Health inspection·April 26, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/25/24 at 10:18 a.m., with Licensed Staff L, Licensed Staff L indicated Resident 29's growth has been getting larger, for example about four to five months ago, it was not as large as it was today. Licensed Staff L indicated that there was old blood type drainage observed around the growth and around the band aide which was visible beyond the band aide but was going to provide any treatment unless Resident 29 would pick at it causing further bleeding. Licensed Staff L indicated the plan was to continue replacing the band aide when soiled and not to pursue any further treatment. During a concurrent interview and record review on 4/25/24 at 2:17 p.m., with Licensed Staff N, Licensed Staff N indicated when Resident 29 was first admitted to the facility in 2022, Resident 29's RP had visited her two times a week and has been subsequently the visiting her less and less. Licensed Staff N indicated, Resident 29's growth on the left side of her nose started out looking like a mole and had has been subsequently growing and getting larger and larger approximately over the last year and a half. Licensed Staff N indicated the facility has not been monitoring the growth as there are no measurements with which to reference the starting size with current size. Licensed Staff N indicate Resident 29 with the coordination of the doctor and Resident 29's RP, there was a dermatology (branch of medicine dealing with the skin) appointment made and Resident 29 had attended, Licensed Staff N indicated at the appointment, Resident 29 had become combative and would not let the clinic staff assess the growth and since the appointment the doctor and RP had indicated there was no further treatment to pursue. Licensed Staff N indicated the growth on Resident 29's nose has grown toward the lower eye lid area. Licensed Staff N indicated the growth has been bleeding more and more when Resident 29 would pick at it. Licensed Staff N indicated Resident 29's RP has not seen the growth and not sure when the medical doctor or nurse practitioner had observed the vascularity or the continually bleeding when the growth was touched by Resident 29. Licensed Staff N indicated there were other treatment options potentially available to Resident 29 and confirmed that the Resident 29's RP was not aware of the current size and bleeding nature of the growth and the current treatment option would pose a potential for infection as whatever would be on Resident 29's fingers would gain access to an open wound when the growth was itched or scratched. The INTEGRETY SKIN ASSESSMENT, which were completed weekly, dated 4/15/24, 4/9/24, 4/8/24, 4/1/24 and 3/27/24 were reviewed and indicated Resident 29 had a skin tag indicated on the left side of her nose, with no changes and treatment to continue as indicated. Licensed Nurse N indicated the weekly skin assessments were not documenting the changing size and daily bleeding events of the growth on Resident 29's nose. The Integrity Skin Assessment dated 2/26/24, revealed a skin tear on the elbow but did not indicate a growth on Resident 29's nose and the assessment dated [DATE] did not indicate a growth on the nose either. Licensed Staff N indicated the health care team was not on the same page and per the documentation the accuracy of the monitoring of the skin growth was not reflected as to the current condition. Licensed Staff N indicated the risk to not addressing the growth on Resident 29's nose as a comprehensive health care team would increase the risk of infection and discomfort for Resident 29. During an on 4/26/24 at 11:19 a.m., Director of Nursing (DON), indicated regarding Resident 29's skin growth on the left side of her nose, the medical doctor had been contacted and Resident 29's fingernails needed to be care planned to keep finger nails short and her hands to need to be sanitized to reduce risk of infection. DON indicated, Resident 29's RP had been contacted and wanted to keep the plan of care as per the medical doctor. DON indicated there was a wound care doctor who made on site visits to the facility and Resident 29's growth on her nose would be evaluated to assess treatment options, since the band aide was not working that well. DON indicated she was not aware that the growth was increasing in size toward the lower eyelid of the left eye and that Resident 29's medical doctor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 2 of 17 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 04/26/2024 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 0684 would assess the growth on the nose. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure, titled Charting and Documentation, dated 7/17 indicated, c. Treatments or services performed .d Changes in the resident's condition; .f. progress toward or changes in the care plan goals and objectives .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . Residents Affected - Some A review of the facility's policy and procedure titled, Skin and Wound Management, dated 3/20, indicated b. Once inspection of skin is completed document the findings on a facility- approved skin assessment tool .c. If a new skin alteration is noted a (pressure or non-pressure) form related to the type of alteration in skin . 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 3 of 17 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 04/26/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the RNA (restorative nursing assistant) program (assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) was being received per physician orders for one of 15 sample residents (Resident 33). This failure resulted in a disruption in treatment and had the potential for Resident 33 to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in ADLs (Activities of Daily Living: activities related to personal care, which includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Findings: A review of Resident 33's admission Record, indicated Resident 33 was admitted to the facility on [DATE], with a diagnosis including cerebral infarction (stroke), major depression disorder, hemiplegia (paralysis on one side of the body), hearing loss, amongst others. A review of Resident 33's Physician Progress Note, dated 1/24/24, indicated Resident 33 had left hemiplegia, and the physician was adding Tylenol to Resident 33's medication list for joint pain. A review of Resident 33's ADL Function and Left-Hand Contracture Management care plan, Focus: decreased functional ability related to CVA (Cerebral Vascular Accident: stroke), decreased/limited ROM (Range of Motion)-left hand/wrist contracture; hemiplegia, initiated 12/19/22 and revision date, 4/5/23. The care plan Interventions/Tasks included: RNA - Transfer Training: from bed to wheelchair with extensive assist, revision on 7/26/23, and Passive Range of Motion (PROM) and stretching to bilateral upper extremities (arms) and Active Range of Motion (AROM) to bilateral lower extremities (legs) ten repetitions (reps) times two sets, revision date, 7/26/23. A review of Resident 33's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 3/22/24, indicated Resident 33 had a BIMS (Brief Interview of Mental Status) score of 12 (resident's mental understanding was moderately impaired), and indicated Resident 33 had functional limitations: impairment of one side: upper/lower extremities, one side. During a concurrent observation and interview on 4/22/24 at 10:33 a.m., Resident 33 stated he had left upper and lower extremity paralysis from a stroke, which occurred over a year ago. Resident 33 stated he was supposed to go to the gym twice a week, but promises were not kept all the time. Resident 33's left arm was elevated on a pad, bent at the elbow, while in his wheelchair. Resident 33 had no function of his left upper extremity because of a stroke. Resident 33 stated once he was assisted up from his wheelchair, he could take steps using the parallel bar. Resident 33 stated he felt his paralysis was getting better. A review of Resident 33's physician order, dated 7/20/23, indicated a request for the RNA Program to help maintain functional mobility and muscle strength 3x-5x/week for 90 days. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps times two, dated 7/1/202 - 8/30/2023, indicated Resident 33 received his ordered exercises on 8/13/23 and 8/17/23 for 15 minutes each day. Resident 33 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 4 of 17 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 04/26/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some received his ordered exercises from the RNA two times in a six-week period. Resident 33 should have been offered his exercises a minimal of 12 times in the six-week period. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps times two, dated 8/31/2023 - 10/29/203, indicated Resident 33 received his ordered exercises from the RNA on 9/22/23, 9/23/23, 10/1/23, and 10/14/23 for 15 minutes each day. Resident 33 refused his exercises on 10/27/23 and 10/28/23. Resident 33 received his ordered exercises from the RNA four times in an 8-week period. Resident 33 was offered his ordered exercises five times in an eight-week period. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in an 8-week period. A review of Resident 33's physician order, dated 10/20/23, indicated a request for RNA Program to help maintain functional mobility and muscle strength 3x-5x/week for 90 days. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps times two, dated 10/30/23 - 12/25/23, indicated Resident 33 received his ordered exercises on 11/11/23, 11/17/23, 12/22/23, and 12/23/23 for 15 minutes each day, 12/8/23 for 30 minutes, 12/25/23 for 45 minutes, refused on 11/25/23, and not available on 12/15/23 and 12/18/23. Resident 33 received his ordered exercises six times in an eight-week period. Resident 33 was offered his ordered exercises from the RNA seven times and not available two times. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in the eight-week period. A review of Resident 33's physician order, dated 1/20/24, indicated a request for RNA Program to help maintain functional mobility and muscle strength 3x-5x/week for 90 days. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps' times two, dated 12/26/23-2/20/24, indicated Resident 33 received his ordered exercises on 12/29/23, 1/12/24, 1/26/24 for 15 minutes each day, and he was not available on 12/28/23 and 1/28/24. Resident 33 received his ordered exercises from the RNA three times in an eight-week period. Resident 33 was offered his ordered exercises three times and not available one time. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in the eight-week period. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps' times two, dated 2/21/24-4/20/24, indicated Resident 33 received his ordered exercises on 2/23/23, 3/9/23, 4/12/24 for 15 minutes each day and 4/20/24 for 30 minutes. Resident 33 received his ordered exercises from the RNA four times in an eight-week period. Resident 33 was offered his exercises from the RNA four times. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in the eight-week period. A review of Resident 33's electronic medical record for the RNA task, Transfer training: from bed to wheelchair with extensive assist, dated 8/31/23-10/28/23, 10/29/23-12-25/23, 12/26/23-2/22/24, and 2/23/24-4/23/24, indicated Resident 33 was offered and performed the Transfer Training exercise on 1/28/24 for five minutes, 4/20/24 for 30 minutes, refused on 10/27/24, and not available on 12/15/23 and 12/25/23. Resident 33 was offered the Transfer Training exercise three times in 33-weeks/eight-month time period. During an interview on 4/24/24 at 11:45 a.m., the Rehab Manager stated supposedly the DON was in charge of the RNA Program, but she has been overseeing the RNA Program for the past three years. The Rehab Manager stated she would initially evaluate the resident to see what exercises the resident would benefit from, then instruct the RNA by the RNA observing her perform the exercises with the resident and then by the RNA repeating the technique with the resident. The Rehab Manager stated it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 5 of 17 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 04/26/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should be the residents' nurse who should oversee to make sure the residents they are assigned to and who are in the RNA program were receiving their physician ordered exercises. The Rehab Manager stated she made the exercise plan for the resident, had the physician approve and sign the plan, and she tried to meet with the RNA at least once a month to go over the resident's progress. During a concurrent interview and record review on 4/24/24 at 12:08 p.m., Unlicensed Staff O stated her RNA schedule was Monday, Wednesday, Friday, and Saturday. Unlicensed Staff O stated she was pulled to be a CNA (Certified Nursing Assistant) and assigned residents to care for on Monday, 4/22/24. Unlicensed Staff O stated she worked as an RNA twice a week and a CNA twice a week lately. Unlicensed Staff O stated there was another CNA who completed her RNA certification a few months ago but she has only shadowed (trained) with Unlicensed Staff O once because she was always placed on the CNA schedule. Unlicensed Staff O stated the RNA in training that one day was pulled because the CNA from the registry had to leave early. Unlicensed Staff O stated she had 19 residents in the RNA program. Unlicensed Staff O stated she tried to see the residents three days per week for 15 min but the residents should be seen three to five days a week for 15 to 30 min. Unlicensed Staff O stated if the residents refused their scheduled exercises she would document refused. Unlicensed Staff O stated Resident 33 has only been seen twice this month, 4/12/23 & 4/20/23 because the facility has been short staffed, so she was pulled from her duties as an RNA to fill a CNA spot. A review of Unlicensed Staff O's RNA resident assignment dated 4/22/24 (Monday), 4/23/24 (Wednesday), 4/26/24 (Friday) and 4/27/24 (Saturday), indicated Resident 33 was scheduled to be seen on Friday and Saturday for 15 minutes. Resident 33's physician ordered RNA Program plan indicated Resident 33 should have been seen by the RNA 3x-5x/week. During an interview on 4/25/24 at 10:03 a.m. the Director of Nursing (DON) stated the Rehab Manager was overseeing the RNA Program. The DON stated the facility had two RNAs, but it was pointed out to the DON the new RNA was pulled to the floor all but one day to fill a CNA spot because the facility was short staffed. The DON stated that was correct, the new RNA has been pulled to fill a CNA spot because the facility has been short staffed CNAs, but at least she was trained. During an interview on 4/25/24 at 3:27 p.m., Resident 33 was dressed and up in his wheelchair near his bed. Resident 33 stated he had not had RNA therapy today. Resident 33 stated he wanted to get stronger but felt like he was being forgotten about. The facility policy/procedure titled, Restorative Nursing Services, revised 7/2017, indicated: Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation: . 5. Restorative goals may include but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining, or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence, and self-esteem; and d. participating in the development and implementation of his/her plan of care . 8. Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. The facility policy/procedure titled, Resident Mobility and Range of Motion, revised 7/2017, indicated: Policy Statement: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 6 of 17 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 04/26/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete The facility job description titled, Restorative Nursing Assistant, undated, indicated: . Job Duties: oWorks with licensed therapy staff during active therapy period to take instruction on individual care of Elders. Follow through with individual Elders discharged from active Rehab Therapy to maintain abilities and improve endurance and independence through bed mobility, transfer skills, active ROM including splints as applicable, ambulation, assistance and instruction in AOL care. *Documents restorative treatments and actions by completing forms, reports, logs, and records. *Documents weekly progress reports for all participating Elders . Event ID: Facility ID: 555207 If continuation sheet Page 7 of 17 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 04/26/2024 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNA). These failures had the potential for unlicensed nursing staff to not have their skills assessed under the performance review and not have necessary training addressed in the performance review. Residents Affected - Few Findings: During a concurrent interview on 4/26/24 at 10:54 a.m., with Director of Nursing (DON) and Director of Staff Development (DSD) (by telephone), DSD was asked about the process for completing annual reviews for certified nursing assistants. DSD indicated the annual performance reviews were behind and agreed that Unlicensed Staff P and Unlicensed Staff Q had outstanding annual performance reviews. DSD indicated that on a three day a week schedule, there were things which were behind for the facility. DSD indicated the process would be to complete them within the month of the employee's hire date and the facility was working on the current year of 2024 and indicated 2023 was not complete with performance reviews for all unlicensed staff. During a review of Unlicensed Staff Q's, Human Resource File, dated 10/12/21, indicated to date of hire, Annual Performance Review was not observed for the year 2023. During a review of Unlicensed Staff P's, Human Resource File, dated 3/25/22, indicated to be date of hire, Annual Performance Review was not observed for the year 2023 or 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 8 of 17 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 04/26/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation and interview, the facility failed to follow a process of ensuring resident meals were served with the appropriate dietary consistency when one of two staff (Licensed Staff L) was observed reviewing the meal tray cards but not reviewing the covered food for accuracy prior to the meal being served to residents. Findings: During an observation on 4/22/24 at 12:34 p.m., with Licensed Staff L who was reviewing the resident meal tray cards and then reviewing the dietary order in the electronic medical record. Licensed Staff L was observed instructing the Certified Nursing Assistant (CNA) the appropriate texture for the tray, for example regular, pureed (food served with a pudding like texture, which is smooth and blended). Licensed Staff L was observed repeatedly checking the electronic medical record, waiting for the CNA staff to return and serve another tray. At one point, a CNA called out the resident's name and Licensed Staff L indicated the texture of the tray and CNA then delivered the tray to the resident. Licensed Staff L did not open the covered meals to view the dietary texture, only the meal tray cards were reviewed against the dietary orders in the electronic medical record. During an interview on 4/22/24 at 12:54 pm., with Licensed Staff L, Licensed Staff L indicated the process for checking meal trays prior to serving the residents was to review the dietary orders in the electronic medical record against the meal tray cards on each resident's tray prior to serving the resident. Licensed Staff L indicated the meals were not uncovered because it would mean the food might be touched. Licensed Staff L indicated he was new but had been working as a licensed staff member for a long time. Licensed Staff L agreed that the process of checking meal trays prior to serving the residents was common practice and not new to this particular facility. Licensed Staff L indicated the reason behind checking the trays was to ensure the consistency was appropriate and the resident would not choke on food which had not been prepared appropriately or aspirate (when food or liquid enters a persons airway and lungs). During a observation on 4/23/24 at 12:31 p.m., the lunch cart had been delivered and Unlicensed Staff Q was observed looking for licensed staff to check the trays. Unlicensed Staff Q indicated Licensed Staff L was at lunch and not available to check the lunch trays. A student was observed to walk up to the lunch cart and proceed to pull out a lunch tray and deliver to a resident. Unlicensed Staff Q was observed to deliver a lunch tray a resident. At 12:32 pm., Licensed Staff L was observed to be rushing onto the unit and indicating out loud that he was late for checking the trays and asked why Unlicensed Staff Q had not gone to get him. Unlicensed Staff Q did not respond to the question but gave a quizzical look. During an interview on 4/25/24 at 2:17 p.m., with Licensed Staff N, Licensed Staff N indicated as part of the role, there would be training with new licensed nurses but in terms of documentation, where and how to document. During an interview on 4/26/24 at 11:00 a.m., with Director of Nursing (DON), DON indicated the role of the licensed staff was to check the meal trays for appropriate consistency against the doctor order to ensure the meal card matched the consistency of the food being served. DON indicated when a new licensed staff person has been hired, there was no formal documentation regarding how to perform the task. DON was asked about the break/lunch schedule for licensed staff and DON indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 9 of 17 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 04/26/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm licensed staff they do their own breaks/lunches. DON indicated she was not aware that meals were not being checked by licensed staff prior to being served to the residents and that licensed staff were not checking the consistency of the food being served for safety purposes. DON indicated the reason for the safety measure was to ensure the residents did not aspirate the meal due to inappropriate consistency being served. Residents Affected - Some During a review of the facility's policy and procedure titled, Policy and Procedure, Tray Line Procedure, dated 2017 indicated, 6. Assigned Staff: a. When a cart is fully loaded the assigned staff delivers the cart to the nurses' station and announces the arrival of the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 10 of 17 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 04/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. This failure can potentially result to food contamination and outbreak of foodborne illness among residents of the facility. Findings: During a concurrent observation and interview on 4/23/24, at 10:02 AM, the final rinse of the high temperature dishwasher was 150 degrees Fahrenheit. Dietary Aide E stated the dishwasher is not holding the final rinse temperature of 180 degrees Fahrenheit. During an interview on 4/24/24, at 5:19 PM, Dietary Aide F when asked about the final rinse temperature of the high temperature dishwasher stated, the dishwasher does not always go up to 180 degrees Fahrenheit at final rinse. Dietary Aide F stated he runs the dishwasher several times to reach 180 degrees Fahrenheit before he continues dishwashig. During an interview on 4/25/24, at 10:45 AM, Dietary Aide E confirmed she runs the dishwasher several times to check if the temperature goes to 180 degrees Fahrenheit. When asked what the final rinse temperature for the current batch of trays and cups, on the right of the washer was, Dietary Aide E stated, it was 150 degrees Fahrenheit. When asked what her course of action is given the dishwasher situation, Dietary Manager D (DM D) stated they will use disposable plates and utensils for lunch. DM D stated they are calling an on-call maintenance service to fix the final rinse booster heater of the dishwasher as their facility maintenance man could not come to fix it. During a review of records on 4/25/24, at 11:08 AM, the monthly Consultant Dietitian Report Card indicated, the dishwasher final rinse booster heater was broken in 1/24 and the dishwasher was not holding temperature. In 2/24, the report card indicated the final rinse booster heater was leaking and dishwasher was not holding temperature. In 3/24, the report card indicated the final rinse booster heater continued to leak and dishwasher was not holding temperature. A review of the undated document provided by the facility titled: Directions for Machine Dish Washing - High Temperature Machine indicated, under Rinse, Keep at 180 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 11 of 17 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 04/26/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and records review, the facility failed to: Residents Affected - Many 1) ensure hand hygiene was practiced by six (6) of 15 sampled residents (Resident 3, Resident 16, Resident 9, Resident 22, Resident 1, Resident 24) before meals. This failure had the potential to cause the spread of infections to other residents and worsen their already compromised health or cause an outbreak; 2) conduct ongoing analysis of infection surveillance. This failure had the potential to result in the facility missing to identify trends in infection types and occurrence and not being able to detect where an infection came from or the presence of an increasing number of infection or an outbreak; 3) ensure physician's orders were being followed when one of 15 sampled residents (Resident 34), who was on oxygen, nasal cannula (a device that delivers extra oxygen through a tube and into your nose) and oxygen humidifier (plastic bottle filled with distilled water that adds moisture to the oxygen being delivered to prevent dryness of the nasal cavity) was not being changed weekly. This failure had potential for the plastic to deteriorate over time leading to tiny cracks and pores in the plastic tubing to occur. In these tiny cracks and pores, bacteria and mold could start to breed, and dirt, dust, and other small irritants, which could lead to lung infections. Findings: 1. During an observation on 4/22/24, at 12:17 PM, Licensed Staff C served Resident 16's meal tray in her room and asked Resident 16 if she would like to eat her lunch. Licensed Staff C did not offer to wash or wipe Resident 16's hands. During continued observation on 4/22/24, at 12:20 PM, Unlicensed Staff G served Resident 9's lunch tray in her room. Unlicensed Staff G was not heard or seen offering to wash or wipe Resident 9's hands. During subsequent observation on 4/22/24, at 12:43 PM, Licensed Staff C went into the room of Resident 22 to serve her meal tray. Licensed Staff C did not offer or remind Resident 22 to wash or wipe her hands before she left the room. Unlicensed Staff G then went into the to help Resident 22 remove the plastic covers over her food. Unlicensed Staff G did not offer or remind Resident 22 to wipe or wash her hands before eating. During an interview on 4/22/24, at 12:47 PM, Unlicensed Staff G when asked if she offered to wash or wipe the hands of her residents' when she served their meal trays stated she did not. During continued interview on 4/22/24, at 12:48 PM, when Unlicensed Staff G was told there were no moist wipes on Resident 22's meal tray, Unlicensed Staff G was surprised and stated there used to be moist wipes in residents' trays. Unlicensed Staff G confirmed there were no moist wipes on Resident 22's tray and stated, it is a good point to clean residents hands. During concurrent interview and observation on 4/22/24, at 12:50 PM, Licensed Staff C stated they use washcloths, but they have not offered to wash or wipe residents hands. Licensed Staff C then went to the linen closet and took some towels and handed them to Unlicensed Staff G. Unlicensed Staff G (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 12 of 17 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 04/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many proceeded to wet the washcloths in the rest room of room [ROOM NUMBER] and wiped the hands of both residents in the room. During an observation and concurrent interview on 4/22/24, at 12:54 PM, Resident 1, who was eating lunch, was asked if facility staff had offered or reminder her to wash or wipe her hands prior to eating, stated staff who served her tray did not offer to wash or wipe her hands. During an interview on 4/22/24, at 1:06 PM, Resident 24 was on her way back to her room from the dining hall, where she ate, stated staff had not offered to wash or wipe her hands before eating. A review of the facility policy titled, Handwashing/Hand Hygiene taken from Nursing Services Policy and Procedure Manual for Long-term care 2001 Med-Pass. Revised 8/19, indicated, hand hygiene is the primary means to prevent the spread of infection and to use an alcohol-based hand rub containing 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water before and after assisting a resident with meals. The policy indicated residents, family members and/or visitors will be encouraged to practice hand hygiene using fact sheets, pamphlets, and/or other written materials. The policy did not indicate for staff to remind or offer hand hygiene to residents before eating their meals. 2. During a concurrent interview and records review on 4/25/24, at 02:16 PM, the facility Infection Preventionist (IP) stated she started working as IP in the facility 3 weeks ago. The IP stated had not seen the IP's folders except for the one on Antibiotic Stewardship. A review of the contents of the folder indicated there was documentation of facility residents on antibiotics for the months of 1/24 to 4/24. A blank page/template titled: Infection Prevention and Control Line Listing Surveillance Log was inserted among the pages and when asked about the completed pages for the previous months, the IP stated she did not have the surveillance documents. On 4/26/24, at 9:15 AM, the Surveillance log for the past 12 months was requested from the DON. During an interview on 4/26/24, at 9:40 AM, when asked where the IP documents were, the DON stated Infection control, surveillance and monitoring, and antibiotic stewardship documents could not be located because the office of the previous IP was at another location in the building and the IP documents could not be located or had been misplaced. Since the current IP's hiring, there were two IPs who had worked in the facility. The DON stated she had called one of the IPs to come to the office to help them locate the documents. A review of the facility Infection Prevention and Control Line Listing Surveillance Logs for the past 12 months indicated, surveillance logs from 8/23 to 4/24 were not completed. There was no documentation to indicate data analysis like plotting monthly infection rates, manual mapping of residents infection in the facility, etc., were done. A review of the facility policy titled: Infection prevention and control program from 2001 Med Pass Inc. revised 10/18 indicated, the infection prevention and control program (IPCP) was established and maintained to provide a safe environment to help prevent the development and transmission of communicable disease and infections. The policy further indicated the elements of IPCP consists of .surveillance, data analysis, outbreak management, etc. Surveillance tools are used for recognizing occurrences of infections, recording the number of infections, detecting outbreaks, and detecting unusual pathogens (microorganisms that can cause disease) with infection control implications. The information obtained from surveillance is compared with that from other facilities with acknowledge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 13 of 17 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 04/26/2024 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 0880 standards and used to assess the effectiveness of the infection prevention and control practices. Level of Harm - Minimal harm or potential for actual harm 3. A review of Resident 34's admission Record indicated Resident 34 was admitted to the facility on [DATE], with a diagnosis including congested heart failure (condition that develops when one's heart doesn't pump enough blood to meet the body's needs), pleural effusion (fluid builds in the space between the lung and the chest wall leading to shortness of breath), palliative care (specialized end-of life medical care for people living with a serious illness, such as heart failure, amongst others). Residents Affected - Many A review of Resident 34's Order Summary Report, dated 4/26/24, indicated Resident 34 to be placed on oxygen (O2) at two liters (L) to five liters per minute via nasal cannula continuously to keep O2 saturation (the amount of oxygen circulating in one's blood) level greater than 90 percent, start date 1/22/24 and change O2 humidifier and nasal cannula every five days and as needed, start date 1/17/24. During an observation on 4/22/24 at 10:12 a.m., Resident 34 was on O2 at 2L/min per nasal cannula and had a humidifier, with adequate water level. The nasal cannula tubing and humidifier were not dated to show when they were last changed. A review of Resident 34's care plan indicated Resident 34 was admitted to Hospice (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life), initiated 1/18/24. Focus was to apply O2 at two to five liters per minute via nasal cannula as needed for O2 saturation level 90% or greater. A review of Resident 34's Treatment Administration Record (TAR), dated 1/2024, 2/2024, 3/2024, and 4/2024, indicated Resident 34's O2 nasal cannula and humidifier were to be changed every five days and as need. The TARs indicated Resident 34's nasal cannula and humidifier was changed one time, 2/28/24. During an observation on 4/25/24 at 3:05 p.m., Resident 34 was resting comfortably in bed and positioned on her right side. Resident 34 was on O2 at 2L but Resident 34's nasal cannula tubing and humidifier were not labeled to indicate when they were last changed. During a concurrent interview and record review on 4/25/24 at 3:16 p.m., Licensed Staff N was asked to look at Resident 34's TARs to see when Resident 34's nasal cannula tubing and humidifier was last changed. Licensed Staff N stated the last time Resident 34's TAR was documented to indicate when Resident 34's nasal cannula tubing and humidifier was changed was 2/28/24 at 10 a.m. Licensed Staff N stated the night nurse was supposed to change the resident's O2 cannula tubing and humidifier weekly and it should be documented on the resident's TAR. Licensed Staff N stated any nurse from any shift could have changed the Resident 34's nasal cannula tubing and humidifier. Licensed Staff N stated if it was not documented it was not done. During an interview on 4/26/24 at 8:58 a.m., the Director of Nursing (DON) stated the night nurse was responsible for making sure the resident's nasal cannula tubing and humidifier was changed, which was scheduled every Wednesday. The DON did not realize Resident 34 had not had her nasal cannula tubing and humidifier changed since 2/28/24. The DON stated the IP (Infection Preventionist) should be overseeing if nasal cannula tubing/humidifiers were changed weekly. The DON stated it sounded like it was a documentation issue. It was pointed out to the DON Resident 34's nasal cannula tubing and humidifier was not labeled with a date to indicate when it was last changed. The IP stated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 14 of 17 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 04/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not started the process of overseeing if the resident's nasal cannula tubing and humidifier was being changed weekly. The facility policy/procedure tiled, Oxygen Therapy, revised 10/2010, indicated: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . The facility job description titled, Infection Preventionist (IP), undated, indicated: Job Responsibility: Develop and maintain a system of care that promotes sound and scientific infection prevention principles and practices. Accountable for decreasing the incidence and transmission of infectious diseases. Through strategic planning, leads the team in the identification and implementation of infection prevention goals and objectives throughout the facility . The facility job description titled, Registered Nurse (RN), updated 12/30/23, indicated: Job Responsibilities: . RNs provide direct nursing care to residents in accordance with facility policy, physician's orders, and State/Federal regulations. RNs also help supervise the day-to-day nursing activities performed by Licensed Vocational/Practical Nurses and Certified Nursing Assistants (CNAs). Job Duties: . *Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary . * Operate and monitor medical equipment . The facility job description titled, Licensed Vocational Nurse (LVN), updated 12/29/23, indicated: Job Responsibilities: . LVNs provide direct nursing care to residents in accordance with facility policy, physician's orders, and State/Federal regulations . Job Duties: * Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary . *Operate and monitor medical equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 15 of 17 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 04/26/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and records review, the facility failed to consistently perform antibiotic stewardship. This failure had the potential to result to inappropriate or unnecessary antibiotic treatment, increase the risk of adverse events, development of antibiotic resistance, and worsen the already frail health condition of residents. Residents Affected - Many Findings: During a concurrent interview and records review on 4/25/24, at 02:16 PM, the facility Infection Preventionist (IP) stated she had started working in the facility 3 weeks ago and had not seen the previous IP's folders except for the folder on Antibiotic Stewardship. A review of the contents of the folder indicated there were documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics for the months of 1/24 to 4/24 but none for the past months. During an interview on 4/26/24, at 9:40 AM, when asked where the IP documents were, the Director of Nursing (DON) stated Infection control, surveillance and monitoring, and antibiotic stewardship documents could not be located or may have been misplaced after the previous IPs left. The DON had called the previous IP to come to the facility to help locate the folders. A review of the Infection Prevention and Control Line Listing Surveillance Logs provided by the IP for the past 12 months indicated, there were no antibiotic surveillance tracking completed for the months from 8/23 to 12/23 as there were no line listing surveillance logs completed for the same months. During a concurrent review of the IP job description with the DON and interview of the IP on 4/26/24, at 9:53 AM, the job description of the IP indicated, the IP was responsible for the ASP (antibiotic stewardship program) in-servicing, tracking, reporting, and educating families, employees and physicians as needed. When asked if she had conducted in-services with staff on AS (Antibiotic Stewardship), the IP stated she had not. A review of the facility Antibiotic Stewardship (AS) policy updated 1/26/24 indicated the purpose of the antibiotic stewardship program was to monitor the use of antibiotic among the facility residents. The AS surveillance policy indicated, antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. As part of the antibiotic stewardship program (ASP), all clinical infections treated with antibiotics will undergo review by the IP, or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 16 of 17 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 04/26/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the safety, and functional environment in the kitchen when cracks and missing tiles on the kitchen floor were not repaired. Residents Affected - Some This failure can cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents. Findings: During initial tour of the kitchen on 4/22/24, at 9:20 AM, cracked tiled were noted on the floor in front of the entrance to the dry good storage. On continued observation on 4/22/24, at 10:06 AM, more cracks on the tiled floor and missing tiles were noted by the washing sinks, by the exit door to the back of the building, and by the entrance way to another dry good storage. During an interview on 4/23/24, at 10:09 AM, Certified Dietary Manager (DM) nodded in acknowledgement when told the cracks on the kitchen floor and missing tiles were findings of non-compliance to regulations. Review of the Food Code 2017 indicated: It is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where FOOD ESTABLISHMENT operations are conducted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555207 If continuation sheet Page 17 of 17