Health inspection·June 6, 2024

F 0623 In an interview on 06/06/2024 at 7:32 AM, the Ombudsman stated the facility did notify their office of residents' transfers or discharges, unless there was something unusual. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 2 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A Face Sheet revealed the facility admitted Resident #41 on 05/14/2020. According to the Face Sheet, the resident had a medical history that included diagnoses of major depressive disorder, anxiety, and psychosis. Resident #41's Diagnoses/Surgical Procedures, document revealed the resident received new diagnoses of unspecified psychosis and anxiety disorder on 12/03/2020. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an active diagnosis to include major depression disorder, anxiety disorder, and psychotic disorder. Resident #41's Care Plan Report, with an effective date of 05/14/2020, indicated the resident had depression with insomnia as manifested by an inability to maintain a normal sleep cycle and the verbalization of feeling sadness. Resident #41's medical record revealed no evidence a new Preadmission Screening and Resident Review [PASARR] Level I Screening Document, was completed after the resident received new mental illness diagnoses of unspecified psychosis and anxiety disorder on 12/03/2020. During an interview on 06/06/2024 at 9:04 AM, Admissions Coordinator (AC) #8 stated the Director of Nursing (DON) was responsible for PASARR completion. On 06/06/2024 at approximately 9:00 AM, the surveyor was informed that the DON was unavailable to be interviewed and she should interview the Corporate Compliance Officer (CCO) in the place of the DON. During an interview on 06/06/2024 at 11:25 AM, the CCO stated the DON was responsible for the facility's PASARR process. According to the CCO, a new PASARR should have been completed when Resident #41 received new mental illness diagnoses. During an interview on 06/06/2024 at 12:22 PM, the Administrator stated if the PASARR was not accurate, a new PASARR should have been completed. Based on interview, record review, and facility policy review, the facility failed to submit a new preadmission screening and resident review (PASARR) level I screening when required for 2 (Resident #41 and Resident #45) of 4 sample residents reviewed for PASARRs. Findings included: An undated facility policy titled, PASARR Screening for MD [mental disorder] and ID [intellectual disorder], indicated, [Name] facilities do not admit any new resident with mental illness or mental retardation unless the State Menal Health Authority has determined that the individual requires the level of services provided by [name] facilities. This determination shall be based on an independent physical and mental evaluation of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 3 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. A Face Sheet revealed the facility admitted Resident #45 on 01/04/2021. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, psychosis, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #45's Preadmission Screening and Resident Review Level I Screening Document dated 01/05/2021, specified Resident #45 had a negative Level I screen due to a 30-day exempted hospital discharge. The document indicated a new Level I was due on the 31st day after admission. During an interview on 06/06/2024 at 9:43 AM, Nursing Supervisor #5 stated she did not know if a new PASARR should have been resubmitted if Resident #45 remained in the facility beyond 30 days. During an interview on 06/06/2024 at 11:25 AM, the Corporate Compliance Officer stated a new PASARR should have been resubmitted since the resident stayed in the facility beyond 30 days. During an interview on 06/0620/24 at 12:22 PM, the Administrator stated Resident #45's PASARR had 30-day criteria and another PASARR was not done. The Administrator stated he expected that a new PASARR should have been done after the resident remained in the facility past 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 4 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) level I screening was accurate upon admission to the facility for 1 (Resident #41) of 4 sampled residents reviewed for PASARRs. Residents Affected - Few Findings included: An undated facility policy titled, PASARR Screening for MD [mental disorder] and ID [intellectual disorder], indicated, [Name] facilities do not admit any new resident with mental illness or mental retardation unless the State Menal Health Authority has determined that the individual requires the level of services provided by [name] facilities. This determination shall be based on an independent physical and mental evaluation of the resident. A Face Sheet revealed the facility admitted Resident #41 on 05/14/2020. According to the Face Sheet, the resident had a medical history that included diagnoses of major depressive disorder, anxiety, and psychosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an active diagnosis to include major depression disorder. Resident #41's Care Plan Report, with an effective date of 05/14/2020, indicated the resident had depression with insomnia as manifested by an inability to maintain a normal sleep cycle and the verbalization of feeling sadness. Resident #41's Preadmission Screening and Resident Review [PASARR] Level I Screening Document, dated 05/15/2020, revealed the resident did not have a diagnoses mental disorder such as schizophrenia/schizoaffective disorder, psychotic/psychosis, delusional, depression, mood disorder, bipolar, or panic/anxiety. During an interview on 06/06/2024 at 9:04 AM, Admissions Coordinator (AC) #8 stated the only thing she did the PASARR was to ensure it was received from the hospital upon the resident's admission to the facility. AC #8 stated she did not review the PASARR for accuracy. According to AC #8, the Director of Nursing (DON) was responsible to ensure the PASARR was accurate. On 06/06/2024 at approximately 9:00 AM, the surveyor was informed that the DON was unavailable to be interviewed and she should interview the Corporate Compliance Officer (CCO) in the place of the DON. During an interview on 06/06/2024 at 9:43 AM, Nursing Supervisor (NS) #5 stated the DON was responsible for the accuracy of the level I PASARR and if Resident #41 had a diagnosis of major depressive disorder upon admission, the initial level I PASARR should have been marked yes for a mental illness. NS #5 stated Resident #41's level I PASARR completed on 05/15/2020 was incorrect if no was marked next to mental illness. During an interview on 06/06/2024 at 11:25 AM, the CCO stated the DON was responsible for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 5 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility's PASARR process and to ensure the PASAR was accurate. According to the CCO, Resident #41's diagnoses of depression, anxiety and psychosis should have been captured on the PASARR. During an interview on 06/06/2024 at 12:22 PM, the Administrator stated the DON reviewed the PASARR for accuracy. Per the Administrator, if the PASARR was not accurate, a new PASARR should have been completed when the resident admitted to the facility. Event ID: Facility ID: 555220 If continuation sheet Page 6 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 4. A Face Sheet revealed the facility admitted Resident #54 on 03/30/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia with other behavioral disturbances, anxiety, and major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident received an antianxiety medication. Resident #54's Care Plan Report, with an effective date of 03/30/2024, indicated the resident may exhibit episodes of anxiety. Interventions directed staff to administer medications as ordered. Resident #54's June 2024 Physician Order Sheet, contained an order dated 03/30/2024 for lorazepam (an antianxiety medication) 0.5 milligram tablet by mouth every four hours as needed for anxiety. The order did not indicate a stop/discontinue date. The Consultant Pharmacist's medication regimen review for the timeframe 04/01/2024 to 04/30/2024, revealed no evidence to indicate there were any irregularities in Resident #54's medication regimen. 5. A Face Sheet revealed the facility admitted Resident #115 on 05/16/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of anxiety, major depressive disorder, and unspecified psychosis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #115 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antianxiety medication. Resident #115's Care Plan Report, with an effective date of 05/16/2024, indicated the resident had intermittent episodes of anxiety with persistent worry that distressed the resident and impaired their daily well-being. Interventions directed the staff to administer medications as ordered. Resident #115's June 2024 Physician Order Report revealed an order dated 05/20/2024, for Ativan (an antianxiety medication) 0.5 milligram tablet by mouth every six hours as needed. The order did not indicate a stop/discontinue date. The Consultant Pharmacist's medication regimen review for the timeframe 05/01/2024 to 05/31/2024, revealed no evidence to indicate there were any irregularities in Resident #115's medication regimen. During an interview on 06/06/2024 at 9:11 AM, the Consultant Pharmacist stated she reviewed each resident's chart monthly and submitted all recommendations. The Consultant Pharmacist stated that when she reviewed the as needed use of psychotropic medications, she had not made any recommendations on changing a resident's order for as needed lorazepam duration and did not take the duration or stop dates into consideration when she made recommendations. Per the Consultant Pharmacist, if a resident had an order for as needed lorazepam (Ativan), she did not recommend adding a stop date or order duration to the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 7 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. A Face Sheet revealed the facility admitted Resident #45 on 01/04/2021. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, psychosis, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received an antianxiety medication. Resident #45's Care Plan Report, with an effective date of 01/04/2021, revealed the resident had anxiety. Interventions directed the staff to administer medication as ordered. Resident #45's June 2024 Physician Orders Sheet contained an order dated 05/30/2024 for lorazepam (an antianxiety medication) 0.5 milligram tablet as needed every six hours. The order did not indicate a stop/discontinue date. The Consultant Pharmacist's medication regimen review for the timeframe 03/01/2024 to 03/31/2024, 04/01/2024 to 04/30/2024, and 05/01/2024 to 05/31/2024, revealed no evidence to indicate there were any irregularities in Resident #45's medication regimen. Based on interview, record review, and facility policy review, the facility failed to ensure the Pharmacist reported medication regimen irregularities to the physician for the extended use of as needed psychotropic medication for 5 (Residents #43, #45, #49, #54, and #115) of 6 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled Drug Regimen Review, Report Irregular, Act On revealed, The consultant pharmacist must devote sufficient number of hours during a regular scheduled visit, for the purpose of coordinating, supervising and reviewing the pharmaceutical services and review the drug regimen of each resident at least monthly. The review must include a review of the resident's medical chart. A report is made to each resident's attending physician and the facility's Medical Director and the Director of Nursing of any irregularities identified by the consultant and these reports must be acted upon. 1. A Face Sheet revealed the facility admitted Resident #43 on 12/16/2021. According to the Face Sheet, the resident had a medical history that included diagnosis of anxiety, psychosis, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received antianxiety medication. Resident #43's Care Plan Report, with an effective date of 12/16/2021, revealed the resident had anxiety. Interventions directed the staff to administer medications as ordered by the physician. Resident #43's physician order, dated 11/30/2023, revealed an order for alprazolam (an antianxiety medication) 0.5 milligram as needed every eight hours. The order did not indicate a stop/discontinue date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 8 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Consultant Pharmacist's medication regimen review for the timeframe 03/01/2024 to 03/31/2024 and 05/01/2024 to 05/31/2024, revealed no evidence to indicate there were any irregularities in Resident #43's medication regimen. 2. A Face Sheet revealed the facility admitted Resident #49 on 05/01/2022. According to the Face Sheet, the resident had a medical history that included diagnosis of anxiety and psychosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received antianxiety medication. Resident #49's Care Plan Report, with an effective date of 05/01/2022, revealed the resident had anxiety. Interventions directed the staff to administer medications as ordered. Resident #49's physician orders, dated 02/29/2024, revealed an order for lorazepam (an antianxiety medication) 0.5 milligram as needed every eight hours. The order did not indicate a stop/discontinue date. The Consultant Pharmacist's medication regimen review for the timeframe 05/01/2024 to 05/31/2024, revealed no evidence to indicate there were any irregularities in Resident #49's medication regimen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 9 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, record review, and facility policy review, the facility failed to ensure as needed psychotropic medication was not ordered for more 14 days for 5 (Residents #43, #45, #49, #54, and #115) of 6 sampled residents reviewed for unnecessary medications. Specifically, Residents #43, #45, #49, #54, and #115 had physician orders for as needed lorazepam (Ativan), an antianxiety medication, with no indicated duration/stop date. Findings included: An undated facility policy titled, Drug Regimen is Free From Unnecessary Drugs/ Free from unnecessary Psychotropic Meds [medications]/ PRN [pro re nata, which meant an needed] Use, indicated, Each resident's drug regimen is free from unnecessary drugs. Drugs shall not be used in excessive doses, duplicate drug, for excessive duration, without adequate indication for use of the drugs, without adequate monitoring or in the presence of adverse consequences. The policy specified, Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. 1. A Face Sheet revealed the facility admitted Resident #54 on 03/30/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia with other behavioral disturbances, anxiety, and major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident received an antianxiety medication. Resident #54's Care Plan Report, with an effective date of 03/30/2024, indicated the resident may exhibit episodes of anxiety. Interventions directed staff to administer medications as ordered. Resident #54's June 2024 Physician Order Sheet, contained an order dated 03/30/2024 for lorazepam (an antianxiety medication) 0.5 milligram tablet by mouth every four hours as needed for anxiety. The order did not indicate a stop/discontinue date. 2. A Face Sheet revealed the facility admitted Resident #115 on 05/16/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of anxiety, major depressive disorder, and unspecified psychosis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #115 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antianxiety medication. Resident #115's Care Plan Report, with an effective date of 05/16/2024, indicated the resident had intermittent episodes of anxiety with persistent worry that distressed the resident and impaired their daily well-being. Interventions directed the staff to administer medications as ordered. Resident #115's June 2024 Physician Order Report revealed an order dated 05/20/2024, for Ativan (an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 10 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0758 Level of Harm - Minimal harm or potential for actual harm antianxiety medication) 0.5 milligram tablet by mouth every six hours as needed. The order did not indicate a stop/discontinue date. 5. A Face Sheet revealed the facility admitted Resident #45 on 01/04/2021. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, psychosis, and anxiety. Residents Affected - Some A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received an antianxiety medication. Resident #45's Care Plan Report, with an effective date of 01/04/2021, revealed the resident had anxiety. Interventions directed the staff to administer medication as ordered. Resident #45's June 2024 Physician Orders Sheet contained an order dated 05/30/2024 for lorazepam (an antianxiety medication) 0.5 milligram tablet as needed every six hours. The order did not indicate a stop/discontinue date. During an interview on 06/06/2024 at 9:11 AM, the Pharmacist stated she reviewed each resident's chart monthly and submitted all recommendations. The Pharmacist stated that when she reviewed the as needed use of psychotropic medications, she had not made any recommendations on changing a resident's order for as needed lorazepam duration and did not take the duration or stop dates into consideration when she made recommendations. Per the Pharmacist, if a resident had an order for as needed lorazepam, she did not recommend adding a stop date or order duration to the order. During an interview on 06/06/2024 at 11:25 AM, the Chief Compliance Officer stated she did not know if a stop date was required. During an interview on 06/06/2024 at 12:01 PM, the Social Services Director stated she was not sure if a stop date or duration needed to be specified with continued orders of as needed psychotropic medication(s). During an interview on 06/06/2024 at 12:22 PM, the Administrator stated he expected trial periods for as needed psychotropic medications to be limited to 14 days, but if the physician thought the resident's need for the medication to be ongoing, there did not need to be a stop date for the continued use. The Administrator stated he felt it was unnecessary for the physician to write a new order for an as needed psychotropic medication every 14 days if the physician felt the medication was necessary. 3. A Face Sheet revealed the facility admitted Resident #43 on 12/16/2021. According to the Face Sheet, the resident had a medical history that included diagnosis of anxiety, psychosis, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received antianxiety medication. Resident #43's Care Plan Report, with an effective date of 12/16/2021, revealed the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 11 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0758 anxiety. Interventions directed the staff to administer medications as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Resident #43's physician order, dated 11/30/2023, revealed an order for alprazolam (an antianxiety medication) 0.5 milligram as needed every eight hours. The order did not indicate a stop/discontinue date. Residents Affected - Some 4. A Face Sheet revealed the facility admitted Resident #49 on 05/01/2022. According to the Face Sheet, the resident had a medical history that included diagnosis of anxiety and psychosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received antianxiety medication. Resident #49's Care Plan Report, with an effective date of 05/01/2022, revealed the resident had anxiety. Interventions directed the staff to administer medications as ordered. Resident #49's physician orders, dated 02/29/2024, revealed an order for lorazepam (an antianxiety medication) 0.5 milligram as needed every eight hours. The order did not indicate a stop/discontinue date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 12 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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, record review, and facility policy review, the facility failed to ensure enhance barrier precautions (EBP) were implemented for 1 (Resident #40) of 2 sampled residents reviewed for urinary catheters and 2 (Resident #1 and Resident #117) of 2 sampled residents reviewed for pressure ulcer/injury. The facility further failed to ensure catheter tubing and a resident's genital area were cleaned during the provision of catheter care for 1 (Resident #40) of 2 sampled residents reviewed for urinary catheters. Residents Affected - Some Findings included: A facility policy titled, Enhanced Barrier Precautions, revised in 08/2022, indicated, Enhanced barrier precautions (EBPs) re utilized to prevent the spread of multi-drug resistant organisms to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions are used as in infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy indicated, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. [et cetera, and other similar things]); and h. wound care (any skin opening requiring a dressing). 1. A Face Sheet indicated the facility admitted Resident #117 on 05/17/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of dermatomyositis (an inflammatory disease marked by muscle weakness and a distinctive skin rash) with myopathy (a disease that affected the muscles that control voluntary movements in the body) and pruritus (itchy skin). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed Resident #117 had two stage 3 pressure ulcers that were present on admission. Resident #117's undated Care Plan Report, revealed the resident had actual impaired skin integrity as described as a stage 3 pressure ulcer to their left buttock. Resident #117's June 2024 Physician Order Sheet, contained an order dated 05/29/2024 that directed staff to apply calcium alginate to resident's left buttock stage 3 pressure ulcer after Medi honey to wound bed then cover with an non-adhesive dressing daily. During an observation on 06/04/2024 at 1:58 PM, the Nurse Practitioner (NP) and the Infection Preventionist (IP) provided wound care for Resident #117. The NP and the IP did not implement enhanced barrier precautions and wore only gloves during the provision of wound care. 2. A Face Sheet indicated the facility admitted Resident #40 on 04/27/2023. According to the Face Sheet, the resident had a medical history that included diagnoses of obstructive and reflux uropathy and malignant neoplasm of unspecified kidney. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2024, revealed Resident #40 had an indwelling catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 13 of 14 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 Resident #40's undated Care Plan Report, revealed the resident a potential for infection and/or complication related to an indwelling urinary catheter. During an observation on 06/04/2024 at 2:24 PM, Certified Nursing Assistant (CNA) #4 and CNA #6 provided indwelling urinary catheter care for Resident #40. CNA #4 and CNA #6 did not implement enhanced barrier precautions and wore only gloves during the provision of indwelling urinary catheter care. 3. A Face Sheet indicated the facility admitted Resident #1 on 10/16/2018. According to the Face Sheet, the resident had a medical history that included diagnoses of cellulitis of the left and right lower limb and type 2 diabetes mellitus with diabetic neuropathy. Resident #1's undated Care Plan Report, revealed the resident had actual impaired skin integrity as described as a stage 3 pressure ulcer on their sacrum. During an observation on 06/05/2024 at 9:27 AM, Licensed Vocational Nurse (LVN) #1 and Certified Nursing Assistant (CNA) #3 provided wound care for Resident #1. LVN #1 and CNA #3 did not implement enhanced barrier precautions and wore only gloves during the provision of wound care. During an interview on 06/05/2024 at 2:13 PM, LVN #1 stated she was not familiar with EBPs, just regular contact precautions. During an interview on 06/05/2024 at 2:19 PM, CNA #3 stated only gloves were used during the provision of indwelling urinary catheter care and wound care. CNA #3 stated she did know what EBPs were. During an interview on 06/06/2024 at 7:11 AM, LVN #2 stated she had not been trained on EBPs. LVN #2 stated staff wore personal protective equipment if there was any type of infection that required gown and gloves to work, but gown and gloves were not worn when only providing care to residents with no infections. During an interview on 06/06/2024 at 7:20 AM, the Infection Preventionist staff had not been educated on EBPs. During an interview on 06/06/2024 at 8:00 AM, the Administrator stated the facility misunderstood the memo from the Centers for Medicare & Medicaid and that was why the facility had not implemented enhanced barrier precautions. During a follow-up interview on 06/06/2024 at 12:22 PM, the Administrator stated ow that he had been enlightened about EBPs, the facility would follow the precautions for that require it. During an interview on 06/06/2024 at 12:50 PM, the Chief Operating Officer stated the facility had not implemented EBPs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 14 of 14