Inspection·January 9, 2024

F 0684 stated lack of these items could result to skin issues and infection. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/9/24 at 10:18 a.m., Unlicensed Staff I stated staff had no access to the storage ship container where management kept briefs and incontinent wipes supplies. Unlicensed Staff I stated, most of the time, staff had no incontinent wipes to use on residents and incontinent wipes were not readily available. Unlicensed Staff I stated it was worse on the weekend because staff had to either contact the Director of Staff Development (DSD) or the Director of Nursing (DON) if they needed incontinent wipes to use on residents. Unlicensed Staff I stated the facility process was for certified nursing assistants (CNAs) to receive 1 pack of wipes per shift and if it was not enough, they had to ask the DSD or the nurse to hand them more wipes. She stated the CNAs do not have direct access to wipes if they ran out of wipes that was provided to them during their shift. Unlicensed Staff I stated there were also times where the facility did not have enough linens, briefs and towels to use on residents. Unlicensed Staff I stated the facility ' s laundry was being sent to the sister facility, so if a resident needed a new towel or linen they had to wait until it was delivered to their facility. Unlicensed Staff I stated delivery was done twice a day. Unlicensed Staff I stated if they ran out of briefs, they also had to wait until it was delivered to their facility. Unlicensed Staff I stated this had resulted to complaints from residents being left soiled in their briefs, resident lying in wet linen for a long period of time. Unlicensed Staff I stated it was hard not having briefs, incontinent wipes, and linen readily available because it delays the care for the resident. Unlicensed Staff I stated the CNAs were only allowed 1 pack of wipes per shift which was not enough since they had resident that would have bowel movement. Unlicensed Staff I stated not having enough wipes, briefs, towels, or linens readily available delays residents ' care and could result to infection and pressure sores. Unlicensed Staff I stated Resident 4 would ask for incontinent wipes all the time but there was just none available. Unlicensed Staff I stated having 1 pack of incontinent wipes per CNA, per shift to use on multiple residents was an infection control issue and could result to cross contamination. Residents Affected - Some During an interview on 1/9/24 at 10:40 a.m., Resident 4 stated the facility was frequently out of incontinent wipes, briefs, and linens. Resident 4 stated there was a time she was left sitting on her feces for hours because the facility did not have wipes and briefs available which made her feel annoyed and frustrated. Resident 4 stated she felt there was no dignity when she was left sitting on her feces because the facility lacked incontinent wipes and briefs. During an interview on 1/9/23 at 10:51 a.m., Resident 5 stated the facility usually had no incontinent wipes, linens and towels to use on residents, stated that somehow, these items was not readily available. Resident 5 stated he recalled there was a time when staff had no incontinent wipes or towels to use on residents for 2 days. Resident 5 stated the facility had to ensure towels, linens and incontinent wipes were readily available for residents use. During an interview on 1/9/23 at 10:56 a.m., Unlicensed Staff J stated the facility often lacked briefs, incontinent wipes, and linens to use on residents. Unlicensed staff J stated this could result in late provision of care and sometimes residents ' sitting on their feces for a long period of time. Unlicensed Staff J stated this could result in Urinary Tract Infection (UTI, an infection in any part of the urinary system)and pressure sores. During an interview on 1/9/23 at 11:02 a.m., Resident 6 stated the facility frequently lacked incontinent wipes, briefs or towels readily available for residents use. Resident 6 stated that last night, she was told by staff there was no incontinent wipes available for her use. Resident 6 stated she was forced to use a tissue and could feel she was still dirty and sticky. Resident 6 stated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 2 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 - Some frustrating, she did not like feeling sticky and felt she could get sick and have an infection. Resident 6 stated she wished the facility had incontinent wipes, briefs, linens, and towels readily available for residents ' use. During an interview on 1/9/24 at 11:10 a.m., Licensed Staff C verified CNAs were only allowed 1 pack of incontinent wipes per shift and if they ran out, they had to ask the DSD or the nurses to give them incontinent wipes. Licensed Staff C stated the facility sometimes did not have enough linens, briefs, and towels readily available for residents use. Licensed Staff C stated the facility ' s laundry was being sent to a sister facility, so if a resident needed a new towel or linen they had to wait until it was delivered to their facility. Licensed Staff C stated towels and linens were only delivered twice a day, so if there was an incontinent accident at night and all the incontinent wipes, briefs, towels, and linens were used, the night shift staff had nothing to use on the residents. Licensed Staff C stated if the facility ran out of briefs, they had to wait until it was delivered to their facility. Licensed Staff C stated not having incontinent wipes, lack of towels, briefs, and linens readily available for residents ' use could result to delay in care which could result to pressure sore and infection. During an interview on 1/9/24 at 11:18 a.m., the Director of Nursing (DON) stated 1 pack of wipes per CNA, per shift was not enough to adequately clean residents. The DON stated briefs, linens, incontinent wipes and towels should be readily available for resident ' s use. The DON stated not having these items readily available for use could lead to delay in care, development of pressure sore and infection. A review of the facility ' s policy and procedure (P&P), titled Residents Rights, revised 12/2016, the P&P indicated residents had a right to dignified existence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 3 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident receive care consistent with professional standards of practice when one out of two sampled residents (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers when Resident 1 developed 4 pressure ulcers: one stage 4 pressure ulcer (PU, the most serious type of pressure ulcer, it extend below the muscle, tendons, and in severe cases, the bone) on his sacrum (the bottom of the spine) and three stage 2 pressure ulcers (PU that extend through deeper tissue and fat but do not reach muscle or bone) on his right inner foot, left inner proximal (near the center) foot and left inner distal (away from the center) foot. These failures led to treatments with antibiotic (medicines that fight infections caused by bacteria) and debridement (the removal of dead or infected skin tissue to help a wound heal). These failures also led to Resident 1 not being able to reach his highest physical level of well-being. Residents Affected - Few Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with a diagnoses of Stage 4 Pressure Ulcer of the sacral region (the portion of the spine - the row of bones down your back, between your lower back and tailbone), Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Urinary Incontinence (the unintentional passing of urine) and Full Incontinence of feces (the accidental passing of bowel movements). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/25/23,Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning) and to help determine if any interventions need to occur) indicated he had a moderately impaired cognition ( poor decision making, needs cues and supervisions with decision making). Resident 1 was dependent on staff assistance with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 was incontinent of bowel but wears a urinary catheter (a medical device, a tube that carries urine out of the bladder (urethra). His MDS section M skin assessment indicated he was at risk for developing pressure ulcers and he had 1 stage 4 pressure ulcer and 2 stage 2 pressure ulcers. In comparison, Resident 1 ' s MDS assessment section M (skin assessment) dated 1/27/23 indicated he was at risk for developing pressure ulcers and he had no pressure ulcers at that time. The MDS assessment dated [DATE] indicated Resident 1 was not on a turning and repositioning program (turning people to change their body position to relieve or redistribute pressure). During an interview on 1/28/23 at 2:11 p.m., Unlicensed Staff A stated residents could have pressure ulcer due to staff not turning and repositioning residents every 2 hours and not providing incontinence care every 2 hours. Unlicensed Staff A stated staff try their best, but it was difficult for staff to turn, reposition and provide incontinence care to the residents every 2 hours when they were frequently short staffed. Unlicensed Staff A stated not turning and repositioning resident and not providing incontinence care every 2 hours could lead to the development of pressure ulcer and wound infection. Unlicensed Staff A stated residents could get sick and hospitalized . During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated to prevent pressure ulcer to develop, the facility policy was to ensure residents were provided incontinence care every 2 hours and as needed and turned and repositioned every 2 hours. Unlicensed Staff B stated these tasks were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 4 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0686 Level of Harm - Actual harm hard to follow as the facility was frequently short staffed. Unlicensed Staff B stated not turning and repositioning residents every 2 hours and leaving residents wet or soiled for prolonged time could lead to the development of pressure ulcer, pain and infection. Residents Affected - Few During an observation on 11/28/23 at 2:51 p.m., Resident 1 was asleep while lying on his back. During a concurrent interview and electronic treatment administration record (eTAR, a system used by nurses in long term care facilities to ensure that treatment was rendered accurately and reliably) on 11/28/23 at 3:17 p.m., the MDS coordinator (a nurse that assess and evaluate the quality of care being given to long-term care residents)verified Resident 1 continued to be treated with an antibiotic per physician ' s order due to active wound infection and prophylaxis (all the things people do to prevent disease). During a concurrent interview and Braden skin assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcer)record review on 11/28/23 at 3:21 p.m., the MDS stated the initial Braden skin assessment done for Resident 1 on 7/17/2019 score was 17, indicating Resident 1 was at risk for pressure ulcer development. The MDS coordinator stated Resident 1 should have been placed on skin intervention such as turning and repositioning every 2 hours and incontinence care every 2 hours per facility policy. The MDS coordinator verified there was no wound Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) note created for the Resident 1 when he started acquiring pressure sores. The MDS coordinator stated there was no care plan that specifically addressed Resident 1 ' s risk factors for developing pressure ulcer when he was initially admitted . The MDS coordinator stated there were no care plans created when Resident 1 initially had an unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic (death of body tissue) tissue or by an eschar (dead tissue that sheds or falls off from the skin) pressure sore on his sacrum. The MDS coordinator stated Resident 1 ' s pressure ulcer care plan was not updated to reflect the status of the pressure ulcer on his right and left inner foot. The MDS coordinator stated the pressure ulcer care plan for sacrum and the right and left inner foot does not really reflect the current treatment being provided for the resident. The MDS coordinator stated care plans were supposed reflect current status, treatment and interventions being provided for the residents. The MDS coordinator stated that in this case, Resident 1 ' s care plan was not updated and was not reflective of Resident 1 ' s current pressure ulcer status. The MDS coordinator stated it was important a care plan was created and updated because this would help staff to determine what type of care the resident need. The MDS coordinator stated Resident 1 currently had 4 pressure ulcers, the biggest and the worst was the one on sacrum at stage 4. The MDS coordinator stated Resident 1 was admitted at the facility with no pressure ulcer. The MDS coordinator verified Resident 1 developed the pressure ulcers on his sacrum, right inner foot, left inner proximal foot and left inner distal foot at the facility. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated staff would need to closely monitor and assess residents for skin issues, turn and reposition residents at least every 2 hours and incontinence care should be provided every 2 hours to prevent pressure ulcer to develop. Licensed Staff C stated Resident 1 was dependent on staff for provision of care. Licensed Staff C stated Resident 1 ' s pressure ulcers could have been prevented if staff were monitoring and assessing Resident 1 ' s skin regularly and closely and Resident 1 was being turned and reposition every 2 hours regularly. Licensed Staff C stated it was difficult for staff to turn and reposition residents every 2 hours and provide incontinence care every 2 hours when the facility was frequently short staffed. When asked what could happen if residents were left in the same position for an extended period of time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 5 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0686 Level of Harm - Actual harm Residents Affected - Few or if residents were left soiled or wet for extended period of time, Licensed Staff C stated residents could develop pressure ulcer, pressure ulcer will increase in size, pressure ulcer could worsen and wound infection could develop. During a visual observation on 11/28/23 at 4:48 p.m., Resident 1 was still in lying on his back. Resident 1 was observed in the same position as seen earlier today at 2:51 p.m. During a telephone interview on 11/30/23 at 1:16 p.m., the Administrator stated nurses were expected to document skin issues and treatment provided for the residents. The Administrator stated if the treatment order on the eTAR was left blank, it could mean that specific treatment was not done. The Administrator stated if it was not documented then it did not happen. When asked what the risk for missing treatment could be, he stated, if it was ordered by the physician then a treatment should be done. During a telephone interview on 11/30/23 at 1:38 p.m., the Director of Nursing (DON) stated staff were expected to document skin status of the residents weekly, and every time there were skin issues. The DON stated to prevent the development of pressure ulcer, staff were expected to turn and reposition the residents every 1 to 2 hours and to offer incontinence care and toileting every 1 to 2 hours as needed. The DON stated residents not being turned and repositioned every 1to 2 hours and residents being left soiled and wet for extended period could develop pressure ulcer and wound infection. When asked what the risk for resident could be if they have a pressure sore and was left wet or soiled for extended period, the DON stated, the wound could worsen and there was a possibility of wound infection. During a telephone interview on 12/1/23 at 2:24 p.m., when asked if she was aware there were no weekly skin checks being completed for Resident 1, the DON stated no. When asked if she was aware the pressure ulcer care plan for Resident 1 was not updated and does not reflect the current status of Resident 1 ' s pressure ulcer and treatment, the DON stated they were trying to do better. The DON stated they knew it was an issue. The DON verified the nurses were signing off on the eTAR indicating they were assessing the resident skin weekly, however the facility was not able to provide documentations nurses were assessing Resident 1 ' s skin weekly. When asked what the risk for the residents could be if staff were not assessing the resident skin weekly, the DON stated staff could miss a skin issue that was starting to develop, and this skin issue could worsen. The DON stated treatment should be done per physician ' s order. The DON stated if an eTAR was left blank, then it meant the treatment was not done. The DON stated it meant the physician order was not followed. When asked what the risk could be if a treatment for pressure ulcer was missed, the DON stated the wound could worsen and could be infected. During a telephone interview on 12/1/23 at 3:19 p.m., the MDS coordinator verified Resident 1 did not have documentations his skin was being assessed by the nurses weekly. The MDS coordinator stated since there were no documentations nurses were completing the weekly skin assessment, it meant the skin assessment was not done by the nurses. The MDS coordinator stated skin assessments were important to ensure prompt identification of skin issues and implementation of prompt treatment. When asked what the risk for the resident could be if staff were not assessing the residents ' skin weekly, the MDS coordinator stated staff could miss a skin impairment and may miss acquiring an appropriate treatment. The MDS coordinator stated this could result to worsening of the skin impairment, infection, and hospitalization. When asked what the risk could be if staff missed rendering a pressure ulcer treatment for a resident, the MDS coordinator stated wound could worsen and could get infected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 6 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0686 Level of Harm - Actual harm Residents Affected - Few A review of Resident 1 ' s eTAR indicated staff were signing the eTAR indicating they had completed a skin assessment audit once a week, the facility was not able to provide weekly skin assessments documentation for these dates: on 2/2023: 2/7/23, 2/14/23, 2/21/23 and 2/28/23, for 3/2023: 3/7/23, 3/14/23, 3/21/23 and 3/28/23, for 4/2023: 4/4/23, 4/11/23, 4/18/23 and 4/25/23, for 5/2023: 5/2/23, 5/9/23, 5/16/23, 5/23/23 and 5/30/23, for 6/2023: 6/6/23, 6/13/23, 6/20/23 and 6/27/23, for 7/2023: 7/4/23, 7/11/23, 7/18/23 and 7/25/23, for 8/2023: 8/1/23, 8/8/23, 8/15/23, 8/22/23 and 8/29/23, for 9/2023: 9/5/23, 9/12/23, 9/19/23 and 9/26/23, for 10/2023: 10/3/23, 10/10/23, 10/17/23, 10/24/23 and 10/31/23, for 11/2023: 11/7/23, 11/14/23, 11/21/23 and 11/28/23. A further review of Resident 1 ' s eTAR indicated the nurses missed the pressure ulcer treatments for Resident 1 on these dates in 2/2023: 2/18/23, 2/19/23 and 2/21/23, in 3/2023: 3/16/23 and in 4/2023: 4/4/23, 4/5/23, 4/6/23 and 4/13/23. A review of Resident 1 ' s medical record indicated there were no wound IDT notes created for Resident 1 when he started developing pressure ulcers. There were no IDT notes created for the stage 4 pressure ulcers on his sacrum, right inner foot and left proximal inner foot and left distal inner foot. A review of Resident 1 ' s pressure sore ulcer plan indicated he was started on antibiotic on 3/29/23 for wound infection. The pressure ulcer care plan did not indicate how to prevent Resident 1 from acquiring pressure ulcers, worsening of pressure ulcer and preventing his pressure ulcers from getting infected. The pressure ulcer care plan was not accurate and did not reflect the status of Resident 1 ' s pressure ulcer. The pressure ulcer care plan did not accurately reflect the current treatments for Resident 1 ' s pressure ulcers. There was no care plan created for the stage 2 pressure ulcer on Resident 1 ' s left proximal inner foot and left distal inner foot. A review of Resident 1 ' s MDS assessment dated [DATE] indicated Resident 1 was always incontinent of bowel and bladder and he was at risk for developing pressure ulcer but he had no pressure ulcer at that time. It also indicated he was not on turning and repositioning program. A review of Resident 1 ' s MDS assessment dated [DATE] indicated he was at risk for developing pressure ulcers and he had 2 stage 2 pressure ulcers and 1 stage 4 pressure ulcer. It also indicated Resident 1 was still not on turning and repositioning program. A review of Resident 1 ' s Admission/readmission Skin assessment dated [DATE] indicated he had no pressure ulcer. The Admit/readmission Assessment V2 dated 2/14/23 indicated there were no pressure sore noted however the wound communication log with the physician dated 2/8/23 indicated Resident 1 already had an unstageable pressure ulcer on his sacrum. The Admit/readmission assessment dated [DATE] indicated Resident 1 had a stage 4 pressure ulcer on his Coccyx with foul odor and copious (abundant) exudate. The wound communication log with the provider dated 3/29/23 indicated Resident 1 was started on oral antibiotic twice a day for 7 days for wound infection. A review of the nurse progress note dated 11/7/23 11:42 indicated Resident 1 was on antibiotic for wound infection on left foot and sacrum. A review of the facility ' s policy and procedure (P&P) titled Pressure Injury Risk Assessment, revised 3/2020, the P&P indicated the purpose of the pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot .risk factors that increases risk susceptibility to develop or to not heal pressure injury include malnutrition, impaired/decreased functional mobility, exposure of skin to urinary and fecal incontinence, altered skin status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 7 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete over pressure points .the risk assessment should be conducted as soon as possible after admission not later than 8 hours after admission was completed .once the assessment is conducted and risk factors identified and characterized, a resident centered care plan can be created to address the risk factors .repeat the risk assessment weekly for the first 4 weeks, if there is a significant change in condition or as often as required based on resident ' s condition.conduct a comprehensive skin assessment with every risk assessment .if a new skin alteration is noted, initiate a (pressure or non pressure sore) form related to the type of alteration in skin .develop an resident centered care plan and interventions based on the risk factors identified . effects of the interventions must be evaluated .care plan must be modified as the resident ' s condition changes or if current interventions are deemed inappropriate. Event ID: Facility ID: 555184 If continuation sheet Page 8 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents were provided an environment that is free from accident hazards over which the facility has control when staff failed to identify, evaluate, analyze hazards and risks and implement interventions to reduce hazards and risks for using a low air loss mattress (LAL, an air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) to prevent avoidable accidents for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 fall incident on 11/4/23 and Resident 1 being sent to the hospital for further evaluation and treatment. This fall incident also resulted in Resident 1 sustaining a laceration (a cut, referring to a skin wound which tends to be caused by blunt trauma- an injury of the body by forceful impact such as falls) on his anterior scalp (located just in front of the head). The fall also resulted in swelling, contusion (a bruise, an injury in which the skin is not broken), hematoma (a collection of blood outside of blood vessels) and small areas of subarachnoid hemorrhage (bleeding in the space that surrounds the brain) in the left frontal (front most part of the brain, important for voluntary movement, expressive language and for managing higher level executive functions) and temporal lobes (part of the brain that sits behind the ear, functions include hearing, memory and learning) of his brain. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with a diagnoses of Pressure Ulcer of the sacral region (the portion of the spine - the row of bones down your back, between your lower back and tailbone) stage 4, Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Urinary Incontinence (the unintentional passing of urine) and Full Incontinence of feces (the accidental passing of bowel movements). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/25/23,Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning) and to help determine if any interventions need to occur) indicated he had a moderately impaired cognition ( poor decision making, needs cues and supervisions with decision making). Resident 1 was dependent on staff assistance with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 was incontinent of bowel but wears a urinary catheter (a medical device, a tube that carries urine out of the bladder (urethra). During an interview on 11/28/23 at 2:11 p.m., Unlicensed Staff A stated to prevent falls, staff should monitor residents every 30 minutes. Unlicensed Staff A stated residents who were unable to move in bed should still be monitored and ensured they were in the right position in bed, so they do not roll off the bed. Unlicensed Staff A stated bed should be in lowest position to prevent injury when a resident falls. Unlicensed Staff A stated sometimes staff could not monitor resident frequently or every 30 minutes because they have a lot of residents to care for so resident sometimes end up on the floor with injury. When asked if staff regularly monitors his LAL mattress to ensure it was working properly and not deflated, she stated no. During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated Resident 1 was dependent on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 9 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 - Actual harm Residents Affected - Few staff for provision of care. Unlicensed Staff B stated Resident 1 hardly moves in bed. Unlicensed Staff B stated falls usually happens when there ' s short staffing. Unlicensed Staff B stated Resident 1 ' s bed was about at hip level when he fell. Unlicensed Staff B stated for some reason, Resident 1 ' s bed could not really be placed in lowest position. Unlicensed Staff B stated Resident 1 was a fall risk so his bed should be in the lowest position to prevent injury in case he falls. Unlicensed Staff B stated the facility ' s fall policy was to monitor residents every 2 hours or more if needed. Unlicensed Staff B stated sometimes it was difficult to monitor residents every 2 hours especially if they were short staffed. During an interview on 11/28/23 at 3:25 p.m., Licensed Staff C stated Resident 1 was a high fall risk. To prevent falls, Licensed Staff C stated staff should be monitoring residents every 2 hours. Licensed Staff C stated Resident 1 was totally dependent on staff for provision of care. Licensed Staff C stated Resident 1 was mostly in bed. During an interview on 11/28/23 at 3:27 p.m., the Minimum Data Set coordinator (MDS coordinator, assess and evaluate the quality of care being given to long-term care residents)stated Resident 1 fell because he had a LAL mattress. The MDS coordinator stated one of the LAL mattress tubes was undone or unlatched so the LAL mattress deflated a bit and then Resident 1 slid off the mattress. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated Resident 1 ' s fall could have been prevented if staff were monitoring Resident 1 regularly and ensuring his LAL mattress was functioning well. Licensed Staff C stated to lessen the risk of fall, staff should monitor residents for safety every 2 hours or more often. Licensed Staff C stated every 2 hours monitoring could be difficult especially if the facility was short staffed. During an interview on 11/28/23 at 3:51 p.m., Licensed Staff D stated to decrease risk of falls staff should monitor residents every 2 hours. Licensed Staff D stated this every 2 hour rounding would be too hard to do at times if the facility was short staffed. During a concurrent interview, care plan (a summary of a person's health conditions, specific care needs, and current treatments, it should outline what needs to be done to manage the residents care needs), nursing note, fall risk assessment (an assessment that checks to see how likely it is that you will fall) and computed tomography scan (CT, a diagnostic imaging procedure that uses a combination of X-rays (a type of radiation called electromagnetic waves, X-ray imaging creates pictures of the inside of your body) and computer technology to produce images of the inside of the body) result record review on 11/28/23 at 4:20 p.m., the MDS coordinator stated for fall prevention, staff should check and monitor residents every 2 hours or more frequently if needed. The MDS coordinator stated fall risk assessments were completed on admission/readmission, when there was a fall incident, and quarterly. The MDS coordinator stated Resident 1 fell in the early morning of 11/4/23 and Resident 1 was sent to hospital on [DATE] at 1:04 a.m. The MDS coordinator stated, the fall progress note dated 11/4/23 04:13 a.m. was not what the facility expected. The MDS coordinator stated when she looks at the progress note she wanted to find out what happened, but this progress note does not have any of that. The MDS coordinator stated Resident 1 ' s fall could have been prevented and stated they could have done a better job with keeping him safe. The MDS coordinator stated fall risk assessment should be completed quarterly and any time there was a fall incident. The MDS coordinator stated, Resident 1 ' s fall risk assessment should have been done on 5/2023, 8/2023 and 11/2023. The MDS coordinator stated fall risk assessment for 5/2023 and 8/2023 were missed, which meant the facility policy was not followed. The MDS coordinator stated the fall risk assessment was done to ensure risk and changes were noted so an appropriate intervention could be implemented as needed based on Resident 1 ' s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 10 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 - Actual harm Residents Affected - Few fall risk assessment. The MDS coordinator stated if a fall risk assessment was not done, new risks and needs would not be identified, and no new interventions would be in place to decrease risks of falls. A review of the result of the CT scan of the brain without contrast done at the hospital on [DATE] indicated Resident 1 had swelling, contusion, and small areas of subarachnoid hemorrhage in the left frontal and temporal lobes of the brain. The MDS coordinator stated these findings were new and was a direct cause of the fall on 11/4/23. A review of the fall care plan dated 2/23/23 only had 2 interventions which was to anticipate his needs and provide devices as needed. The MDS coordinator stated the care plan does not have an intervention that would prevent Resident 1 from falling. The MDS coordinator stated there was no fall care plan created after Resident 1 fell on [DATE]. The MDS coordinator stated fall care plan were important to identify needs and mitigate risks factors. The MDS coordinator stated if a fall care plan was not created, it could lead to safety risk because resident needs would not be identified, and intervention could not be implemented. The MDS coordinator stated having a care plan could help identify what the residents ' needs were. When asked if staff should be monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated, the MDS coordinator stated yes. When asked if the there was a documentation the nurses or CNAs were monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated, the MDS stated she was not aware there were any documentations regarding staff monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated. When asked if the facility staff now had a tracking log or a monitoring log to ensure the LAL mattress was functioning well and the tubes were well connected and not dislodged and the mattress was not dedflated, she stated no. The MDS coordinator stated there were no documentation to prove staff were monitoring the LAL mattress was functioning well, the tubes were well connected and not dislodged and the LAL mattress was not deflated even before Resident 1 fell. The MDS coordinator stated monitoring LAL mattress if it was functioning well, the tubes were well connected and not dislodged, and the mattress was not deflated could have possibly prevented Resident 1 from falling off his bed due to a deflated LAL mattress. The MDS coordinator stated it was important to monitor the LAL mattress was working well and the tubes are intact, connected, not dislodged and mattress not deflated for safety reasons and to prevent another fall incident due to deflated LAL mattress. During a concurrent interview and care plan record review on 11/28/23 at 5:09 p.m., the MDS coordinator stated there was no care plan for Resident 1 ' s fall incident on 11/4/23 and there was no IDT fall meeting done as well. The MDS coordinator stated it was a safety risk if a fall care plan and IDT meeting was not done with regards to fall incidents. The MDS coordinator stated it was important to create a fall care plan and complete an IDT to identify problem and implement intervention to decrease likelihood of falls and injuries. During a telephone interview on 11/29/23 at 4:29 p.m., Licensed Staff E stated there were no documentation to prove staff were monitoring Resident 1 ' s LAL mattress for functionality, ensuring tubes were connected and the mattress was not deflated. During a telephone interview on 11/30/23 at 1:16 p.m., the Administrator stated falls were a change in condition and as such the IDT should meet to discuss fall during the clinical meeting. The Administrator stated the IDT meeting was to talk about root cause analysis and possible interventions to prevent the fall incident to occur again. When asked if staff were expected to monitor the LAL mattress to ensure it was functioning well and the tubes were connected properly, the Administrator stated that Resident 1 ' s cause of fall was sliding off the LAL mattress due to deflated mattress caused by tube not connected properly so staff were expected to monitor the LAL mattress was functioning well and the tubes were connected properly as often as needed. The Administrator was not able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 11 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 - Actual harm Residents Affected - Few provide documentations that would verify staff were monitoring the LAL mattress was functioning well and the tubes were connected properly. When asked if the staff were expected to create a care plan after a fall incident, the Administrator stated yes. During a telephone interview on11/30/23 at 1:38 p.m., the Director of Nursing (DON) stated staff were expected to create a care plan for every fall incident. The DON stated she was aware there was no care plan created for Resident 1 ' s fall incident on 11/4/23. The DON stated it was expected that staff monitor the LAL mattress was functioning well and the tubes were connected properly as often as needed. The DON stated they do not have a documentation to prove staff were monitoring the LAL mattress was functioning well and the tubes were connected properly. The DON stated it was important staff were monitoring the LAL mattress was functioning well and the tubes were connected properly to prevent another fall incident caused by a LAL mattress deflating. The DON stated there should be an IDT completed for Resident 1 ' s fall incident on 11/4/23, however there was none completed for this incident. The DON was also aware there was no care plan created for Resident 1 ' s fall on 11/4/23. The DON stated creating a care plan and completing an IDT meeting for the fall incident was important for resident ' s safety, so the team could discuss resident ' s status, the cause of the fall, interventions to prevent further occurrence of fall incidents and to prevent injury. During a telephone interview on 12/1/23 at 2:24 p.m., the DON verified there was a fall care plan on 9/2020 about a perimeter mattress. When asked what a perimeter mattress was, the DON stated it was a type of bed that was slightly raised at the sides to keep the resident positioned at the center. The DON verified Resident 1 was not using a perimeter mattress when he fell. The DON verified the fall care plan was not updated to reflect the perimeter mattress was not appropriate for use based on Resident 1 ' s current condition. The DON stated it was expected that care plans were current and updated. The DON stated it was important care plans were followed. When asked if Resident 1 ' s fall incident on 11/4/23 could have been prevented, the DON stated yes. The DON stated the fall care plan should have been updated to ensure current interventions were appropriate. The DON stated it was important care plans address the issue and the fall risk. A review of the facility ' s policy and procedure (P&P) titled Falls and Fall Risk, Managing revised 3/2018, the P&P indicated the staff with the input of the attending physician will implement a resident centered fall prevention care plan to reduce the specific risk factors of falls for each residents at risk or with a history of falls . in conjunction with the consultant pharmacist and nursing staff , the attending physician will identify and adjust medications that may be associated with increased risk of falling, or indicate why those medications could not be tapered or stopped . in conjunction with the attending physician , staff will identify and implement relevant interventions to try to minimize serious consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 12 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure they were adequately staffed for 18 out of 31 days in 10/2023 and 12 out of 28 days from 11/1/23 up to 11/28/2023 which resulted in complaints of assistance not being provided by staff in a timely manner and call light not being answered timely for two out of two sampled residents (Residents 2 and 3) which led to Resident 1 feeling upset and frustrated and Resident 3 feeling worried staff would not come on time if there ' s an emergency. This failure could also lead to increased incidence of falls, development and worsening of pressure sores (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) due to staff difficulty with frequently monitoring residents for safety, providing incontinence (partial or complete loss of bladder or bowel control) care timely and repositioning residents as dictated by their needs. Findings: During a review of Resident 2 ' s face sheet (demographics) it indicated he was initially admitted on [DATE] with a diagnoses of Hyperlipidemia (HLP, or high cholesterol is an excess of lipids or fats in your blood), Type 2 Diabetes Mellitus (DM, a chronic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves) and Muscle Weakness (a lack of strength in the muscles). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/18/23 indicated his Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 15, indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 2 required a moderate assistance (resident highly involve in activity, staff provide non (weight bearing- staff supporting the weight of your body) to maximum assistance (resident was involved in activity, staff provides weight bearing support) of 1 staff with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 2 was always incontinent of urine and feces and required an extensive assistance (a resident would not be able to perform or complete the ADL without staff to aid in performing the complete task) of 1 staff with toileting. During a review of Resident 3 ' s face sheet, it indicated he was admitted on [DATE] with a diagnoses of Type 2 DM, Muscle Weakness and Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). His MDS assessment, dated 10/20/23 indicated his BIMS score was 14 indicating intact cognition. Resident 3 need a moderate assistance (staff provide less than half the effort when performing a task) to maximum assistance (staff provide more than half the effort when performing a task). Resident 2 was always incontinent of bowel and bladder. During an interview on 11/28/23 2:11 p.m., Unlicensed Staff A stated the facility did not have enough staff to care for the residents. Unlicensed Staff A stated sometimes she had 12 to 13 residents in the morning shift. Unlicensed Staff A stated short staffing contributed to residents fall incidents and residents acquiring pressure sores. Unlicensed Staff A stated it makes it difficult to care for a lot of residents if they were short staffed. Unlicensed Staff A stated resident suffers when the facility was short staffed. Unlicensed Staff A stated it was not safe for the residents when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 13 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0725 facility was short staffed. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/28/23 at 2:31 p.m., Resident 2 stated the facility was short staffed and they need to add more staff so they could better take care of the residents at the facility. Resident 2 stated staff would tell him they were short staffed. Resident 2 stated he knew the facility was short staffed because it takes a while for staff to answer his call lights. Resident 2 stated when he asked why it takes them a while to help him, staff would respond they were short staffed. Resident 2 stated it was upsetting and frustrating when the facility was short staffed. Resident 2 stated short staffing meant long wait time for staff to attend to his needs. Residents Affected - Some During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated the facility staffing was bad. Unlicensed Staff B stated there were times she had to care for 19 residents on her shift. Unlicensed Staff B stated residents ' safety was compromised if the facility was short staffed. Unlicensed Staff B stated short staffing contributes to residents falls and pressure sore development. During an interview on 11/28/23 at 2:54 p.m., Resident 3 stated the facility lacked adequate number of staff to care for the residents safely and appropriately at the facility. Resident 3 stated staff would tell him they were short staffed. Resident 3 stated he did not receive a shower for a week and a half because there was not enough staff to provide care for the resident at the facility. Resident 3 stated knowing the facility was short staffed was not a good feeling especially if he ends up waiting for a long time to have someone take care of his needs. Resident 3 stated it worries him staff would not come in time if there ' s an emergency. During an interview on 11/28/23 at 3:02 p.m., the Staffing Coordinator (SC) stated she does the staffing, and she was the only one in charge of staffing the facility. The SC stated staffing included PPD (calculating nursing hours allotted per day per patient/resident). The SC stated staffing was based on census (a complete count of a population). The SC stated the facility follows a staffing guideline to assist her when she was staffing the facility. She stated the staffing guideline requirement was the only guideline she used to staff the facility. She stated there were no other guidelines or criteria she used when staffing the facility. She stated she knew the facility was adequately staffed when she meets the number of staff needed per the staffing guideline. The SC stated she had received complaints from the staff they were short staffed. The SC stated short staffing placed residents ' safety at risk. The SC stated short staffing could lead residents ' not receiving the proper care they need. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated the facility was short staffed and they could use more help on the floor. Licensed Staff stated there was a decline in the quality of care provided to the resident when the facility was short staffed. Licensed Staff C stated short staffing could result to increase incidents of falls and development of pressure sores. Licensed Staff C stated short staffing makes it difficult for staff to frequently provide incontinent care to residents timely or reposition the residents every 1 to 2 hours. Licensed Staff C stated short staffing also leads to delayed answering of call lights, late provision of care and longer wait time for the resident for staff to assist with their needs. When asked if short staffing was a safety issue for the residents, she nodded her head and stated yes. During an interview on 11/28/23 at 3:51 p.m., Licensed Staff D stated the facility was short staffed. Licensed Staff D stated short staffing could contribute to residents falls and pressure sore development. Licensed Staff D stated short staffing could result to late provision of care and late response to call light. Licensed Staff D stated short staffing could put residents ' safety at risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 14 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/28/23 at 5:04 p.m., Licensed Staff C stated short staffing takes a toll on residents ' wellbeing and puts residents ' safety at risk. During an interview on 11/28/23 at 5:05 p.m., the Minimum Data Set Coordinator (MDS coordinator, nurse that assess and evaluate the quality of care being given to the residents) stated the facility was short staffed. The MDS coordinator stated short staffing had negative impact on residents ' wellbeing. The MDS coordinator stated short staffing directly affects residents ' care. The MDS coordinator stated short staffing could result to staff rushing when caring for a resident and they could hurt the residents ' accidentally. The MDS coordinator stated that several times, the Certified Nursing Assistants (CNAs, helps patients with direct health care needs, often under the supervision of a nurse) had about 19 residents on morning shift. The MDS coordinator stated 2 hours rounding was not feasible when the facility was short staffed. The MDS coordinator stated she had been working on the floor pretty much all the time and that ' s why a lot of her assessment was not done. A review of the facility ' s staffing guideline which indicated the total number of CNAs and nurses needed in a 24 hours period based on the facility census indicated that for a census of 66 up to 70, the facility would need a total of 9 nurses, for a census of 58 to 65, the facility would need a total of 8 nurses, for a census of 51 to 57, the facility would need a total of 7 nurses, for a census of 44 to 50, the facility would need a total of 6 nurses, for a census of 36 to 43, the facility would need a total of 5 nurses, for a census of 32 to 35, the facility would need a total of 4 nurses. For CNA staffing, for a census of 70, the facility would need a total of 21 CNAs, for a census of 67 up to 69, the facility would need a total of 20 CNAs. for a census of 64 up to 66, the facility would need a total of 19 CNAs, for a census of 60 to 63, the facility would need a total of 18 CNAs, for a census of 57 to 59, the facility would need 17 CNAs, for a census of 54 to 56, the facility would need 16 CNAs, for a census of 50 to 53, the facility would need a total of 15 CNAs, for a census of 47 to 49, the facility would need a total of 14 CNAs and for a census of 44 to 46, the facility would need a total of 13 CNAs. For a census of 40 to 43, the facility would need a total of 12 CNAs, for a census of 37 to 39, the facility needed a total of 11 CNAs, for a census of 34 to 36, the facility needed a total of 10 CNAs, for a census of 32 to 33, the facility needed a total of 9 CNAs. A review of the facility staffing indicated staffing were not met based on the weekday staffing guideline for the CNAs for 18 out of 31 days for 10/2023 on these dates: 10/3/23 census of 48, the facility only had a total of 12 CNAs that worked in a 24 hour period. 10/4/23 census of 50, the facility only had a total of 14 CNAs that worked in a 24 hour period. 10/5/23 census of 50, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/6/23 census of 50, the facility only had a total of 14 CNAs that worked in a 24 hour period. 10/7/23 census of 51, the facility only had a total of 13.5 CNAs that worked in a 24 hour period. 10/8/23 census of 52, the facility only had a total of 14 CNAs that worked in a 24 hour period. 10/9/23 census of 51, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/10/23 census of 50, the facility only had a total of 14 CNAs that worked in a 24 hour period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 15 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0725 10/11/23 census of 50, the facility only had a total of 14 CNAs that worked in a 24 hour period. Level of Harm - Minimal harm or potential for actual harm 10/12/23 census of 48, the facility only had a total of 12 CNAs that worked in a 24 hour period. 10/13/23 census of 48, the facility only had a total of 13 CNAs that worked in a 24 hour period. Residents Affected - Some 10/15/23 census of 48, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/22/23 census of 48, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/23/23 census of 49, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/27/23 census of 50, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/28/23 census of 50, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/29/23 census of 49, the facility only had a total of 13 CNAs that worked in a 24 hour period. 10/30/23 census of 49, the facility only had a total of 12 CNAs that worked in a 24 hour period. A review of the facility staffing indicated staffing was not met based on the weekday staffing guideline for the CNAs for 12 out of 28 days for 11/2023 on these dates: 11/1/23 census of 50, the facility only had a total of 13 CNAs that worked in a 24 hour period. 11/2/23 census of 50, the facility only had a total of 12 CNAs that worked in a 24 hour period. 11/6/23 census of 49, the facility only had a total of 13 CNAs that worked in a 24 hour period. 11/16/23 census of 52, the facility only had a total of 14 CNAs that worked in a 24 hour period. 11/17/23 census of 53, the facility only had a total of 13 CNAs that worked in a 24 hour period. 11/19/23 census of 53, the facility only had a total of 15 CNAs that worked in a 24 hour period. 11/20/23 census of 53, the facility only had a total of 15 CNAs that worked in a 24 hour period. 11/22/23 census of 54, the facility only had a total of 14 CNAs that worked in a 24 hour period. 11/23/23 census of 53, the facility only had a total of 11 CNAs that worked in a 24 hour period. 11/24/23 census of 54, the facility only had a total of 14 CNAs that worked in a 24 hour period. 11/25/23 census of 55, the facility only had a total of 10 CNAs that worked in a 24 hour period. 11/26/23 census of 54, the facility only had a total of 15 CNAs that worked in a 24 hour period. A review of the Facility Assessment Fall 2022 did not provide any staffing information with regards to Staffing, Training, Services and Personnel when it only stated these areas were evaluated. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 16 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Facility Assessment did not include information on the # of nurses and CNAs needed in a 24 hour period to safely care for the residents for day to day operations and for emergency situations. A review of the facility ' s policy and procedure (P&P) titled Staffing revised 10/2027, the P&P indicated the facility provides sufficient number of staff with the skills and competency necessary to provide nursing and related care and services for all residents in accordance with residents ' care plans and the facility assessment. Event ID: Facility ID: 555184 If continuation sheet Page 17 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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, interviews and record review, the facility failed to ensure the 1. kitchenette area was clean, free from dusts and cobwebs and was regularly cleaned 2. there were no personal staff items in the kitchenette area when a gray colored jacket was on top of a tray used to serve residents ' meals. 3. towels used for cleaning the kitchenette counter were discarded properly in a receptacle and not placed on food tray cart after use 4. the baseboard in the kitchenette area was well maintained and was properly sealed. These failures could result in cross contamination, infection from food borne illnesses (an illness that comes from eating contaminated food) and pest infestation. Residents Affected - Some During an observation on 1/9/23 at 9:28 a.m., the kitchenette was unkempt, the resident ' s refrigerator was dirty and dusty, there was a gray colored jacket on a tray used for serving residents meals and a used towel was on a food tray cart inside the kitchenette area. There were portions on the baseboard that was coming apart on the kitchenette area near where the ice machine was located. During a concurrent observation and interview interview on 1/9/23 at 9:29 a.m., Unlicensed Staff F stated it was the housekeeping ' s job to ensure the floors were clean, however housekeepers get busy, so they were not able to do so regularly and consistently. Unlicensed Staff F stated the kitchenette was not clean as she hoped and reiterated the kitchenette was supposed to be always clean because this was where resident ' s food was stored after it was delivered by their sister facility, prior to meals. Unlicensed Staff F stated the kitchenette was supposed to be clean, floors clean and refrigerators dust free for infection control purposes. Unlicensed Staff F stated dirty kitchen could result in resident getting sick from diarrhea. Unlicensed Staff F stated the gray jacket on top of a resident meal tray belonged to her and should not be there in the first place. Unlicensed Staff F also stated the used towel should be disposed of in a receptacle and not be left lying on the food rack where they usually have items that would be served to the residents for infection control issue. Unlicensed Staff F stated the goal was to keep resident free from getting sick. Unlicensed Staff F verified the baseboard in the kitchenette near where the ice machine was located had areas where it was coming apart and the maintenance staff knew about it but never repaired it. Unlicensed Staff F stated baseboard in the kitchenette should be well maintained with no areas coming apart to make sure pest doesn ' t get inside the kitchenette where they keep resident ' s food prior to serving their meals. Unlicensed Staff F stated this was an infection control issue and could result in residents getting sick. During an interview on 1/9/23 at 9:43 a.m., Unlicensed Staff G stated the kitchenette was not clean as they would like. Unlicensed Staff G stated the kitchenette was not being cleaned by housekeeping staff consistently and regularly. Unlicensed Staff G stated the kitchenette was supposed to be always clean because this was where food was kept prior to serving it to the residents. Unlicensed Staff G stated if the kitchenette was not clean, it could result in residents getting sick. Unlicensed Staff G stated there should be no staff personal items in the kitchenette. Unlicensed Staff G stated there should be no jacket in the resident ' s food tray and used towel should not be left lying on the food rack where they usually have items that would be served to the residents because residents might get sick. Unlicensed Staff G stated the baseboard should be repaired and the baseboard should be intact so rodents, pest or mold could not infest the kitchenette which could result in residents getting sick. During a concurrent observation and interview on 1/9/23 at 9:45 a.m., the Administrator acknowledged the cobwebs on the kitchenette door and the base board had areas where it was not intact and stated he would have maintenance staff fix it today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 18 of 19 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 - Some During a concurrent observation and interview on 1/9/23 at 9:50 a.m., the Dietary Manager (DM) acknowledged there were cobwebs by the kitchenette door. The DM acknowledged the baseboard had areas where it was not properly sealed. The DM stated the baseboard had to be patched all throughout because it was a barrier to ensure no pest goes into the kitchenette where they keep resident ' s food prior to meals. The DM stated they had to ensure the kitchenette was clean for infection control issue and to make sure resident does not get a food borne illness. During an interview on 1/9/23 at 11:15 a.m., the new Director of Nursing (DON) stated the kitchenette should be always clean, free from dust and cobwebs for infection control measures. The new DON stated if the kitchenette was not clean and there were staff personal item inside the kitchenette, it was an infection control issue that needed to be corrected right away for resident safety. The new DON stated the baseboard should be intact so pest could not access the kitchenette. The new DON stated a dirty kitchenette, staff having personal item inside the kitchenette placed resident ' s at risk for gastrointestinal illness (any ailments linked to the digestive system, including the throat, stomach and intestines). A review of the facility ' s policy and procedure (P&P) titled Infection Control, undated, the P&P indicated it was the facility ' s policy to maintain a safe, sanitary and comfortable environment for residents. A review of the facility ' s policy and procedure (P&P) titled Maintenance Services, undated, the P&P indicated it was the maintenance department responsibility for maintaining the building, grounds and equipment in a safe and operable manner .maintaining the building in good repair and free from hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 19 of 19