Health inspection·January 25, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm stated the heater company was working on the boiler to the heater, so the heaters were turned off. Observed a space heater in RM [ROOM NUMBER] located in between bed A and B causing the electrical cord to be resting on the floor triggering a trip hazard. The thermostat in RM [ROOM NUMBER] read 63 degrees. Resident 14 stated she was freezing, absolutely freezing while up in her wheelchair layered in clothing, Residents Affected - Many Rm 101's thermostat read 64 degrees. There was a space heater in the room, left of the door when walking into the room, The west hall thermostat read 63 degrees and there were three space heaters in the hallway, Rm 105 thermostat read 61degrees, Rm 114 thermostat read 61 degrees, Rm 123 thermostat read 61 degrees. Resident 40 stated she was chilly. She was layered with blankets. Rm 120 thermostat read 60 degrees, Rm 115 temperature measured 61 degrees per maintenance assistant using a surface thermometer (uses infrared laser technology to measure surface temperatures). Resident 39 was layered with blankets and was wearing a sweatshirt. The thermostat outside of the Director of Staff Development's office read 67 degrees, The Maintenance Assistant stated everything throughout facility was set at 68 degrees and each resident room had its own thermostat. The Maintenance Assistant stated those residents not cognitively able to adjust the room thermostat were set at 68 degrees. The Maintenance Assistant stated the heating company was working on the boiler for the heating system and he was not aware of any issues with the heater unit prior to today. During an interview on 1/17/23 at 11:35 a.m., the Administrator stated supposedly the heater went out last night (1/16/23). During an interview on 1/17/23 at 12:20 p.m., the Maintenance Supervisor stated the boiler to the heater system went out Sunday night (1/15/23) around 8 p.m., per his phone. The Maintenance Supervisor stated he had a phone app showing the water temperature of the boiler for the hydronic heater system was dropping. The Maintenance Supervisor stated a technician came out this morning and worked on the boiler. The Maintenance Supervisor stated he went to the facility right away on Sunday (1/15/23), to put out space heaters, six to eight around the facility. The Maintenance Supervisor stated the space heaters did not get scalding hot and there was no other alternative to keep residents warm. The Maintenance Supervisor stated the boiler for the facility baseboard heaters had to be turned off when the technician was working on the boiler this morning. The Maintenance Supervisor stated the valves to turn on the baseboard heater in RM [ROOM NUMBER], the beauty salon, and the Administrator's office were broken and needed to be replaced. The Maintenance Supervisor stated, normally the thermostats throughout the facility were set at 78 degrees and every resident room had its own thermostat, which the residents could regulate. The Maintenance Supervisor stated the temperature of the resident areas should be reading 78 degrees. The Maintenance Supervisor stated RM [ROOM NUMBER] baseboard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 Level of Harm - Minimal harm or potential for actual harm heater had been broken since late 11/2023. The Maintenance Supervisor stated they never logged the room temperatures. During concurrent observations and interviews on 1/17/23 at 3:10 p.m. to 3:20 p.m., the Maintenance Assistant made rounds to check the temperatures of the resident areas: Residents Affected - Many *Activities Room thermostat read 61 degrees, *Rm 116 thermostat read 61 degrees, *Space heater outside room [ROOM NUMBER] still on, *Rm 119 thermostat read degrees and baseboard heater was not on, Resident 26 stated it was cold last night, *Rm 123 thermostat read 69 degrees, *Rm 114 thermostat read 64 degrees. Space heater in RM [ROOM NUMBER] was off. The Maintenance Assistant stated he was supposed to be removing all space heaters. While make rounds with the Maintenance Assistant, observed the baseboard heater screens and coils looked dirty with lots of cobwebs. *Rm 112 thermostat read 66 degrees, *Observed baseboard heaters in the east hall were off, *West hall baseboard heater was off and space heater was on, and *Rm 101 thermostat read 67 degrees. During concurrent observations and interviews on 1/17/23 at 3:35 p.m. to 4:05 p.m., the Administrator made rounds to see if the resident baseboard heaters were working after boiler to hydronic heating system was worked on using a surface thermometer (infrared gun) and to check the resident room thermostat readings: *Rm 101 baseboard heater measured 67 degrees. There was no warmth to the floor heater, *Rm 102 baseboard heater measured 66 degrees. There was no warmth to the baseboard heater, *The west hall baseboard heater across from RM [ROOM NUMBER] and next to RM [ROOM NUMBER] was not on. *Rm 105 thermostat read 70 degrees, *Rm 106 baseboard heater measured at 91 degrees and the thermostat read 66 degrees, *Rm 107 baseboard heater measured 93 degrees and the thermostat read 68 degrees, *Rm 108 baseboard heater measured 96 degrees and thermostat read 66 degrees, *Rm 109 baseboard heater measured 66 degrees and thermostat read 66 degrees, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 *Rm 110 baseboard heater measured 92 degrees and thermostat read 66 degrees, Level of Harm - Minimal harm or potential for actual harm *Rm 111 baseboard heater measured 95 to 98 degrees and thermostat read 68 degrees, *Rm 112 baseboard heater measured 103 degrees and thermostat read 66 degrees, Residents Affected - Many *West hall baseboard heater left of RM [ROOM NUMBER] was not on, *North hall baseboard heater outside of RM [ROOM NUMBER] measured 87 degrees, *North hall baseboard heater next to Certified Nursing Assistant (CNA) work area where ice machine was located was not working, *Baseboard heater between shower rooms was not working, *Rm 126 baseboard heater measured 99 degrees and thermostat read 67 degrees, * East hallway baseboard heater across from RM [ROOM NUMBER] measured 91 degrees, * RM [ROOM NUMBER] baseboard heater measured 101 degrees and thermostat read 62 degrees, *Rm 123 baseboard heater measured 105 degrees, thermostat read 70 degrees, and space heater on near bedroom door, * RM [ROOM NUMBER] baseboard heater read 95 to 97 degrees and thermostat read 66 degrees, *Rm 121 baseboard heater 98 to 99 degrees and thermostat read 60 degrees, * RM [ROOM NUMBER] baseboard heater measured 90 degrees and thermostat read 69 degrees, * RM [ROOM NUMBER] baseboard heater measured at the low 70s and thermostat read 69 degrees, *Rm 120 baseboard heater not working, and thermostat read 64 degrees, * RM [ROOM NUMBER] baseboard heater measured 72 degrees and thermostat read 65 degrees, * RM [ROOM NUMBER] baseboard thermostat read 62 degrees. The Administrator stated the baseboard heater was not working, * RM [ROOM NUMBER] thermostat read 66 degrees. The Administrator stated the pipes to the baseboard heater should be hot to touch but were not. The baseboard heater was not working. * RM [ROOM NUMBER] baseboard heater measured 66 degrees. The Administrator stated no heat was coming out of the baseboard heater, * East hall baseboard heater next to RM [ROOM NUMBER] was not working, * East hall baseboard heater next to RM [ROOM NUMBER] measured 94 degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 1/17/23 at 5:05 p.m., asked the Administrator for the invoice for the work done on the boiler for the hydronic heating system and for the servicing of the heating unit done last year. During an interview on 1/17/23 at 5:25 p.m., the HVAC (heating, ventilation, and air condition) Technician stated they were at the facility from 9 to 11 a.m. this morning. The HVAC Technician stated they found air pockets in the hydronic lines so the lines were purged (bleeding the lines on the water heater removes trapped air and the mineral deposits that can affect the water heater's ability to heat water). The HVAC Technician stated because the heater system was hydronic it would take 12 to 24 hours for the heated water to circulate throughout each resident room baseboard heater and for the resident rooms to warm up. The HVAC Technician stated the system was over [AGE] years old as were the pipes, but everything worked very well. The HVAC Technician stated trapped air caused an electronic glitch, but the system was running fine. The HVAC Technician stated to give it 12 to 24 hours to heat the entire facility. The HVAC Technician stated the facility maintenance was now bleeding (draining the water in the line to remove air pockets/bubbles) off the radiators in each resident baseboard heater because air must have gotten trapped in the lines. The HVAC Technician stated the air vents in the boiler room were working so he was not concerned the baseboard heaters would not work. During an interview on 1/17/23 at 5:30 p.m., the Administrator stated he and the Maintenance Assistant were opening the valve of each baseboard heater not working and letting water drip out into a bucket to get rid of air bubbles. He stated they were manually overriding the thermostat by turning the valve located on the baseboard heater. During a concurrent observation and interview on 1/18/23 at 8:40 a.m., the Maintenance Supervisor stated they were still working on some of the baseboard heaters, which were still not working. They were purging the line to each baseboard heater not working to remove the trapped air. The temperature outside was 37 degrees and the building felt very cold. The Maintenance Supervisor stated he was worried about air pockets getting trapped in the hydronic heating system when the HVAC technicians had to drain the boiler and reset the system. He hoped air had not gotten into the heater lines, but air was trapped somewhere in the lines. The Maintenance Supervisor stated they still were having issues with the resident baseboard heaters in the east hallway and most all hallway baseboard heaters. The baseboard heater coils looked very dirty; lots of cobwebs, dust, and cat hair. The Maintenance Supervisor agreed all baseboard heaters needed to be cleaned. During an observation on 1/18/23 at 9:10 a.m., the residents' thermostat readings: *Rm 101 thermostat read 64 degrees, * [NAME] hall baseboard heater across from RM [ROOM NUMBER] was being purged, *Rm 111 thermostat read 66 degrees. Resident 244, who was dressed and up in his wheelchair, stated he was cold especially when the door to his room was left open from the cold air coming from the hallway, *North hall baseboard heater nearest ice machine/CNA workstation was not working, *North baseboard heater between the two shower rooms was not working. *Rm 119 thermostat read 63 degrees, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 *Rm 120 thermostat read 61 degrees, Level of Harm - Minimal harm or potential for actual harm *Rm 117 thermostat read 60 degrees, Resident 17 stated it had been cold all night, *Rm 118 thermostat read 63 degrees Residents Affected - Many *Rm 116 thermostat read 60 degrees, *Rm 115 thermostat read 60 degrees, *East baseboard heater across from RM [ROOM NUMBER] was being purged. During an interview on 1/18/23 at 4:40 p.m., the Administrator was asked about the baseboard heaters not working in room [ROOM NUMBER], 102, 115, 116, 118, 120 and the hall baseboard heaters not working. The Administrator stated it still was a challenge, bleeding the lines was helping to get heat out of the baseboard heaters at first, and then the heaters stopped working. The Administrator stated the Maintenance Supervisor had called the HVAC Technician, who will be coming tomorrow to work on the heating system again. The Administrator was asked if he had reached out to HCAI (Department of Health Care Access and Information) in the meantime to get direction regarding keeping the residents warm such as approving the portable space heaters. The Administrator reached out to the City of Napa Fire Prevention Officer who approved the oil space heaters for the meantime but directed the Administrator to make sure to place the space heaters at least three feet from anything combustible. During a concurrent observation and interview on 1/18/23 at 5:05 p.m., the Administrator left a voice message to HCAI regarding the facility's broken hydronic heating system and the short-term use of portable space heaters as a corrective action to help keep residents warm. During a concurrent observation and interview on 1/18/23 at 5:30 p.m., the Administrator was placing portable space heaters throughout the hallways. He stated he would inform the staff to make sure residents did not get near the space heaters. During a concurrent observation and interview on 1/19/23 at 9:20 a.m., the Administrator stated the HVAC Technician was at the facility and working on the hydronic heater system. The Administrator stated HCAI had reached out to him and informed him how to ask for an emergency use of the space heaters because the heating system was not working properly. It felt very cold in the facility. Resident 14 was in the hallway huddled next to a space heater. She stated she was trying to get warm. During an interview on 1/19/23 at 2:20 p.m., the Administrator stated the HVAC Technician had just left. He had flushed the hydronic heating system, fixed air gaps, and increased the temperature of the boiler. The Administrator stated it should take about two to four hours to warm the facility. During a concurrent observation and interview on 1/19/23 at 2:40 p.m., the Maintenance Supervisor checked the room temperatures: *Rm 120 thermostat read 62 degrees, *Rm 118 thermostat read 61 degrees, *Rm 116 thermostat read 63 degrees, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 *Rm 115 thermostat read 63 degrees, Level of Harm - Minimal harm or potential for actual harm *Activity Room wall by bookcase measured 64 degrees, *Rm 101 thermostat read 63 degrees, Residents Affected - Many *Rm 102 thermostat read 62 degrees, *West baseboard heater across from RM [ROOM NUMBER] was not working. During an observation and concurrent interview on 1/20/23 at 2:50 p.m., Administrator checked resident room temperatures: *Rm 115 thermostat read 64 degrees, *Rm 116 thermostat read 62 degrees, *Rm 117 thermostat read 65 degrees, resident was wrapped in blankets around her shoulders and on her lap, had hooded sweatshirt on with the hood up, stated she was warm enough, *Rm 118 thermostat read 63 degrees, *Hallway by thermostat by RM [ROOM NUMBER], read 67 degrees, *Rm 120 thermostat read 66 degrees. During a concurrent observation and interview on 1/23/23 at 9:28 a.m., the Administrator stated a rental company had come over the weekend and hooked up an outside heater located outside of RM [ROOM NUMBER]'s sliding door connected to an accordion duct leading from the sliding door connected to a HEPA (high-efficiency particulate air) filter, located in the east hallway, outside of RM [ROOM NUMBER], which blew warm air into the hall to temporarily keep resident rooms warm. The thermostat temperature rounds with the Administrator: *Rm 124 thermostat read 68 degrees. Resident 108, who was up in her wheelchair, positioned at the foot of her bed, dressed, and looking at her I-pad, stated she was comfortable, * RM [ROOM NUMBER] thermostat read 67 degrees, *Rm 119 thermostat read 71 degrees. Resident 26 stated he has gotten used to the room temperature, *Rm118 thermostat read 63 degrees, *Rm 117 thermostat read 66 degrees, *Rm 115 thermostat read 62 degrees, *Rm 101 thermostat read 67 degrees, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 Level of Harm - Minimal harm or potential for actual harm *Rm 102 thermostat read 66 degrees. Resident 244 stated she was cold. She had a down comforter on her. The Administrator stated if she left her door open the warm air would come into the room. Resident 244 stated she had her door closed because she did not want cats coming into her room. The Administrator stated he could have a scat mat (a training tool used to keep cats away from areas you wish) placed in the entrance of her door preventing the cats from wanting to enter her room. She agreed. Residents Affected - Many * [NAME] hall thermostat across from RM [ROOM NUMBER] read 66 degrees, *Rm 103 thermostat read 69 degrees. During a phone conversation on 1/23/23 at 4:20 p.m., asked the Administrator to have someone check the resident room temperatures in the six problem rooms throughout the night (starting after dark) until surveyors returned in the morning. The Administrator agreed to have staff start at 6 p.m. and every two hours. During a concurrent interview and record review on 1/24/23 at 8:55 a.m., the Administrator provided the resident, Room Temperature Log taken on 1/23/23, starting at 6 p.m. through 1/24/23 at 8 a.m., which showed Rooms 101, 102, 115, 116, and 118 were still having temperatures ranging from 61 to 67 degrees. He stated there were still some low room temperatures. During observations on 1/24/23 at 9 a.m., the portable heating unit and HEPA filter was running. The thermostat readings in resident rooms: *Rm 101 thermostat read 67 degrees, *Rm 102 thermostat read 65 degrees * [NAME] hallway right of RM [ROOM NUMBER] thermostat read 68 degrees, *Rm 103 thermostat read 69 degrees, *Rm 107 thermostat read 72 degrees, *Rm 112 thermostat read 68 degrees. Resident 14, who was dressed, up in her wheelchair and propelling self, stated she was more comfortable, *North hall thermostat read 70 degrees, *Rm 123 thermostat read 74 degrees, *East hall thermostat read 69 degrees, *Rm 119 thermostat read 74 degrees, *Rm 116 thermostat read 64 degrees, *Rm 115 thermostat read 66 degrees. During an interview on 1/24/23 at 9:55 a.m., the Administrator and the Maintenance Supervisor were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many asked why the fan to the HEPA filter connected by duct tubing to the outside portable heater was so quiet. The Maintenance Supervisor stated there was a low to high dial on the fan. The Maintenance Supervisor stated the rental company delivered the portable heating unit on Saturday (1/21/23). The Maintenance Supervisor stated he was having to go frequently to get diesel fuel yesterday. At some point in the early morning the unit stopped producing heat and he did not know why. When informed the tape holding the duct to the HEPA filtration system was coming apart and the hot air was mainly blowing back into RM [ROOM NUMBER] (where the unit was set-up), the Administrator stated he would check on it. During an interview on 1/24/23 at 10:10 a.m., before leaving the facility, asked the Administrator and Maintenance Supervisor to make sure the room temperatures for resident rooms that were remaining below 68 degrees were logged every two hours starting at 6 p.m. until surveyors returned on 1/25/23. During a concurrent interview and record review on 1/25/23 at 8:35 a.m., the Administrator provided the resident Room Temperature Log taken on 1/24/23, starting at 6 p.m. through 1/25/23 at 8 a.m. He stated the temperatures looked good. Rooms 101, 102, 103, 117, 118, 119, and 120 room temperatures were within normal range (68 to 81 degrees). RM [ROOM NUMBER] had dropped to 66 degrees on 1/25/23 at 6 a.m. but went back up to 71 degrees at 8 a.m. During a concurrent observation and interview on 1/25/23 at 8:40 a.m., the residents in RM [ROOM NUMBER] had been moved to RM [ROOM NUMBER] and the temporary portable heating unit was set-up in RM [ROOM NUMBER]. Asked the Administrator for the invoices done by the HVAC Technician, HVAC company who serviced the heating system last year, and the rental company where the portable heating unit came from. During observations on 1/25/23 at 08:50 a.m., thermostat readings in resident rooms: *Rm 101 thermostat read 70 degrees, *Rm 102 thermostat read 68 degrees, *Rm 103: thermostat read 67 degrees. Thermostat was off, and resident stated he was comfortable. *West hall right of RM [ROOM NUMBER] thermostat read 69 degrees, *Rm 116 thermostat read 72 degrees, *East hallway thermostat read 72 degrees, *Rm 117 thermostat read 71 degrees, *Rm 118 - Resident busy *Rm 120 thermostat read 71 degrees, *Rm 119 thermostat read 75 degrees, *Rm 125, where residents were moved to from RM [ROOM NUMBER], thermostat read 72 degrees, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 *East hall left of RM [ROOM NUMBER] thermostat read 72 degrees. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/25/23 at 9:11 a.m., the Administrator stated the portable heating unit was moved from room [ROOM NUMBER] to room [ROOM NUMBER] yesterday and set-up around 1:30 p.m. The Administrator stated plastic was placed in the sliding door frame and a hole cut out for the duct to go through. The HEPA filters were in the hallway. One was hooked up to the heater unit and the other filtering the air. The Administrator stated the portable heating system was hooked up by the supplier on Saturday (1/21/23) at 12 p.m. The facility maintenance did the switch yesterday. Residents Affected - Many On 12/25/23 at 9:49 a.m., the Surveyor requested copies of the HVAC repair invoices, the heating servicing invoice and the rental supplier invoice for the portable heater. The Administrator stated he would e-mail them when he received them. The Administrator understood the facility needed to get the hydronic heating system working in all resident livable areas, and he needed to be submit to HCAI as well as all temporary emergency authorization plans. A review of the Heating Service Invoice, dated 1/17/23, and e-mailed to surveyor on 1/26/23 at 9:02 a.m., indicated the hydronic heating system was serviced on 12/20/22. The technician found the hydronic boiler system was intermittently misfiring due to multiple issues. The burners and gas orifices (openings) were filled with debris. He cleaned the debris and found the pilot (light or burner) assembly was cracked which was causing a spark to round in the wrong direction. The facility policy and procedure titled, Quality of Life - Homelike Environment, revised 5/2017, indicated: Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation: .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . h. Comfortable and safe temperatures (68 degrees - 81 degrees) . The facility Maintenance Supervisor job description, undated, indicated: Purpose of Your Job Position: Assure that all systems and environments are clean, safe, and functional for the wellbeing of the residents as well as the employees. Job Function: Supervise all functions and all employees in the maintenance department (maintenance, housekeeping, laundry, and grounds) as well as perform all duties of Maintenance Mechanic . Working Conditions: Works on patient rooms, bathrooms, shower rooms, utility rooms, hallways, living room . Review of website localconditions.com, accessed on 1/26/23, revealed the following weather conditions at the location of the facility: On 1/19/23 the temperature was recorded as a low of 35° F and a high of 54° F, 1/20/23 low 34° F, high 55° F, 1/21/23 low 29° F, high 58° F, 1/22/23 low 37° F, high 57° F, 1/23/23 low 40° F, high 60° F, 1/24/23 low 34° F and high 60° F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0584 Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 1/9/23 at 10:27 a.m., a space heater was noted in room [ROOM NUMBER] pushed against the wall between two nightstands. During an interview on 1/9/23 at 11:41 a.m., Resident 17 stated it was cold in her room at night. She stated she had a little heater the facility gave her, but someone took it, and she wanted it back. Residents Affected - Many During an observation on 1/10/23 at 11:44 a.m., a space heater was noted in room [ROOM NUMBER] next to the bathroom door. During an interview on 1/11/23 at 3:09 p.m., Unlicensed Staff E stated he was caring for the residents in room [ROOM NUMBER]. Unlicensed Staff E stated the residents were using the space heater in their room a few days ago. Unlicensed Staff E verified it was the space heater by the wall between the nightstands. He stated it was placed in the middle of the room, and it was turned on in the late afternoon. During an interview on 1/13/23 at 11:04 a.m., when queried about the facility policy on use of space heaters, Maintenance Supervisor stated, We don't like using them. He stated the valves on three of the hydronic heaters needed to be repaired, and the space heaters were short term use only until he could get some time to fix them. During an interview on 1/17/23 at 12:15 p.m., Maintenance Supervisor stated that space heaters were in resident rooms because the residents were complaining of being cold. When asked if the hydronic heater was broken in room [ROOM NUMBER], Maintenance Supervisor stated he did not recall, and he would have to check. When asked about his knowledge of the life safety code pertaining to space heaters, Maintenance Supervisor stated he knew using space heaters in nursing homes was not ideal, but he chose to prioritize the residents' comfort over that (the safety code). During an observation on 1/17/23 at 3:08 p.m., three space heaters were noted in the west hallway, two space heaters in the east hallway, and a space heater was noted in resident rooms 101, 112, 114, 115, and 123. Review of facility policy titled, Electrical Safety for Residents, last revised 1/2011, revealed, Portable space heaters are not permitted in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for four out of six residents: Resident 13, who was transferred to an acute care facility and Resident 43, 247, and 249, who were discharged to home. This failure had the potential for Resident 43, 247, and 249 being inappropriately discharged and Resident 13, 43, 247, and 249 not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to the acute care facility. Findings: A review of Resident 13's Nurse's Progress Notes, dated 1/7/23, indicated Resident 13 was transferred to the Emergency Department (ED) because Resident 13 had started spiking a temperature (99.8 degrees), CBC (complete blood count: used to diagnose and monitor numerous diseases) was abnormal, and had vomited large amount with food particles, on 1/7/23 at 3:32 p.m. A review of Resident 13's Emergency Department (ED) History and Physical, dated, 1/7/23, indicated Resident 13 was to be admitted to the acute care facility with the possibility of pneumonia. A review of Resident 13's Nurse's Progress Notes, dated 1/14/23, indicated Resident 13 returned to the facility on 1/14/23, at 6:40 p.m. During an interview on 1/18/23 at 3:00 p.m. when Social Services was asked if she notified the Ombudsman's office about Resident 13 being transferred to the acute care facility, Social Services state she informed Resident 13's Conservator about Resident 13 being hospitalized by e-mail. Social Services stated she never informed the Ombudsman's office about a resident being transferred to the hospital. Social Services stated her hire date was 7/2021 and she was never taught to notify the Ombudsman's office about a resident being transferred to the ED and admitted to the acute care facility if the resident's stay was more than 24 hours. Social Services stated she only notified the resident's responsible party. A review of Resident 247's Notice of Transfer and Discharge, dated 8/8/22, indicated Resident 247 was discharged to home on 8/8/22. Resident 247's admission Record, indicated Resident 247 was admitted on [DATE] and was discharged on 8/8/22 at 1:06 p.m. A review of the facility's fax notification to the Ombudsman's office of Resident 247's discharge to home, indicated the facility faxed the notification on 11/9/13 (date on document) at 2:10 p.m. per the Transmission Verification Report. The fax had a handwritten note indicating the Ombudsman's office was faxed the discharge notification at 12:45 p.m., but no date was noted. A review of Resident 249's Nurse's Progress Notes, dated 9/23/22, indicated Resident 249 was picked up by her daughter on 9/23/22 at 10:59 a.m., and discharged to home. Resident 249's Notice of Transfer and Discharge, dated 9/23/22, indicated Resident 249 was discharged to home on 9/23/22. A review of Resident 249's Discharge Summary, indicated per a written note, Social Services e-faxed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Ombudsman's office on 9/26/22 at 10:30 a.m. notifying the office of Resident 249's discharge, which took place on 9/23/22. During an interview on 1/18/23 at 3:00 p.m., Social Services stated when a resident was ready to be discharged , she would fax over the Discharge Notification to the Ombudsman's office once the nurse had gone over all discharge information with the resident and/or responsible party, all discharge paperwork was completed, and right before the resident left the facility. Social Services stated notifying the Ombudsman's office was the last step to the completion of the resident's discharge. When Social Services was asked what the Ombudsman's purpose was for coming to the facility, Social Services stated the Ombudsman advocated for the residents/spoke on the resident's behalf regarding a concern. When asked how the Ombudsman could advocate for the resident if the resident was upset about his/her discharge if the Ombudsman's office was notified minutes before the resident was discharged or after the fact, Social Services stated she was never trained to inform the Ombudsman's office as soon as the facility was aware of the resident's discharged . Social Services stated she was trained to notify the Ombudsman's office via way of fax of the resident's discharge after the resident or responsible party signed all the discharge paperwork and were about to leave the facility. Social Services stated if a resident was discharged over the weekend she would fax the discharge information to the Ombudsman's office on Monday, when she returned to work. During an interview on 1/19/23 at 10:24 a.m., when the Administrator was asked if the facility followed the facility policy/procedure (p/p) titled, Transfer or Discharge Notice, revised 12/2016, for reporting to the Ombudsman's Office a resident going to be discharge or transferred from the facility, which did not give a time frame of when to notify the Ombudsman's office or did the facility follow the AFL (All Facilities Letter) 17-27 under the HSC (Health and Safety Code) section 1439.6, indicating the facility should send a notice to the Ombudsman's office regarding a facility-initiated transfer or discharge at the same time the notice was provided to the resident or the resident's representative, the Administrator stated the facility needed to update their p/p titled, Transfer or Discharge Notice, because the policy did not indicate a timeframe of when to notify the Ombudsman's office. A review of Resident 43's Nurse's Progress Notes, dated 10/29/22, indicated Resident 43 was discharged on 10/29/22 at 10:26 a.m. A review of Resident 43's Notice of Transfer and Discharge, dated 10/29/22, indicated Resident 43 was discharge to his son's home on [DATE]. During an interview on 1/19/23 at 12:30 p.m., Social Services stated she was not working when Resident 43 was discharged on 10/29/22. Social Services stated the Ombudsman's office was not notified of Resident 43's discharge. The facility policy/procedure titled, Transfer or Discharge Notice, revised 12/2016, indicated: Policy Statement: Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Policy Interpretation and Implementation: .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . A document titled All Facility Letter (17-27) Summary, dated 12/26/17, based on Health and Safety Code (HSC) section 1439.6, which indicated Long Term Care (LTC) facilities were to notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representatives when a facility-initiated transfer or discharge occurred. The facility must send a notice to the local Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0623 agrees with the facility's decision. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain safe water temperatures when the water temperatures in eight of 14 residents' bathroom sinks were too hot, one over 130 degrees Fahrenheit (° F). This failure could potentially result in vulnerable residents getting scalded or burned from hot water. Findings: During an observation on 1/9/23 at 10:27 a.m., the water from the faucet in the bathroom between rooms [ROOM NUMBERS] felt very hot to the touch. During an observation on 1/9/23 at 11:11 a.m., the water from the faucet in the bathroom between rooms [ROOM NUMBERS] felt very hot to the touch. During an interview on 1/9/23 at 11:41 a.m., Resident 17 stated that one of the two showers had fluctuating water temperatures that were so uncomfortable she refused to use that shower. During an observation on 1/9/23 at 3 p.m., the water from the faucet in one of the front public restrooms was scalding hot. During an observation on 1/9/23 at 3:41 p.m., Maintenance Supervisor checked the temperature of the water from the faucet in the bathroom between rooms [ROOM NUMBERS]. The thermometer read 124.9° F. Maintenance Supervisor stated the water was supposed to be less than 120 degrees. During an interview on 1/9/23 at 3:51 p.m., Unlicensed Staff B stated when she washed her hands in a resident's bathroom, she would turn on the cold and hot together otherwise the hot water would be too hot to touch/wash her hands. During an observation on 1/9/23 at 3:58 p.m., Maintenance Supervisor checked the temperature of the water from the faucet in the bathroom for room [ROOM NUMBER]. The thermometer read 134.4° F. During a concurrent observation and interview on 1/9/23 at 4:09 p.m., Licensed Staff A stated she had a high tolerance for the hot water, but if she was washing her hands in a resident's bathroom, the hot water would be a little too hot if she did not turn on the cold water with the hot water. Licensed Staff A was asked to wash her hands in the bathroom shared by the residents in RM [ROOM NUMBER] and RM [ROOM NUMBER] just using the hot water. Licensed Staff A stated the hot water was too hot and she was not able to tolerate the hot water alone. Licensed Staff A stated her hands were turning red. During an observation and concurrent interview on 1/9/23 at 4:18 p.m., in the boiler room, the temperature gauge on the pipe that Maintenance Supervisor stated was running from the mixing valve to the residents' bathrooms read 123° F. Maintenance Supervisor made some adjustments to the boiler and ran hot water through hoses onto the ground outside the boiler room. When queried, Maintenance Supervisor stated the water pipe that runs to the residents' bathrooms has a monitor that sends him an alert on his phone if the water temperature gets too high. He stated he did weekly spot checks on the water temperature in the residents' bathrooms, but he did not document the temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 During observations on 1/9/23 at 4:45 p.m. when running the hot water in Room (Rm) 101's bathroom, within 30 seconds, the hot water was too hot to touch. Level of Harm - Minimal harm or potential for actual harm *Rm 102's bathroom hot water was too hot to touch within 10 seconds. Residents Affected - Many *Rm 104 and RM [ROOM NUMBER] shared bathroom hot water was too hot to touch. *Rm 107 and RM [ROOM NUMBER] shared bathroom hot water was too hot to touch. *Rm 108 and RM [ROOM NUMBER] shared bathroom hot water was too hot to touch. During a group interview on 1/10/23 at 10:11 a.m., an anonymous resident stated the larger of the two showers had big fluctuations in water temperature. During an interview on 1/10/23 at 11:33 a.m., Maintenance Supervisor stated he had consulted with a plumber who stated the mixing valve was probably sticking due to its age and recommended replacing the whole unit. Maintenance Supervisor stated a new mixing valve had been ordered over-night delivery. Review of facility policy Water Temperatures, Safety of, last revised 12/2009, revealed, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120° F. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. Review of the American Burn Association's Scald Injury Prevention Educator's Guide, not dated, (accessed at website https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educ on 1/25/23) revealed, Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. The guide further indicated that hot water can cause third degree burns at 140° F after five seconds and at 133° F after fifteen seconds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep residents' pneumonia vaccines up to date when residents were not offered the 23-valent pneumonia vaccine, as recommended by the Centers for Disease and Prevention (CDC). This failure could potentially leave vulnerable residents unprotected from preventable lung infections that can lead to hospitalization or death. Residents Affected - Some Finding: During an interview on 1/13/23 at 2:33 p.m., the Director of Nursing (DON) stated the immunization program was usually overseen by the Infection Preventionist (IP), Director of Staff Development (DSD), and nursing. DON stated the program was a work in progress since they had not had stable IP coverage. DON stated she had been doing her best to keep up. DON stated IP and DSD were presently going through resident records and creating a spreadsheet of resident vaccinations. DON stated the system for tracking resident vaccinations to ensure they were current was overseen by MDS Nurse. When asked which guidance the facility policy followed for vaccinations, DON stated she did not know and would have to read the policy. DON stated it was the responsibility of the DON, the IP, and the administrator to follow the most recent guidance, but ultimately it was the IP's responsibility. DON stated that once IP was fully in her role, she would be ensuring the most recent guidance was implemented. During an interview on 1/13/23 at 3:40 p.m., DON nor IP knew that residents who had received the Prevnar 13 (pneumococcal/pneumonia vaccine) needed to receive a dose of the 23-valent Pneumococcal Polysaccharide Vaccine (PPSV23/Pneumovax 23). The DON and the IP stated none of the residents had received the PPSV23. During an interview on 1/17/23 at 10:10 a.m., when queried, IP stated that residents who were not up to date on their pneumonia vaccines could potentially have lessened immunity to pneumonia. IP stated the CDC recommended the 23-valent should be given a year after the first dose unless they had comorbidities that indicated they needed it sooner. During an interview on 1/18/23 at 1:05 p.m., MDS Nurse stated that in 2019 they were trying to get everyone up to date on their immunizations. MDS Nurse stated she just recently made a spread sheet for DON with the residents that needed to get updated on their immunizations. Review of the most recent MDS (minimum data set, an assessment tool) records for all 39 residents revealed the pneumonia vaccine status for 11 residents was coded as up to date, one was coded as not up to date with the reason left blank, the pneumonia vaccine status for 21 residents was coded as not given with the reason coded as offered and declined, the pneumonia vaccine status for two residents was coded as not eligible, and the pneumonia vaccine status for four residents was coded as not assessed. Per MDS Nurse interview on 1/18/23 at 1:05 p.m., Not assessed usually meant the documentation for the vaccine status had been requested but not provided by the time the assessment was submitted. Review of the electronic medical records for all 39 residents revealed under the Immunizations section that, of the 21 residents whose MDS was coded as offered and declined for the pneumonia vaccine, three residents had documentation that the Pneumovax-23 had been refused, six residents had documentation that the Prevnar-13 had been refused, and 12 residents had no documentation that a pneumonia vaccine had been refused. Of the 11 residents whose MDS was coded as up to date for the pneumonia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some vaccine, one resident had documentation that the Pneumovax-23 had been received, five residents had documentation that the Prevnar-13 had been received, three residents had no documentation of having received a pneumonia vaccine, and one resident had documentation that the Pneumovax-23 was refused. Review of facility policy Pneumococcal Vaccine, last revised 10/2019, revealed, Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of section References revealed an article from the CDC Morbidity and Mortality Weekly Report 63(37)titled, Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults >/= 65 years . The Centers for Disease Control and Prevention (CDC) recommendations, dated 4/1/22, for adults [AGE] years old and older, and adults 19 through [AGE] years old with certain underlying medical condition or other risk factors, indicated revaccination of PPSV23 at least one year after PCV13 (Pneumococcal conjugate vaccine) dose and at least five years after any PPSV23 dose (https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 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 555207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to install call lights that could be accessed by a resident lying on the floor in the bathroom or shower room. This could potentially result in a resident falling to the floor and unable to signal to staff that they need immediate assistance. Residents Affected - Many Finding: During observations on 1/9/23 between 3:41 p.m. and 4:30 p.m., all resident bathrooms and showers were noted to have call lights with a red button and no cord or other device to activate the call system from the floor. During an observation on 1/9/23 at 4:45 p.m., room [ROOM NUMBER]'s bathroom call light was located on the wall right of the sink. If a resident fell to the floor while in the bathroom, the resident would not be able to reach the call light to call for assistance. During a concurrent observation and interview on 1/12/23 at 10:15 a.m., the large shower room had shower equipment and other equipment that prevented one from being able to reach the shower call light without moving the equipment. The shower call light was out of reach from the shower area and could not be reached if a resident was on the floor. When the Maintenance Assistant was asked how a resident would be able to reach the call light if the resident fell to the floor, he stated, Good question; don't know. The Maintenance Assistant stated the piled-up equipment in the large shower room was always like this. During an observation and concurrent interview on 1/13/23 at 11:04 a.m., in the bathroom between room [ROOM NUMBER] and 166, Maintenance Supervisor verified there was no way to activate the call system if a resident was on the bathroom floor. Maintenance Supervisor stated he was not aware bathroom and shower call systems should be accessible to residents on the floor. Maintenance Supervisor verified that all 14 resident bathrooms and the showers had the same call button as the one in the bathroom for rooms [ROOM NUMBERS]. During an interview on 1/13/23 at 12:05 p.m., when Licensed Staff C was asked how a resident could reach a bathroom call light from the floor, Licensed Staff C stated the residents were assisted to the bathroom. When Licensed Staff C was asked what about an independent resident who went to the bathroom on their own and fell to the floor while in the bathroom. Could the resident reach the call light from the floor? Licensed Staff C stated it would depend on where the resident fell in the bathroom, but probably not. During a concurrent observation and interview on 1/13/23 at 12:10 p.m., in the bathroom shared by the residents in room [ROOM NUMBER]/126, Unlicensed Staff D was asked if a resident fell to floor in the bathroom, could the resident reach the call light (push button on wall left of toilet) from the floor. Unlicensed Staff D stated the resident would need to be near the call light to be able to push the button on the wall left of the toilet. Unlicensed Staff D stated all residents are assisted with their shower. The shower call light was more for the Certified Nursing Assistant needing assistance with a resident. A policy for call light accessibility was requested. Per Administrator, the facility did not have such a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 19 of 19