Health inspection·June 19, 2025

F 0550 the wheat plant and some other grains] Free .Mechanical Soft [easy to chew and swallow] . Level of Harm - Minimal harm or potential for actual harm - Under item Dietary Preference (Cultural, Religious, Likes/Dislikes) staff documented, .No rice it makes [Resident 5] cough/choke. Likes (GF (Gluten Free)) gravy with meat and starches . Residents Affected - Few - Under item, PLAN OF CARE and sub-item Nutrition Diagnosis staff documented that Resident 5 was noted to have .Chewing/swallowing difficulty .inability to tolerate regular texture .need for Mechanical Soft diet/coughing when eating . Also, RD 1 wrote, .Requests brown gravy, which may be difficult to obtain [gluten free] . A review of Observation Details List Report, dated 6/9/25, completed by (RD) 2, showed no follow-up or mention of Resident 5's request for gravy. During a phone interview on 6/19/25, at 8:28 a.m., RD 1 confirmed she had been exploring options to accommodate Resident 5's request for gravy because it was difficult for the kitchen to prepare gravy for just one resident every meal. RD 1 stated she had been working with kitchen staff in finding either a pre-made, packaged, or jarred, gluten free gravy for Resident 5. However, RD 1 admitted that she had not spoken with Resident 5 since documenting the request in March of 2025. RD 1 acknowledged there was a failure to follow up and communicate with Resident 5 after her repeated requests. A review of the Facility's undated Policy titled, RESIDENT RIGHTS indicated, .The resident has a right to a dignified existence .communication with and access to persons and services inside and outside the facility .A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. (a) Dignity. The Facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. (b) Self-determination and participation. The resident has the right to (1) choose .health care consistent with his or her assessment .(3) Make choices about aspects of his or her life in the facility that are significant to the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. 1c. Review of Resident 33's physician's order for lorazepam dated 8/16/24, indicated, .Start date 8/16/24 .End Date .Open Ended .lorazepam .tablet .0.5 mg [mg-a unit of measure] .1 tab .Every 12 hours .PRN . Review of the document did not include an end date for the PRN lorazepam. During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 33's clinical record and confirmed the order for PRN lorazepam with a start date of 8/16/24. The DON acknowledged the order had no end date. The DON confirmed Resident 33's physician progress notes did not contain a rational or justification for Resident 33's use of the PRN lorazepam. The DON stated the PRN lorazepam should have had a physician progress note that included a justification for the medication's continued use and the lorazepam order should have had a stop date. 1d. Review of Resident 49's physician's order for lorazepam dated 8/21/24, indicated, .Start Date .2/17/2025 .End Date .Open Ended .lorazepam .tablet 0.5 mg .1 tablet .Every 12 Hours .PRN for anxiety . Review of the document noted no end date on the PRN lorazepam prescription order. During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 49's lorazepam prescription order and confirmed there was no stop date and stated it was open ended. The DON explained a stop date was important due to the medication being a sedative (a medication that can make a person sleepy) and would want to make sure there was not an overuse of the medication. The DON stated the risk involved if the medication was not monitored was the resident becoming a fall risk and medication dependance since some psychotropics were addictive. The DON agreed all psychotropic medications should have an end date and stated this was important for lorazepam. Through review of Resident 49's physician progress notes for the months of 5/2025 and 6/2025, the DON confirmed there was no rational or justification given for the continued use of lorazepam for Resident 49. 1e. Review of Resident 54's Medication Administration History, dated 6/2025, indicated, .lorazepam .tablet 0.5 mg .1 tablet .Every 6 Hours PRN .Special instructions .*May give 1 tablet 0.5 mg 1 hour prior to shower days (Monday and Thursday PM [night] shift) Diagnosis [area blank] .Start/End Date .5/27/25-Open Ended . During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 54's medical record and confirmed the order for PRN lorazepam had no stop date and lacked rational or justification in the physician progress notes for the continued use of lorazepam for Resident 54. During an interview on 6/18/25, at 3:36 p.m., the ADM acknowledged the facility was currently not following regulation for PRN psychotropic medications. The ADM stated her expectation was for the facility to follow the regulation to protect residents from chemical restraints (the use of medication to control or restrict a person's behavior). The ADM stated her understanding was for PRN psychotropic medications to be stopped after 14 days or require a justification be documented in the resident's medical record of why the medication would continue. The ADM explained this justification would be from the physician and should be written in the physician's progress note. During a phone interview on 6/27/25, at 12:01 p.m. with the Medical Director (MD), the MD stated he was aware of the limitations of ordering PRN psychotropics and it was his understanding they can be written for up to 14 days unless otherwise indicated. The MD explained he can order PRN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some psychotropics for up to six months if the residents' behavior warrants. Through review of Resident 33, Resident 34, Resident 43, Resident 49, and Resident 54's PRN lorazepam medication orders, the MD acknowledged the lorazepam medication orders were open ended and without a stop date. The MD stated that when he initially orders PRN psychotropics he will have an automatic stop date for 14 days. The MD further explained that the nurse will send him a message to continue the PRN psychotropic medication, and he will approve continuing the medication for up to six months due to chronic symptoms of some nature that he anticipates will continue for the resident for the next six months. The MD stated the nurse will write the extension of the phone order for the PRN psychotropic and then he would sign off on the order later. The MD acknowledged he does not write or document a rationale or justification of the continued use of the PRN psychotropic in a progress note. The MD stated he felt like as long as the nurse documents the PRN psychotropic order extension in the medical record of the resident and he signs off on the extension, this would suffice. The MD stated he was not aware that this process was a problem. Review of a facility Policy and Procedure (P&P) titled, FACILITY POLICY: RESTRAINTS:POLICY ON PHYSICAL AND CHEMICAL RESTRAINTS AND DEVICES, revised 6/28/24, indicated, .A chemical restraint is a drug used to control behavior and used in a manner not required to treat the resident's symptoms .Compliance .Each resident shall receive, and the facility shall provide, the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well being . Review of facility P&P titled, FACILITY POLICY: MEDICAL DIRECTOR, RESPONSIBILITES, OF, revised 5/18/22, indicated, .The .Medical Director .is responsible for overseeing the implementation of resident care policies and the coordination of medical care in the facility to ensure to the extent possible that care is adequate and appropriate steps are taken to correct identified problems .Medical care direction and coordination of patient/resident care provided in the facility .Supervision and evaluation of patient/resident care programs ensuring compliance with policies and procedures .Consultation with the Administrative Director .and Inter Department Team in the development of patient/resident care policies and to assure that such policies are implemented and followed .Participate in surveys and inspections with responsibility for follow-up and remedial action, if needed .Intervene and report incidents of inadequate/inappropriate care or practice . 1b. Review of Resident 43's physician order for PRN lorazepam indicated, .Start Date .6/12/25 .lorazepam tablet .0.5mg .amt [amount] .0.25mg .Once a Day .PRN .End Date .open ended . During an interview with the Administrative Director of Post Acute Services (ADM) on 6/18/25 at 3:36 p.m., the ADM acknowledged the facility was currently not following regulation for PRN psychotropic medications. The ADM further stated her expectation was for there to be a stop date after 14 days of PRN use or a physician's justification or rationale documented in the resident's medical record for continued use. Based on interview and record review, the facility failed to ensure safe use and monitoring of psychotropic medication (mind altering drugs) for 5 out of 5 sampled residents (Resident 33, Resident 34, Resident 43, Resident 49 and Resident 54) reviewed for unnecessary medication when Resident 33, Resident 34, Resident 43, Resident 49 and Resident 54's physician orders for PRN (as needed) lorazepam (a psychotropic medication used to treat anxiety) was ordered without a stop date. In addition, Resident 33, Resident 34, Resident 43, Resident 49, and Resident 54's medical record showed no evidence of documented clinical justification or a rationale for the continued use of PRN lorazepam by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These failures placed Resident 33, Resident 34, Resident 43, Resident 49 and Resident 54 at risk for adverse effects of unsafe medication use and monitoring including drowsiness, falls, or other injuries. Findings: 1a. Review of Resident 34's medical record titled, Medications Administration Record [MAR], for the months of May 2025 and June 2025 indicated, .lorazepam 0.5 mg (milligram: unit of measurement) .Amount to Administer 0.25 mg .Twice a day .Q 8 hrs (every 8 hours) PRN , Max of 2 doses in 24 hours .Start/End Date .5/13/2025 - Open Ended . During a concurrent interview and record review with the DON (Director of Nursing) on 6/18/25, at 12:48 PM, the DON acknowledged there was no stop date for Resident 34's PRN Lorazepam order and confirmed there was no documented rational or justification in the physician progress notes for the continued use of PRN lorazepam for Resident 34. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foods were stored and prepared in accordance with professional standards for food service for 57 residents who ate facility prepared meals when: 1. A one-gallon plastic container of [NAME] wine (a type of wine used for cooking) had a sticker which indicated the product was past the used by date (the last day for food to be consumed or eaten); 2. Four 16 ounce plastic containers of Tahini paste (a smooth, savory condiment made from ground, hulled sesame seeds) lacked dates that indicated a recieved date (a date a food item was received in a facility), a manufacturer's expiration date (the date when the maker of a product indicates it was no longer expected to be at its optimal quality or may become unsafe to eat), the date the product was opened, or a use by date; and 3. Seven kitchen cutting boards contained deep grooves and had visible stains. These failures had the potential to put residents who received food from the kitchen at risk for foodborne illnesses (an illness resulting from eating contaminated food or beverages) and unintended weight loss. Findings: 1. During a concurrent observation and interview on 6/16/25 at 9:15 a.m. with the Director of Nutrition Services (DNS) during the initial kitchen tour, a one-gallon plastic container of [NAME] wine was on a shelf in the dry storage room, had been opened, and attached to the container was a sticker that indicated a use by date of 5/13/25. The DNS confirmed the observation and stated it was not acceptable to store food items past their used by date. The DNS stated, if food or cooking ingredients were consumed past the used by date, the food may not taste good and could become contaminated. The DNS further stated, if food becomes contaminated, it could cause residents to get sick. During a concurrent observation and interview on 6/18/25 at 2:47 p.m. with the DNS and the Dietary Supervisor Nutrition Services (DSNS) in person, and Registered Dietician (RD) 1 and RD 2 via a video call platform (VCP-online service that allows users to communicate with each other using live video and sound) images of a one-gallon container of [NAME] wine were reviewed. RD 1 affirmed if a container had a use by sticker dated 5/13/25 it was expired. RD 1 stated expired food items could break down into something unappealing, residents would not want to eat it, and it could spoil and become harmful. RD 1 continued, if residents ate spoiled food, it could make them sick, lead to food borne illness, and lead to unintended weight loss. 2. During a concurrent observation and interview on 6/16/25 at 9:15 a.m. with the DNS during the initial kitchen tour, four 16 ounce, white containers of Tahini paste were located on a shelf in the dry storage room. All four containers of Tahini paste lacked manufacturer expiration dates, recieved dates, open dates, or use by dates. The DNS confirmed the observation and stated it was not acceptable to store undated food items which should indicate the timeframe for safe consumption. The DNS stated the purpose of a date recieved label was to know when food items were received at the facility. The DNS continued, if undated food was used it could cause residents to get sick and lead to food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 borne illness. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 6/18/25 at 2:47 p.m. with the DNS and the DSNS in person, and with RD 1 and RD 2 via VCP, images of four Tahini past containers were reviewed. RD 1 verified that undated Tahini paste containers did not meet her expectations of the facility's food labeling requirements. RD 1 stated if residents consumed food which was outside safe consumption parameters, it could lead to resident illness, weight loss, and ultimately resident death. Residents Affected - Some During a review of the facility's Policy & Procedure (P&P) titled, MODEL POLICY: FOOD STORAGE, revision date 10/14/24, the P&P indicated, .General Food Storage Requirements .Food is routinely rotated first in, first out .All stored food must be properly labeled and dated .The use-by date or date marked may not exceed the manufacturer's use-by date .Dry or staple items, including spices, must be used by the manufacturer's use-by date or if that is not available, within one year from the date received . A review of the US Food and Drug Administration (FDA) 2022 Food Code, version dated 1/18/23, indicated, .Section 3-501.17 (A) (B) (C) (D) .required food labeling and dating .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day . 3. During a concurrent observation and interview on 6/16/25 at 9:15 a.m. with the DNS during the initial kitchen tour, green, yellow, red, purple, brown, blue, and white cutting boards, located in a clean storage rack had deep grooves and visible stains. The DNS confirmed the observation and stated the cutting boards looked old. The DNS stated deep grooves in cutting boards could provide a place for bacteria (germs) to grow which could increase the risk for residents to contract food borne illness. During a concurrent observation and interview on 6/18/25 at 2:47 p.m. with the DNS and the DSNS in person, and with RD 1 and RD 2 via VCP, images of the cutting boards were reviewed. RD 1 affirmed cutting boards with deep grooves and stains should be replaced. RD 1 stated, deep grooves in cutting boards could harbor bacteria which could grow and cause cross contamination that could lead to residents contracting food borne illness. RD 1 further stated, when residents get sick, they were at higher risk for weight loss and ultimately death. During a review of the facility's P&P titled, STANDARD POLICY: SANITATION [the process of disinfection and cleaning of an area of an item] OF WORK AREAS AND EQUIPMENT, revision date 11/29/18, the P&P indicated, .All kitchen and food contact areas shall be kept clean and sanitized .All utensils used for eating, drinking and in the preparation and serving of food and drink shall be cleaned and disinfected .Equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas where food may become trapped .Fixed and mobile equipment shall be washed, rinsed, sanitized . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 4-202.11 .Multiuse FOOD-CONTACT SURFACES shall be .Smooth .Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections .Free of sharp internal angles, corners, and crevices . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 4-501.12 .Cutting Surfaces .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 difficult to clean and sanitize .As a result, pathogenic microorganisms [germs that could make you sick] transmissible through food may build up or accumulate .These microorganisms may be transferred to foods that are prepared on such surfaces . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to use its Quality Assurance Performance Improvement (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program to address PRN (given as needed or requested) psychotropic medication (a drug that affects brain activities associated with mental processes and behavior) use, for a census of 57 residents, when the facility did not collect data (information) or identify corrective measures for PRN psychotropic medication use without a stop date (date indicated on physicians orders for when the use of the medication would end) and/or without a documented rationale for ongoing use of PRN psychotropic medication in the affected residents' medical record. These failures led to ongoing PRN psychotropic medication use without proper documentation and justification in the affected residents' medical record and had the potential to negatively impact the affected residents' psychosocial health and well-being. Findings: During a concurrent interview and record review on 6/19/25 at 1:39 PM, the Director of Nursing (DON) reviewed the previous survey's (assessment of a healthcare facility's compliance with established standards, quality of care, and safety protocols) plan of correction (POC -a document that outlines the steps a facility will take to address and correct deficiencies identified during a survey) dated 5/22/24, for PRN psychotropic medication use. The DON confirmed the POC indicated PRN psychotropic medication use would be added to their QAPI program monitoring and the pharmacist would review the psychotropic medication use monthly, during the QAPI meetings (QAPI meetings are usually held monthly and/or quarterly). The DON further stated the POC indicated, .Reports and corrective action from any findings will be reported at QAPI monthly . The DON confirmed these corrective measures were not added to the QAPI program and were never addressed. The DON further stated the corrective measures were missed due to the QAPI committees focus being on another portion of the POC. The DON explained it was the facility's procedure to add all deficiencies from the previous survey to QAPI, so all items were addressed to prevent the deficiencies from reoccurring. During an interview on 6/23/25, at 10:57 AM, the Administrative Director (ADM) confirmed the facility's process after survey was to add all survey deficiencies to the QAPI program. The ADM further confirmed the PRN psychotropic medication use was not addressed and was not added to the QAPI program as they had indicated they would on their POC. The ADM further stated the risk of not addressing the PRN psychotropic medication use in their QAPI program was that the problem reoccurred this year during the current survey. The ADM further stated PRN psychotropic medication use was important to address for resident rights and safety. A review of the facility's policy and procedure (P&P) titled, FACILITY POLICY: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI), SNF, revised 8/16/23, indicated, . QAPI takes a systematic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes .Quality Assurance/QAA committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the QAPI program when fully implemented, develop and implement corrective action when necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control measures for a census of 57 residents when: Residents Affected - Some 1. The bathroom toilets were dirty in both Resident 27, Resident 54, Resident 14, and Resident 5's shared bathroom; and in Resident 50 and Resident 37's shared bathroom along with the sink; 2. Licensed Nurse (LN) 4 did not store Resident 15's used feeding tube syringe (a medical device that helps deliver liquid nutrients, medications, or fluids directly into a resident's stomach/intestines via an external tube) back in the manufactures packaging or a sealed bag; and, 3. LN 7 did not perform hand hygiene prior to and after entering and exiting resident rooms during a medication pass and/or in between passing medications to Resident 5, Resident 17, Resident 42, Resident 407, and Resident 39. These deficient practices had the potential to result in the transmission and spread of infection among staff and residents of the facility as well as negatively impacting residents' health and well-being. Findings: 1a. During a concurrent observation and interview on 6/16/25, at 10:05 a.m., with LN 5, in the shared bathroom of Resident 37 and Resident 50, LN 5 acknowledged the bathroom toilet and sink was dirty. LN 5 stated the risk to residents of the toilet and sink being dirty would be the spread of infections and was a dignity issue. LN 5 stated the bathroom toilet had a dirty ring in it and should be cleaned daily and deep cleaned once a month. During an interview on 6/16/25, at 10:11 a.m., with the Environmental Services (ES, housekeeper), the ES stated she had cleaned Resident 37 and Resident 50's shared bathroom the day before. b. During a concurrent observation and interview on 6/16/25, at 10:36 a.m., with LN 5, in the shared bathroom of Resident 27, Resident 54, Resident 14, and Resident 5, it was observed that the toilet was dirty. LN 5 stated the ring in the toilet looked moldy. LN 5 stated in her opinion the toilet did not look like it had been cleaned in a while. LN 5 stated it was her understanding the bathrooms and toilets were cleaned daily. LN 5 stated Resident 54 uses the bathroom on occasion. LN 5 stated the expectation would be the bathroom would be a clean area for residents to use as this was important for their dignity and was an infection control issue. During an interview on 6/16/25, at 12:09 p.m., the Director of Environmental Services (DES) stated the expectation was that the resident's bathroom and rooms are cleaned daily and receive a deep clean once a month. The DES stated there should not be a ring around the toilet and a ring would not accumulate within a day. The DES explained dirty bathrooms did not represent the standard. The DES further explained that the hazard of dirty bathrooms was the spread of infection since residents share bathrooms frequently. The DES stated the dirty bathrooms could also affect resident dignity. During an interview on 6/18/25, at 1:56 p.m., the DON stated her expectation was that EVS for all departments provided a clean homelike environment for residents. The DON explained the Residents dirty bathrooms was not reflective of that expectation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 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 Review of facility policy and procedure (P&P) titled, FACILITY POLICY: All Level of Harm - Minimal harm or potential for actual harm PATIENT ROOM AND BATHROOM CLEANING, revised 4/25/24, indicated, .To ensure the complete and systematic daily cleaning and disinfection of each occupied patient room .Toilet: Wipe and disinfect in the following order .Toilet handle .Toilet seat .Under the bowel .Toilet rim .Clean inside of bowl with disinfectant cleaner and toilet brush . Residents Affected - Some 2. During an observation on 6/16/25, at 11:26 a.m., LN 4 was observed performing Resident 15's tube feeding. At the conclusion of the feeding, LN 4 was observed washing the used syringe in Resident 15's shared bathroom sink. LN 4 then placed the syringe in an open bin, along with other feeding supplies including containers of formula, on Resident 15's side table. It was observed the syringe was not placed back into the dated syringe package from which it was originally removed. During an interview on 6/16/25, at 11:40 a.m., with LN 4 in the hallway, LN 4 acknowledged she left Resident 15's used syringe out and exposed to air, in the open bin, on the side table. LN 4 stated the syringe should have gone back into the plastic sleeve when she was finished rinsing it. LN 4 stated the syringe should be stored in the sleeve for infection control purposes. During an interview on 6/16/25, at 4:08 p.m., LN 6 stated the syringe used during the administration of a tube feeding was changed out every 24 hours and the new sleeve it came in was to be dated. LN 6 explained after use, the syringe should be cleaned and placed back in the sleeve to keep it clean. LN 6 further explained this was done for infection prevention and cleanliness and for the prevention of bacterial (germs) growth. During an interview on 6/18/25, at 1:56 p.m., the DON stated her expectation for residents with feeding tubes would be the LN was to follow the tube feeding policy. The DON stated a syringe used for administering a feeding should be placed back in the sleeve or placed in a zip lock bag. The DON explained this protects the syringe from air while awaiting reuse. The DON stated the risk of the syringe being improperly stored was introducing more bacteria and germs to the resident during the administration of the tube feedings. Review of facility P&P titled, FACILITY POLICY: ENTERAL TUBE FEEDING, revised 8/14/24, indicated, .Procedure .Follow good infection control practice . 3. During an observation on 6/16/25, at 11:45 a.m., LN 7 was observed in unit 6 (where residents are housed), performing a medication pass for Resident 39. LN 7 was observed not performing hand hygiene in the preparation of Resident 39's medication. LN 7 was observed not performing hand hygiene prior to entering and upon exiting Resident 39's room. During an observation on 6/16/25, at 11:47 a.m., LN 7 was observed in unit 6, performing a medication pass for Resident 5. It was observed LN 7 did not perform hand hygiene in the preparation of Resident 5's medication. It was observed LN 7 did not perform hand hygiene prior to entering and upon exiting Resident 5's room. During an observation on 6/16/25, at 11:59 a.m., LN 7 was observed in unit 6, performing a medication pass for Resident 406. It was observed LN 7 did not perform hand hygiene in the preparation of Resident 406's medication. It was observed LN 7 did not perform hand hygiene prior to entering and upon exiting Resident 406's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 6/16/25, at 12:50 p.m., LN 7 was observed in unit 6, performing a medication pass for Resident 17. It was observed LN 7 did not perform hand hygiene in the preparation of Resident 17's medication. It was observed LN 7 entered the Activity Room and performed Resident 17's medication administration. It was observed LN 7 did not perform hand hygiene prior to Resident 17's medication administration. LN 7 was observed performing hand hygiene in the sink in the Activity Room after Resident 17's medication administration. During an observation on 6/16/25, at 12:56 p.m., LN 7 was observed in unit 6, performing a medication pass for Resident 42. It was observed LN 7 entered the Activity Room and performed Resident 42's medication administration. After Resident 42's medication administration, LN 7 was not observed performing hand hygiene upon entering or exiting the Activity Room. During an interview on 6/16/25, at 2:05 p.m., LN 7 acknowledged during the medication passes she performed for Resident 5, Resident 39, Resident 406, Resident 17, and Resident 42, she did not perform hand hygiene prior to or after administering medications to the residents. LN 7 acknowledged hand hygiene was not performed including the use of hand sanitizer and/or washing hands in a sink prior to entering or exiting the resident's rooms. LN 7 explained she does not like the hand sanitizer and preferred to wash her hands in the sink. LN 7 confirmed she had only washed her hands in the sink once during her medication administration for five residents. LN 7 stated she should be performing hand hygiene prior to and after administering medications and upon entering and exiting resident rooms. LN 7 explained hand hygiene was performed to prevent cross-contamination from one resident to the other and for infection control purposes. During an interview on 6/18/25, at 1:56 p.m., the DON stated her expectation regarding LN's administering medications was the LNs should gel (hand sanitizer) upon entering and exiting rooms or wash their hands prior to and after administering medications. The DON stated the risk if hand hygiene was not performed would be the spread of unwanted germs and bacteria. During a concurrent interview on 6/19/25, at 11:27 a.m., with Infection Prevtionist (IP) 1 and IP 2, IP 1 stated her expectation was for the LN to perform hand hygiene prior to and after medication passes for each individual resident. IP 1 explained for hand hygiene the LN could use hand sanitizer or wash their hands in the sink and the goal was to prevent infection and/or the spread of infection. Review of a facility P&P titled, FACILITY POLICY: MEDICATION ADMINISTRATION RECORD (MAR), revised 5/14/25, indicated .Use Aseptic [germ free] non-touch medication administration to prevent infection .Perform proper hand hygiene . Review of a facility P&P titled, FACILITY POLICY: HANDWASHING / HAND HYGIENE, revised 11/30/23, indicated, .Effective handwashing/hand hygiene is performed by all personnel to prevent the spread of infection .Handwashing .Washing the hands with plain (i.e., non-antimicrobial) soap and water .Hand Hygiene .All personnel are instructed about proper hand hygiene techniques during orientation with demonstration and return demonstration. These techniques are reviewed annually .Decontaminate hands with alcohol based hand rub .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 12 of 12