nurse (LVN) 1, LVN 1 stated Resident 67 was positive for COVID-19 upon admission to the facility, but had been cleared to come off isolation precautions. LVN 1 stated the face shield should have been removed after Resident 67 was taken off of isolation precautions for COVID-19. During an interview on 9/11/25 at 10:48 a.m. with the Infection Preventionist (IP), the IP stated the face shield in Resident 67's room should have been discarded since Resident 67 was cleared from isolation precautions. The IP further stated the face shield could have led to cross-contamination. During a review of the facility policy and procedure (P&P) titled, Isolation - Initiating Transmission-Based Precautions, the undated P&P indicated, .When Transmission-Based Precautions are implemented, the Infection Preventionist .clearly identifies the type of precautions, the anticipated duration and the personal protective equipment that must be used .Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met . 2. During an observation on 9/8/25 at 1:53 p.m. Resident 18, 24, 32, 45, 52, 66 and 73 had EBP signs posted on the wall above the resident name tags. In addition, there was no PPE posted outside of Resident 18, 24, 32, 45, 52, 66 and 73’s room (Rooms 5, 6, 8, 10, 12, 14, and 16). During a concurrent interview and record review on 9/9/25 at 3:32 p.m. with the Infection Preventionist (IP), the Director of Nursing (DON) and the Administrator (Admin), the following documents were reviewed: -The “California Department of Public Health (CDPH)’s All Facilities Letter (AFL) 24-15,” dated 6/13/24, the document indicated, “California SNFs [Skilled Nursing Facilities] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 10 of 11 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 09/11/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should refer to the CDC website on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) . for guidance and tools for implementing EBP…” -CDC’s “Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs),” dated 4/2/24, the document indicated, “When implementing… Enhanced Barrier Precautions, it is critical to ensure staff have… access to appropriate supplies. To accomplish this… Make PPE, including gowns and gloves, available immediately outside of the resident room…” The IP, DON, and Admin confirmed the PPE was not available immediately outside Resident 18, 24, 32, 45, 52, 66 and 73’s room (Rooms 5, 6, 8, 10, 12, 14, and 16). The IP, DON and Admin further stated the PPE should have been available immediately outside of the resident rooms. During a review of the facility’s policy and procedure (P&P) titled, “Enhanced Barrier Precautions,” dated December 2024, the P&P indicated, “Personal protective equipment and alcohol-based hand-rub are readily accessible to staff…” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555127 If continuation sheet Page 11 of 11