Health inspection·December 18, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on interview and record review, the facility failed to coordinate the Medical Doctor's (MD) appointment for Level II Preadmission Screening (PASARR) for one (1) of eight (8) residents, Resident 52. This failure resulted in cancellation of MD's evaluation for mental illness and a delay of care and services needed for Resident 52. Findings: Level II PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in a nursing home for long term care. A record review of Resident 52 titled admission record indicated she was initially admitted to the facility on [DATE] with mental conditions of agoraphobia (is afraid to leave environments they know or consider to be safe) with panic disorder, Bipolar II disorder and panic disorder (episodic anxiety). A record review of Resident 52's evaluation titled Level I PASARR dated 9/27/23 was positive indicated a Level II PASARR mental health evaluation from Department of Health Services was required. A review of the letter from the Department of Health Service, for Resident 52, addressed to the Administrator titled Unable to complete evaluation for Level II PASARR dated 9/20/23, indicated After reviewing the Positive Level I Screen and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: o The individual was unable to participate in the Evaluation. The case is now closed. To reopen, please submit a new Level I Screen. During an interview on 12/12/23 at 2:30 p.m. in Social Service office, Social Worker stated that the previous Social Worker did not follow up the Level II PASARR evaluation, therefore Resident 52 needed to repeat the Level I PASARR to get another MD's evaluation appointment for Level II PASARR. A review of Resident 52 medical record did not indicate there was a re-evaluation done for Level I PASARR. During an interview on 12/14/23 at 3:30 p.m. the DON stated, there was no Policy & Procedure (P&P) for PASARR. A review of the regulatory health and safety code § 483.20(e)(1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. A review of the regulatory health and safety code § 483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Mental Disorder (MD) For purposes of this section, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 2 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 - Few term mental disorder is the equivalent of mental illness used in the definition of serious mental illness in 42 CFR. A review of regulatory health and safety codes §483.102(b)(1), which states: An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. This mental disorder is(A) A schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 3 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure staff were aware of the Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) completion time frame and BCP's were completed timely for two out of two sampled residents (Residents 40 and 49). These failures had the potential to put residents' safety at risk and for residents not receiving the care that they need. Findings: A review of Resident 40's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 10/9/23, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) indicated she was moderately impaired and required cues and supervision in making decisions regarding tasks of daily life. Resident 40's functional status indicated she needed supervision or touching assistance of staff when performing her Activities of Daily Living (ADL, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 49's face sheet indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), Type 2 Diabetes Mellitus (a chronic-long-term condition, in which a high level of glucose (sugar) is present in the bloodstream) and Muscle Weakness (a lack of muscle strength). Her MDS dated [DATE] BIMS score was 12 indicating moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 49's functional status indicated she needed extensive assistance of 1 to 2 staff when performing her Activities of Daily Living. Resident 49 was not confined to bed. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated she was not sure of BCP completion time frame. Licensed Staff P stated care plans were important for residents safety and to ensure residents receive the care that they need. During an interview on 12/15/23 at 10:56 a.m., the Director of Staff Development (DSD) stated BCP should be done within 48 hours of admission. The DSD stated if a resident was readmitted to the facility, a new BCP should be completed. The DSD stated if a BCP was done late, not within 48 hours of admission, then the facility process and policy was not followed. The DSD stated BCP was important because the Interdisciplinary Team (IDT, group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) worked together to create a thoughtful, resident centered individualized care. The DSD stated if the BCP was not done on time, residents would be at risk for not receiving the individualized and thoughtful care that they need. The DSD stated residents or responsible party (RP, the person who is responsible for making health care decision or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 4 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the person paying the resident's bills) were involved in baseline care planning. The DSD stated once the BCP was done, a copy should be given to the resident or RP. During a concurrent interview and Residents 40 and 49's BCP record review on 12/15/23 at 2:08 p.m., the Director of Nursing (DON) stated BCP should be completed within 48 hours of admission per facility policy. The DON stated a new BCP would be completed if a resident was readmitted to the facility. The DON verified Resident 40's BCP completion date was confusing but stated she should have another BCP done if she was readmitted on 3/2023. The DON verified Resident 49 was admitted on [DATE] however her BCP was completed 4 days later on 5/30/23. During an interview on 12/15/23 at 2:58 p.m., Licensed Staff V stated she was not sure of the completion time frame for BCP. Licensed Staff V stated care plan was important, so staff knew about residents' needs and the type of care they need. During an interview on 12/15/23 at 2:59 p.m., the DON verified there was no new BCP completed for Resident 40 when she was readmitted on [DATE] and the BCP for Resident 49 was completed late. Based on the facility's policy and procedure (P&P) titled Care Plans-Baseline, revised 12/2022, the P&P indicated a baseline plan of care should be developed for each residents within 48 hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 5 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure five sampled residents (Resident 1, Resident 14, Resident 35, and Resident 38, Resident 51) and resident's representative(s) participated in the plan of care when Care Conferences were not held for the last two quarters according to facility Policy and Procedure. This failure had the potential to interfere with the five resident's ability to achieve and maintain their highest level of activity and independent. Findings: (Refer F 745) During an interview with Resident 14 on 12/12/23, at 9:45 a.m., he stated he was concerned about getting out of the facility and back to his apartment. He stated he wanted to be back in (name of town), a town located 43 miles away, where all his friends and family were located. He stated there were rehabilitation facilities in (name of town) he wanted to transfer to, and had told staff of his desire to transfer, but staff had told him that he could not. Resident 14 stated he did not remember being involved in a Care Conference or Team Meeting to talk about his plan of care. He stated it made him feel like he did not matter. During an interview on 12/12/23, at 12:50 a.m., Resident 38 stated she wanted to go home. She stated she would like to go to a group home. She stated she did not remember a meeting with staff to discuss her care while in the facility and did not know what discharge planning had been done and would like to know. During an observation and interview on 12/12/23 at 12:58 p.m., Resident 1 was observed to be wringing her hands and furrowing her eyebrows. She stated she wanted to go home. She stated she has told the staff about it and did not understand why she could not go home. She stated it had been months since she talked to someone about it and it made her feel ignored and sad. She stated it was close to Christmas and she did not want to be in the facility. During a telephone interview on 12/12/23 at 11:57 a.m., with Responsible Party S, she stated I have not been asked to participate in a Care Conference since Resident 51 was admitted . She stated she made phone calls to the facility to find out how the resident was doing but a lot of times no one would answer the phone. She stated she had cancer and could not come into the facility and no one from the facility had called her about anything unless Resident 51 falls. She stated the last Care Conference she participated in was when they decided to put the Resident 51 in long term care and that has been over a year. She stated she had not participated in the plan of care for Resident 51 since he went into long term care and it made her miss Resident 51 even more. During an interview with Social Services Director on 12/14/23, at 9:44 a.m., she stated she had been in role for only three weeks and Resident 1 was one of the cases that she became aware of early in her role that she knew the previous person in this role had messed up. She stated there had been a lack of discharge planning for Resident 1 and she had to start the planning over again from the beginning. She stated this had delayed Resident 1's discharge and made the resident feel anxious and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 6 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0657 sad. Level of Harm - Minimal harm or potential for actual harm During an interview with Social Services Director and Administrator in Training 12/14/23, at 2:37 p.m. Social Service Director stated she had only been in current role for three weeks and knew the previous person had not conducted Care Conferences regularly. She stated the Care Conferences should have been done once a quarter and whenever needed. Residents Affected - Some During an interview on 12/15/23 at 1:27 p.m., FACILITY CONSULTANT T stated there was no documentation of Care Conferences or Interdisciplinary Team Meetings, for the past two quarters for the Resident / Responsible party for Resident 14, Resident 35, Resident 38, Resident 1 or Resident 51. During a review of a document titled admission Record, it indicated Resident 14 was admitted [DATE] with diagnoses that included Hemiplegia (Paralysis of one side of the body) and Hemiparesis (Weakness in your arms, hands, face, chest, legs and or feet that can make it hard to perform everyday activities like eating or dressing.) following Cerebral Infarction (Stroke) Affecting Right Non-Dominant (Right Side), Chronic Obstructive Pulmonary Disease (COPD) (A type of progressive lung disease that limits airflow and results in shortness of breath and a cough that worsens with time.) and Ataxia (Lack of coordination of arms and legs resulting in lack of balance, and trouble walking.). During review of a document for Resident 14, titled Minimum Data Set (MDS) summary of information to assess and manage care of residents in skilled nursing homes.) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) (A scoring assessment system used to determine how mentally intact a resident is. 0-7 points is severely impaired, 8-12 moderately impaired and 13-15 no impairment.) indicated Resident 1 had a score of 14. During a review of a document titled admission Record, it indicated Resident 35 was admitted [DATE] with diagnoses that included Brain Injury, Muscle weakness, and chronic pain. During a review of a document for Resident 35, titled MDS, Section C Cognitive Patterns, the BIMS inicated Resident 35 had a score of 14. During a review of a document titled admission Record, it indicated Resident 38 was admitted [DATE] with diagnoses that included Unspecified Lack of Expected Normal Physiological Development in Childhood (Someone who did not developed physically or mentally during childhood.), Obsessive-Compulsive Disorder, Unspecified (repetitive thoughts or actions without a specific diagnosis.) During review of a document for Resident 38, titled Minimum Data Set (MDS) indicated Resident 38 had a score of 13. During a review of document titled admission Record, it indicated Resident 1 was admitted [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant (Left Side), COPD. During review of a document for Resident 1, titled Minimum Data Set (MDS) summary of information to assess and manage care of residents in skilled nursing homes.) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) indicated Resident 1 had a score of 14. During a review of document titled admission Record, it indicated Resident 51 was admitted [DATE] with diagnoses of Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Side, Aphasia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 7 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0657 Level of Harm - Minimal harm or potential for actual harm (Difficulty / inability to talk), Unspecified Dementia with other Behavioral Disturbance (Impaired concentration, apathy, agitation) During review of a document for Resident 51, titled Minimum Data Set (MDS) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) indicated Resident 51 had a score of 4. Residents Affected - Some A document for Resident 51, titled Baseline Care Plan Person-Centered Care Planning, dated 9/7/23, indicated Social Services Resident and/or Resident Representative (RR) Interview 1. Initial Plan for Placement: a. Short Term. Review of a facility Policy and Procedure titled INTERDISCIPLINARY PLAN OF CARE CONFERENCE, not dated, indicated An Interdisciplinary Care Planning Conference identifies resident needs and establishes obtainable goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents . The MDS Coordinator chairs all POC Review meetings. Conferences for all residents are held within seven (7) days following admission and every 90 days thereafter or when a change in condition occurs. The review includes the following: A review of current long-term and short-term goals. Resident care problems, goals and approaches with appropriate time frames. Discharge Planning. Resident and family education . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 8 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation and interview on 12/12/23 at 11:10 a.m., in Resident 37's room, Resident 37 stated that he was not getting showers regularly. Resident 37 stated that he got showers once every two week or longer and not knowing when he would get a shower next. Resident 37 stated that he would like more showers than once every two weeks. Resident 37's had malodorous body odor and his hair was not combed and clean. Residents Affected - Few A record review titled Brief Interview for Mental Status (BIMS) dated 1/15/2023 for Resident 37 indicated, Resident 37 was cognitively intact. A record review titled Activity of Daily Living, under shower in November 2023 for Resident 37 indicated that Resident 37 had showered 2 times in a month. A record review titled Activity of Daily Living, under shower in December 2023 for Resident 37 indicated that Resident 37 had shower on 12/11 and 12/13 during the Survey week. During an interview on 12/13/23 at 12:50 p.m., with Licensed A (Charge Nurse) stated that Certified Nursing Assistance (CNA) was responsible for entering information on showers activity. Licensed Nurse A stated when a resident refused a shower, CNA would ask resident three times and if still refused, then the Charge Nurse would talk with the resident. License Nurse A stated, when resident completely refused shower then CNA should fill out a slip titled shower day skin inspection. Licensed Nurse A stated the charge nurse would document in the electronic charting that resident refused the shower. A record review of shower scheduled for November and December 2023 indicated that Resident 37 was scheduled twice a week. A record review of shower ADLs for Resident 37 indicated, Resident 37 received once every two weeks or longer. A record review titled Progress Notes for Resident 37 indicated, no shower refusal documented. There were no shower day skin inspection sheet filled out by a CNA. A review of the facility's policy and procedure (P&P) titled Requesting, Refusing and/or Discontinuing Care or Treatment, revised 2/2021, the P&P indicated if a resident refused care or treatment, an appropriate member of the IDT would meet with the RP to determine why they were refusing care .try to address residents concerns and discuss alternative options .discuss the potential outcomes or consequences of the decision. A review of the facility's policy and procedure (P&P) titled Residents Rights, revised 2/2021, the P&P indicated residents had a right to a dignified existence. Based on interviews and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when 1. the facility failed to notify the physician of resident's blood sugar of 400 or more for one out of one sampled resident (Resident 49) 2. the facility failed to provide regular scheduled showers for three out of three sampled residents (Residents 65, 49 and 37). These failures could lead to 1. complications associated with Diabetes Mellitus such as hypoglycemia (a condition in which your blood sugar (glucose-body's main energy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 9 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm source) level is lower than the standard range, hyperglycemia (high blood glucose (blood sugar)and stroke (brain attack, occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). 2. residents looking unkempt, undignified, feeling insecure and uncomfortable. Findings: Residents Affected - Few A review of Resident 65's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Essential Hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), and Muscle Weakness (lack of muscle strength). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 8/19/23, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 65's functional status indicated she needed extensive assistance of 1 to 2 staff when performing her Activities of Daily Living (ADL, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 65 was not confined to bed. A review of Resident 49's face sheet indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), Type 2 Diabetes Mellitus and Muscle Weakness. Her MDS dated [DATE] BIMS score was 12 indicating moderately impaired cognition. Resident 49's functional status indicated she needed extensive assistance of 1 to 2 staff when performing her Activities of Daily Living .Resident 49 was not confined to bed. 1. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated reporting parameters were established by the physician and should be followed. Licensed Staff P stated if the reporting parameter was not followed, it could result to blood sugar instability. Licensed Staff P stated unstable blood sugar could affect every system in the body and could result to resident getting sicker. During an interview on 12/15/23 at 11:34 a.m., the Director of Staff Development (DSD) stated blood sugar readings of 60 and below or 400 and above should be reported to the physician, however it still depends on the physician's reporting parameter order. The DSD stated the risk for not notifying the physician per reporting parameter could result to hypoglycemia where a resident becomes unresponsive and could die. The DSD stated another risk was hyperglycemia where the blood sugar was high and could lead to coma and death. During an interview on 12/15/23 at 2:08 p.m., the Director of Nursing (DON) stated staff should always follow the physician's orders. The DON did not respond when asked what the risks were if staff did not notify the physician about a residents blood sugar reading per his reporting parameter order. During a concurrent interview, physician order and blood sugar logs record review on 12/15/23 at 3:16 p.m., the Regional Nurse Consultant stated per the physician order, staff would have to call the physician for a blood sugar less than 60 and greater than 400. The Regional Nurse Consultant stated physician's orders needed to be followed. The Regional Nurse Consultant verified Resident 49's blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 10 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sugar result for the following dates: 6/7/23 447 milligram per deciliter (mg/dl, a unit of measurement), 7/2/23 403 mg/dl, 7/11/23 445 mg/dl and 7/31/23 444 mg/dl should have been reported to the physician. During a telephone interview on 12/15/23 at 3:34 p.m., Physician D stated despite having an order for blood sugar result reporting parameter, he was not notified of Resident 49's blood sugar of greater than 400. Physician 1 stated the facility will correct this and will improve. During an interview on 12/15/23 at 3:38 p.m, the Regional Nurse Consultant verified the physician was not notified on Resident 49's blood sugar result on these dates: 6/7/23 447 milligram per deciliter (mg/dl, a unit of measurement), 7/2/23 403 mg/dl, 7/11/23 445 mg/dl and 7/31/23 444 mg/dl. A review of Resident 49's physician order dated 5/26/23 indicated to notify the physician for a blood sugar result of less than 60 and greater than 400. A review of the facility's policy and procedure (P&P) titled Nursing Care of the Older Adult with Diabetes Mellitus, revised 11/2020, the P&P indicated staff should follow the provider's order for blood glucose monitoring and established provider notification protocols. 2. During an interview on 12/12/23 at 9:10 a.m., Resident 65 stated she's not receiving showers regularly. Resident 65 stated staff were busy all the time. Resident 65 stated she was so frustrated and tired of asking she just did not ask for showers anymore. A review of Resident 65's shower documentation indicated she received no showers from 11/14/23 up to11/30/23 but had 7 refusals on these dates: 11/16/23, 11/19/23, 11/20/23, 11/23/23, 11/26/23, 11/28/23 and 11/30/23. A review of Resident 65's shower documentation from 12/1/23 to 12/12/23 indicated she only received 1 shower on 12/4/23 with 4 refusals on these dates: 12/3/23, 12/7/23, 12/10/23 and 12/11/23. A review of Resident 65's shower schedule indicated she should received showers every Mondays and Thursdays. A review of Resident 65's shower schedule indicated she should have received a total of 5 showers from 11/14/23 to 11/30/23 and 4 showers from 12/1/23 to 12/14/23. During a concurrent observation and interview on 12/12/23 at 3:02 p.m., Resident 49 was noted to be unkempt and had about a week old visible facial hairs on her chin and upper lip. When asked if staff offered to shave her facial hairs, she stated no. When asked how she felt about having visible facial hair, Resident 49 kept quiet and looked away. Resident 49 stated staff did not shave her and could not recall when the last time was, she had a shower. Resident 49 stated she would love to receive showers and get a shave but sometimes staff gets busy. Resident 49 stated not receiving shower and not getting a shave saddened her and made her feel uncomfortable. Resident 49 stated she would like to receive showers and a shave and had requested it but so far she had not gotten it yet. Resident 49 stated staff were busy taking care of other residents and they don't have the time. A review of Resident 49's shower documentation indicated Resident 49 received 4 showers on these dates: 11/16/23, 11/20/23, 11/26/23 and 11/30/23 with 2 refusals on these dates: 11/19/23 and 11/23/23 between 11/14/23 to 11/30/23. Resident 49's shower documentation also indicated she received 2 showers on these dates: 12/4/23 and 12/7/23 with 3 refusals on these dates: 12/9, 12/10 and 12/11 from 12/1/23 to 12/12/23. A review of Resident 49's shower schedule indicated she should be receiving showers every Mondays, Thursdays and Sundays. Resident 49 should have received a total of 7 showers from 11/14/23 to 11/30/23 and a total of 5 showers from 12/1/23 to 12/14/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 11 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated the facility policy was for residents to receive 2 showers a week. Unlicensed Staff O stated showers (a place in which a person bathes under a spray of typically warm or hot water) was not the same as bed bath ( an all-over wash given to a person confined to bed). Unlicensed Staff O stated shower refusals needs to be documented and reported to the nurse. Unlicensed Staff O stated not receiving showers regularly could lead to skin infections, skin breakdown, residents could feel insecure, uncomfortable, and irritable. Unlicensed Staff O stated it would look undignified if a female resident had visible facial hair. Unlicensed Staff O stated staff should offer to shave residents' facial hair. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated residents should be receiving showers twice a week and if residents were not receiving showers twice a week it could lead to skin breakdown, unidentified wounds, worsening of wounds and infection. Licensed Staff P stated shower was different from bed bath. Licensed Staff P stated residents should be showered regularly, unless they refuse and female residents should be offered a shave if they have facial hair on chin and upper lip. Licensed Staff P stated not receiving showers regularly and a female resident having visible facial hairs on chin and upper lip was a dignity issue as resident would look unkempt which could result to low self-esteem. During an interview on 12/15/23 at 11:34 a.m., the Infection Preventionist (IP) stated residents should be receiving showers twice a week and as much as needed per residents' preference. IP stated risk for not receiving regular showers included skin breakdown, skin issues could be missed, infection, wound could develop and worsen. IP stated shower was not the same as bed bath. IP stated shower refusals should be reported to the physician and the responsible party (RP, the person managing the resident's money and care) and should be documented. IP stated if shower refusals were not reported to the physician and RP they would not know about the refusals and it would run the risk of missing on important interventions that could help residents to take showers. During an interview on 12/15/23 at 12:46 p.m., the Director of Nursing (DON) would not respond when asked what the next step would be if a resident had multiple shower refusals or what the risks were if resident refused showers. During a concurrent observation and interviews on 12/15/23 at 4:02 p.m., Resident 49 was in her room, still looked unkempt, hair appeared greasy, still with very visible facial hairs on chin and upper lip. Resident 49 stated she had not received a shower and a shave despite requests to staff. Resident 49 stated staff might be busy or sometimes they just lacked staff. Resident 49 stated she would like to be showered sometime after dinner tonight. Resident 49 stated staff did not shave her either despite requests. Resident 49 stated she would like for staff to shave her facial hairs. During an interview on 12/15/23 at 4:04 p.m., Licensed Staff Y was notified of Resident 49's request for shower and a shave. Licensed Staff Y verified Resident 49 had visible facial hair on her chin, upper lip and face and that she needed a shave. The nursing notes record review for Residents 49 and 65 indicated their respective physician and RP was not notified of their shower refusals. Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan of care for residents) notes regarding Residents 49 and 65 shower refusal was requested but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 12 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0685 Assist a resident in gaining access to vision and hearing services. 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 record review, the facility failed to help schedule an appointment for evaluation of a hearing aid device for one resident, Resident 37. Residents Affected - Few This failure resulted in Resident 37 feeling frustrated and angry due to hearing loss and not being able to hear adequately without the use of hearing aid device. Findings: A record review titled admission Record for Resident 37 indicated he was admitted on [DATE] with a condition of Hearing loss. During an observation and interview on 12/12/23 at 11:10 a.m., in Resident 37's room, Resident 37 wore a large headphone while watching television (TV). Resident 37 removed his headphone and was not able to hear what was said to him. This surveyor had to get close to Resident 37's ear and speak loudly for Resident 37 to be able to hear. Resident 37 apologized for not being able to hear well. Resident 37 stated that he requested to get a hearing aid from the Social Worker since July 2023 with no results to this date. Resident 37 stated that he was not getting information on the request for hearing aids appointment. Resident 37 stated that he was frustrated because he could not hear well and getting angry because he felt that the facility was not telling him the truth. During an interview on 12/12/23 at 2:15 p.m. Social Service Director stated that the previous Social Worker dropped the ball and did not follow up on the hearing test that was ordered. The current Social Service Director stated that she arranged the hearing test evaluation scheduled for 12/27/23 and transportation was arranged. A record review of Resident 37's Order Summary Report dated 6/15/2023 indicated Audiology referral for further evaluation and treatment of diminished hearing per Ear Nose Throat (ENT) Doctor's recommendation. Appointment was scheduled for 7/12/23. A record review titled Care Plan for Resident 37 indicated dated 9/6/23 under Focus, Hard of Hearing (HOH). Under Interventions: dated 9/6/23 Audiology referral was indicated. A review of a letter from Mendocino Lake Hearing Care dated 7/12/23 indicated that Resident 37 had a [hearing loss on both ears]. Under recommendations: 1) [A trial of hearing device to treat both ears with hearing loss is recommended]. This Surveyor requested for the Policy & Procedure (P&P) for the Hearing Aide, the facility did not have a P&P for Hearing Aid. A review of the regulation under Health & Safety Code §483.40(d) indicated, To assure that sufficient and appropriate social services are provided to meet the resident's needs. Medically related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health. A review of the Health and Safety Code §483.25(a) Vision and hearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 13 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. Event ID: Facility ID: 555222 If continuation sheet Page 14 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interviews and record reviews, the facility failed to ensure 1. they were adequately staffed for 21 out of 31 days for CNAs and nine out of 31 days for licensed nurses in 10/2023, 19 out of 30 days for CNAS and 8 out of 30 days for licensed nurses for 11/2023 and 8 out of 12 days for CNAs and 4 out of 12 days for licensed nurses for 12/2023 which resulted in residents' complaints of assistance not being provided by staff in a timely manner and call light not being answered timely for five out of five sampled residents (Residents 380, 376, 68, 332 and 226 ) and residents feeling scared and anxious staff would not get to them on time in case of medical emergency 2. staff were provided in service on Trauma Informed Care (TIC, eliminate or mitigate triggers that may cause re-traumatization of the resident) which could result in staff not knowing how to properly and competently care for residents with trauma and staff inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience) of a resident with trauma. Findings: During an interview on 12/11/23 at 1:36 p.m., Resident 380 stated staff call light response time was an issue. Resident 380 stated the facility was short staffed but staffing at night was the worst. Resident 380 stated she had experienced having had to wait for an hour to receive her pain medication. Resident 380 stated you know it's a long time to wait especially if you were in pain. I started shaking because I was in so much pain. Anonymous Resident 1 stated the facility would do well if they add more staff at night or at least 2 more staff in the hallways to attend to the resident needs timely. During an interview on 12/11/23 at 1:49 p.m., Resident 376 stated staff answers call light between 10 to 20 mins. Resident 376 stated the facility could benefit from having more staff so they could respond to residents' needs on time. During a concurrent observation and interview on 12/11/23 at 1:52 p.m., Resident 68's call light was on. Resident 68 stated his call light had been on for a while. Resident 68 stated he had been waiting for a while for staff to help him. Resident 68 stated that so far, he had not received help from the staff yet. Resident 68 stated he probably had to wait for a while because the facility might be short staffed again. During an observation on 12/11/23 at 2:03 p.m., Resident 68's call light was still on. During an observation on 12/11/23 at 2:06 p.m., Resident 68's call light was still. Resident 68 call light was now on for the last 17 minutes. During an interview on 12/12/23 at 9:10 a.m., Resident 65 stated the facility was short staffed. Resident 65 stated she had to wait for hours before staff came to help her. Resident 65 stated staffing at night was worst. Resident 65 stated the facility did not have enough staff to care for all the residents at the facility. Resident 65 stated this made her anxious because if she needed an emergency medical attention, nobody could get to her on time. During an interview on 12/12/23 at 9:17 a.m., Resident 375 stated the facility was short staffed. Resident 375 stated he felt frustrated he had to wait for hours, especially at night, before staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 15 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some comes to help him. Resident 375 stated he wondered what could happen if there was a medical emergency. During an interview on 12/12/23 at 9:52 a.m., Resident 226 stated the facility was short staffed and could do well to hire more professional staff. Resident 226 stated the facility was short staffed. Resident 226 stated it takes forever for staff to answer their call light. Resident 226 stated it scared her to think there could be a medical emergency and there were no staff that could get to her on time. During an interview on 12/12/23 at 12:59 p.m., Management Staff F stated she was the only one in charge of staffing the facility with nurses and certified nursing assistants (CNAs). Management Staff F stated she staffed the facility based on census and uses the hours patient per day (HPPD, the total number of nursing hours in a unit in a 24-hour period.) census (a complete count of residents in the facility) calculation guideline by the facility. Management Staff F stated she does not use any other guidelines when ensuring the facility was adequately staffed. During an interview on 12/13/23 at 9:00 a.m., the facility nursing consultant (NC) stated the tab that stated nurses and CNAs on the HPPD census calculation corresponds to the total number of CNAs and nurses needed in a 24 hour period based on the facility census. A record review of the HPPD census calculations indicated the facility needs in a 24 hour period based on census. For a census of 62 to 65, the facility needed 8 nurses, census of 66-72, the facility needed 9 nurses, for a census of 73 to 79, the facility needed 10 nurses and for a census of 80 to 81, the facility needed 11 nurses. For CNAs, in a 24 hour period, the facility needed for a census of 62 to 63, 18 CNAs, for a census of 64 to 66, the facility needed 19 CNAs, for a census of 67 to 69, the facility needed 20 CNAs, for a census of 70 to 73, the facility needed 21 CNAs, for a census of 74 to 76, the facility needed 22 CNAs, for a census of 77 to 79, the facility needed 23 CNAs, for a census of 80 to 81, the facility needed 24 CNAs. A review of the facility's staffing for October 2023 indicated the staffing for CNAs were not met for 21 out of 31 days on these dates: 10/1/23 Census of 81, 21 CNAs 10/2/23 Census of 80, 22 CNAs 10/6/23 Census of 79, 21 CNAs 10/7 /23 Census of 79, 21 CNAs 10/8/23 Census of 80, 21 CNAs 10/9/23 Census of 81, 22 CNAs 10/13 /23 Census of 79, 22 CNAs 10/14 /23 Census of 79, 20 CNAs 10/ 15/23 Census of 79, 21 CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 16 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0726 10/16 /23 Census of 80, 22 CNAs Level of Harm - Minimal harm or potential for actual harm 10/18/23 Census of 80, 22 CNAs 10/ 20/23 Census of 79, 21 CNAs Residents Affected - Some 10/21/23 Census of 80, 21 CNAs 10/22 /23 Census of 80, 20 CNAs 10/23/23 Census of 80, 21 CNAs 10/24/23 Census of 80, 22 CNAs 10/ 25/23 Census of 81, 22 CNAs 10/26/23 Census of 81, 23.5 CNAs 10/28/23 Census of 78, 22 CNAs 10/29/23 Census of 77, 20 CNAs 10/ 31/23 Census of 77, 21 CNAs A review of the facility's staffing for October 2023 indicated the staffing for licensed nurses were not met for 9 out of 31 days on these dates: 10/1/23 Census of 81, 8 licensed nurses 10/7 /23 Census of 79, 7 licensed nurses 10/8/23 Census of 80, 7 licensed nurses 10/14 /23 Census of 79, 7 licensed nurses 10/ 15/23 Census of 79, 7 licensed nurses 10/21/23 Census of 80, 7 licensed nurses 10/22 /23 Census of 80, 7 licensed nurses 10/28/23 Census of 78, 7 licensed nurses 10/29/23 Census of 77, 7 licensed nurses A review of the facility's staffing for November 2023 indicated the staffing for CNAs were not met for 19 out of 30 days on these dates: 11/4/23 Census of 74, 21 CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 17 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0726 11/5/23 Census of 74, 19 CNA's Level of Harm - Minimal harm or potential for actual harm 11/6/23 Census of 73 20 CNA's 11/11/23 Census of 74, 20 CNAs Residents Affected - Some 11/12/23 Census of 75, 20 CNAs 11/13/23 Census of 75, 21 CNAs 11/14/23 Census of 79, 20 CNAs 11/15/23: data requested but not provided. 11/16/23 Census of 80, 23 CNAs 11/17/23 Census of 80, 22 CNAs 11/18/23 Census of 79, 20 CNAs 11/19/23 Census of 79, 20 CNAs 11/20/23 Census of 79, 21 CNAs 11/23/23 Census of 78, 21 CNAs 11/24/23 Census of 80, 21 CNAs 11/25/23 Census of 80, 20 CNAs 11/26/23 Census of 80, 21 CNAs 11/27/23 Census of 81, 21 CNAs 11/28/23 Census of 81, 23 CNAs A review of the facility's staffing for November 2023 indicated the staffing for licensed nurses were not met for 8 out of 30 days on these dates: 11/5/23 Census of 74, 7 licensed nurses 11/11/23 Census of 74, 7 licensed nurses 11/12/23 Census of 75, 7 licensed nurses 11/15/23 data requested but not provided 11/19/23 Census of 79, 7 licensed nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 18 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0726 11/23/23 Census of 78, 7 licensed nurses Level of Harm - Minimal harm or potential for actual harm 11/24/23 Census of 80, 7 licensed nurses 11/25/23 Census of 80, 7 licensed nurses Residents Affected - Some 11/26/23 Census of 80, 7 licensed nurses A review of the facility's staffing for December 2023 indicated the staffing for CNAs were not met for 8 out of 12 days on these dates: 12/1/23 Census of 81, 20 CNA 12/2/23 Census of 78, 19 CNAs 12/3/23 Census of 78, 18 CNAs 12/4/23 Census of 78, 21 CNAs 12/6/23 Census of 78, 20 CNAs 12/7/23 Census of 81, 22 CNAs 12/8/23 Census of 80, 22 CNAs 12/9/23 Census of 79, 20 CNAs A review of the facility's staffing for December 2023 indicated the staffing for licensed nurses were not met for 4 out of 12 days on these dates: 12/2/23 Census of 78; 7 licensed nurses 12/3/23 Census of 78; 7 licensed nurses 12/9/23 Census of 79; 8 licensed nurses 12/10/23 Census of 78; 8 licensed nurses During an interview on 12/14/23 at 11:37 a.m., Unlicensed Staff N stated sometimes the facility was short staffed and the patient load could be heavy. When asked what risk would be for the residents if the facility was short staffed, he did not respond. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O the facility was short staffed. When asked what risk would be for the residents if the facility was short staffed, Unlicensed Staff O stated short staffing could led to staff not giving enough time to residents so there was less individualized care time for residents. During an interview on 12/15/23at 10:20 a.m., Licensed Staff P stated there were times when the facility was short staffed. When asked what risk would be for the residents if the facility was short (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 19 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staffed, Licensed Staff B stated staff could get stressed out temperamental, which could lead to residents feeling anxious. Licensed Staff P stated short staffing could also lead to decreased amount of care rendered to residents. Licensed Staff P stated staff could skip care if trying to meet needs of multiple residents and staff could be not as thorough when providing care for the residents. 2. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated she could not recall if she had received an in service regarding TIC. Unlicensed Staff O stated she did not know what trauma informed care was. Unlicensed Staff O stated she would not know how to properly care for residents with trauma. Unlicensed Staff O stated not knowing how to properly care for residents with trauma could be a safety issue and could lead to inadequate care. During an interview on 2/15/23 at 10:20 a.m., Licensed Staff P stated she did not receive any in service regarding trauma informed care but would love to receive it to properly care for residents with trauma. During an interview on 12/15/23 at 11:34 a.m., the Director of Staff Development (DSD) stated she did not give an in service about trauma informed care. The DSD stated it was important staff knew how to deal with residents who had emotional, psychological and physical trauma. When asked what risk would be for the residents if staff did not receive training or in services regarding trauma informed care, the DSD stated trauma survivor residents could receive less than optimal care, staff could be insensitive and would not know what could trigger the behavior. The DSD stated it becomes counterproductive for the residents. During an interview on 12/15/23 at 2:57 p.m., Unlicensed Staff U stated he did not receive in service or training about TIC. Unlicensed Staff U stated he would not know how to properly provide care for residents who had trauma. During an interview on 12/15/23 at 2:58 p.m., Licensed Staff V she had not received a TIC training or in service. Licensed Staff V stated it was important to receive TIC training, so staff knew how to care for residents adequately and properly with trauma. A policy and procedure for Trauma Informed Care was requested but was not provided. A review of the facility assessment attachment 1 titled Medicare and Medicaid Programs; Reform of requirements for Long Term Care Facilities indicated the facility must have a sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well being of each residents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 20 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient and appropriate social services were provided to meet the needs of Resident 1, Resident 14, Resident 51, Resident 38, Resident 35, Resident 52 & Resident 37, when: Residents Affected - Few 1. The facility did not conduct and document an Interdisciplinary Team Meeting and Care Conference for the last two quarters for Resident 1, Resident 14, Resident 51, Resident 38, Resident 35. 2. The facility did not ensure that Resident 52 had the Level II PASARR evaluation by a Medical Doctor's scheduled in 9/23. Failure to attend the scheduled Medical Doctor's appointment for Level II PASARR evaluation resulted in cancellation, and therefore Resident 52 needed to begin with the entire process for PASARR evaluation. Level II PASARR evaluation will determine the proper care and home placement. 3.The facility failed to arrange the Medical Doctor's (MD) appointment for Resident 37's evaluation for Hearing Aide device that was very much needed due to his hard of hearing since the Ear Nose Throat (ENT) Doctor recommended in July 2023. Resident 37 stated that the facility promised him multiple times that he would get the hearing aid test soon, but it did not happen. Resident 37 was very frustrated and angry for not able to hear adequately. Findings: (Refer F 657) During an interview with Resident 14 on 12/12/23, at 9:45 a.m., he stated he was concerned about getting out of the facility and back to his apartment. He stated he wanted to be back in (name of town), a town located 43 miles away, where all his friends and family were located. He stated there were rehabilitation facilities in (town) he wanted to transfer to, and had told staff of his desire to transfer, but staff had told him that he could not. Resident 14 stated he did not remember being involved in a Care Conference to talk about his plan of care. He stated it made him feel like he did not matter. During an interview on 12/12/23, at 12:50 a.m., Resident 38 stated she wanted to go home. She stated she would like to go to a group home. She stated she did not remember a meeting with staff to discuss her care while in the facility and did not know what discharge planning had been done and would like to know. During an observation and interview on 12/12/23 at 12:58 p.m., Resident 1 was observed to be wringing her hands and furrowing her eyebrows. She stated she wanted to go home. She stated she has told the staff about it and does not understand why she could not go home. She stated it had been months since she talked to someone about it and it made her feel ignored and sad. She stated it was close to Christmas and she did not want to be in the facility. During a telephone interview on 12/12/23 at 11:57 a.m., with Responsible Party S, she stated I have not been asked to participate in a care conference since he was admitted . She stated she made phone calls to the facility to find out how the resident was doing but a lot of times no one would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 21 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0745 Level of Harm - Minimal harm or potential for actual harm answer the phone. She stated she had cancer and could not come into the facility and no one from the facility had called her about anything unless Resident 51 fell. She stated the last care conference she participated in was when they decided to put the resident in long term care and that has been over a year. She stated she had not participated in the plan of care for Resident 51 since he went into long term care and it made her miss Resident 51 even more. Residents Affected - Few During an interview with Social Services Director on 12/14/23, at 9:44 a.m., she stated she had been in role for only three weeks and Resident 1 was one of the cases that she became aware of early in her role that she knew the previous person in this role had messed up. She stated there had been a lack of discharge planning for Resident 1 and she had to start the planning over again from the beginning. She stated this had delayed Resident 1's discharge and made the resident feel anxious and sad. During an interview with Social Services Director and Administrator in Training 12/14/23, at 2:37 p.m. Social Service Director stated she had only been in current role for three weeks and knew the previous person had not conducted Care Conferences regularly. She stated the Care Conferences should have been done once a quarter and whenever needed. During an interview on 12/15/23 at 1:27 p.m., FACILITY CONSULTANT T stated there was no documentation of Care Conferences or Interdisciplinary Team Meetings, for the past two quarters for the Resident / Responsible party for Resident 14, Resident 35, Resident 38, Resident 1 or Resident 51. During a review of a document titled admission Record, it indicated Resident 14 was admitted [DATE] with diagnoses that included Hemiplegia (Paralysis of one side of the body) and Hemiparesis (Weakness in your arms, hands, face, chest, legs and or feet that can make it hard to perform everyday activities like eating or dressing.) following Cerebral Infarction (Stroke) Affecting Right Non-Dominant (Right Side), Chronic Obstructive Pulmonary Disease (COPD) (A type of progressive lung disease that limits airflow and results in shortness of breath and a cough that worsens with time.) and Ataxia (Lack of coordination of arms and legs resulting in lack of balance, and trouble walking.). During review of a document for Resident 14, titled Minimum Data Set (MDS) summary of information to assess and manage care of residents in skilled nursing homes.) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) (A scoring assessment system used to determine how mentally intact a resident is. 0-7 points is severely impaired, 8-12 moderately impaired and 13-15 no impairment.) indicated Resident 14 had a score of 14. During a review of a document titled admission Record, it indicated Resident 38 was admitted [DATE] with diagnoses that included Unspecified Lack of Expected Normal Physiological Development in Childhood (Someone who did not developed physically or mentally during childhood.), Obsessive-Compulsive Disorder, Unspecified (repetitive thoughts or actions without a specific diagnosis.) During review of a document for Resident 38, titled Minimum Data Set (MDS) indicated Resident 38 had a BIMS score of 13. During a review of document titled admission Record, it indicated Resident 1 was admitted [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant (Left Side), COPD. During review of a document for Resident 1, titled Minimum Data Set (MDS) Section C Cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 22 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0745 Patterns, the Brief Interview Mental Status (BIMS) indicated Resident 1 had a score of 14. Level of Harm - Minimal harm or potential for actual harm During a review of document titled admission Record, it indicated Resident 51 was admitted [DATE] with diagnoses of Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Side, Aphasia (Difficulty / inability to talk), Unspecified Dementia with other Behavioral Disturbance (Impaired concentration, apathy, agitation). Residents Affected - Few During review of a document for Resident 51, titled Minimum Data Set (MDS) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) indicated Resident 51 had a score of 4. A document for Resident 51, titled Baseline Care Plan Person-Centered Care Planning, dated 9/7/23, indicated Social Services Resident and/or Resident Representative (RR) Interview 1. Initial Plan for Placement: a. Short Term. Review of a facility Policy and Procedure titled INTERDISCIPLINARY PLAN OF CARE CONFERENCE, not dated, indicated An Interdisciplinary Care Planning Conference identifies resident needs and establishes obtainable goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents . The MDS Coordinator chairs all POC Review meetings. Conferences for all residents are held within seven (7) days following admission and every 90 days thereafter or when a change in condition occurs. The review includes the following: A review of current long-term and short-term goals. Resident care problems, goals and approaches with appropriate time frames. Discharge Planning. Resident and family education . (2) Resident 52 Resident 52 was initially admitted to the facility on [DATE] with mental conditions of agoraphobia (is afraid to leave environments they know or consider to be safe) with panic disorder, Bipolar II disorder and panic disorder (episodic anxiety). A record review of Resident 52's evaluation for Level I PASARR dated 9/27/23 was positive indicated a Level II PASARR mental health evaluation from Department of Health Services was needed. A review of the letter for Resident 52 from the Department of Health Service, addressed to the Administrator titled Unable to complete evaluation for Level II PASARR dated 9/20/23, indicated After reviewing the Positive Level I Screen and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: o The individual was unable to participate in the Evaluation. The case is now closed. To reopen, please submit a new Level I Screen. During an interview on 12/12/23 at 2:30 p.m. in Social Service office, Social Worker stated that the previous Social Worker did not follow up the Level II PASARR evaluation, therefore Resident 52 needed to repeat the Level I PASARR to get an evaluation for Level II PASARR. A review of Resident 52 medical record did not indicate there was a re-evaluation done for Level I PASARR. During an interview on 12/14/23 at 3:30 p.m. with the DON stated that there was no P&P for PASARR. A review of the health and safety code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 23 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 483.20(e)(1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. A review of the health and safety code 483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Mental Disorder (MD) For purposes of this section, the term mental disorder is the equivalent of mental illness used in the definition of serious mental illness in 42 CFR A review of health and safety codes 483.102(b)(1), which states: An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. This mental disorder is(A) A schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability. (3) Resident 37 During a concurrent observation and interview on 12/12/23 at 11:10 a.m., in Resident 37's room, Resident 37 wore a large headphone while watching television (TV). Resident 37 removed his headphone and was not able to hear what was said to him because he was hard of hearing. This surveyor had to get close to Resident 37's ear and spoke loudly to be able to hear. Resident 37 stated he apologized for not able to hear well. Resident 37 stated that he requested to get a hearing aid from the Social Worker since July 2023 and no results to this date. Resident 37 stated that he was not getting information on the request for hearing aids. Resident 37 stated that he was frustrated because of he could not hear well and getting angry because he felt that the facility was not telling the truth. During an interview on 12/12/23 at 2:15 p.m. with the Social Service stated that the previous Social Worker dropped the ball meaning she did not follow up the hearing test ordered. The current Social Service stated that she arranged the hearing test evaluation scheduled for 12/27/23 and transportation was already arranged. A record review of Resident 37's Order Summary Report dated 6/15/2023 indicated Audiology referral for further evaluation and treatment of diminished hearing per Ear Nose Throat (ENT) Doctor's recommendation. Appointment was scheduled for 7/12/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 24 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0745 Level of Harm - Minimal harm or potential for actual harm A review of the regulation 483.40(d) indicated, To assure that sufficient and appropriate social services are provided to meet the resident's needs. Medically related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 25 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interviews and record reviews, the facility failed to ensure the development of a plant-based menu. This failure had the potential for vegetarian residents to not meet the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins which could further compromise their medical status . Findings: During an interview on 12/13/23 at 2:31 p.m., the RD stated the facility did not have a plant based menu. The RD stated if a resident was vegetarian, they would be served the same food as the resident with a regular diet, however, they would substitute it with vegan option. The RD stated the facility did not have a menu specific to cater to resident who was vegetarian. The RD stated she was not aware having a plant based menu was a standard. When asked if she thought having a plant based menu for the facility was important to meet vegetarian resident's needs, she did not respond to this question, but she stated they had not admitted residents who was vegetarian for months now. When asked if the facility had admitted residents who was vegetarian in the past, she stated yes, but not in a while. During an interview on 12/13/23 at 3:21 p.m., [NAME] 2 stated if there were residents who were vegetarian, he would check the facility's plant based menu to plan for their meals. [NAME] 2 did not know the facility did not have a plant based menu. When asked how he could be sure the facility was serving a nutritious vegetarian meal that would meet the residents nutritional needs, he did not respond and looked at the Dietary Manager (DM) who shook her head. When asked if it was important to have varied menu for residents who were vegetarian, he did not respond. When asked if there was a risk for residents who had a vegetarian diet to not receive a meal that would meet their nutritional needs, [NAME] 2 stated there was a risk. During an interview on 12/13/23 at 3:23 p.m., the DM stated they do not have a plant based meal menu, but she had now ordered the plant based menu from the company. When asked how the facility could be sure they were serving nutritious meals that meet a vegetarian resident nutritional need, the DM did not respond. When asked if it was important to have varied menu for a resident that were vegetarian, the DM did not respond. During an interview on 2/14/23 at 5:50 a.m., [NAME] 1 stated if a resident requested a plant based meal, he would check the facility's plant based meal menu. [NAME] 1 stated he was not aware the facility did not have a plant based meal menu available to use if a resident requested a plant based meal. [NAME] 1 stated having a plant based menu was important because he needs to follow the recipe to make sure he was serving a plant based meal that would meet residents' nutritional needs. [NAME] 1 stated not having a plant based meal menu put vegetarian residents at risk for not meeting their nutritional needs. [NAME] 1 stated a plant based meal menu was important so that he could follow the recipe for a plant based meal. During an interview on 12/15/23 at 10:56 a.m., the Director of Staff Development (DSD) stated having a menu with recipe was important. The DSD stated not having a menu with recipe could lead to residents not meeting their optimal nutritional needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 26 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0803 The facility did not have a policy and procedure specific to vegetarian menu. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled Menu Planning, undated, the P&P indicated the menus are planned to meet the nutritional needs of the residents in accordance with established national guidelines and in accordance with the most recent recommended daily allowances of the food and nutrition Board of the National Research Council National Academy of Sciences .menus are planned to consider religious, cultural and ethnic needs of the residents as well as input received from residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 27 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to ensure the food was palatable, was served timely and was served at temperatures in accordance with resident preferences for seven out of seven sampled residents (Residents 376, 68, 65, 375, 226, 52 and 50). These failures had the potential to result in residents not eating the food served which could result in weight loss and further compromise their medical status. Residents Affected - Many Findings: During an interview on 12/11/23 at 1:49 p.m., Resident 376 stated he dislike the food at the facility. Resident 376 stated food had no taste and vegetables were soggy. During an interview on 12/11/23 at 1:52 p.m., Resident 68 stated food comes in late, so it was usually cold by the time he gets it. Resident 68 stated food at the facility was not good, bland and had no taste. During an interview on 12/12/23 at 9:10 a.m., Resident 65 stated food at the facility was not great. Resident 65 stated food was very bland and had no taste. Resident 65 stated meal trays comes late so food was already cold when it gets to her. During an interview on 12/12/23 at 9:17 a.m., Resident 375 stated the facility food was so-so, and did not have a lot of taste. Resident 375 stated vegetables were usually mushy and soggy. During an interview on 12/12/23 at 9:52 a.m., Resident 226 stated the food at the facility was not good and had no taste. During an interview on 12/12/23 at 12:49 p.m., Resident 52 stated the facility food was sometimes good and sometimes it's not. Resident 52 stated sometimes food was already cold when they serve it. Resident 52 stated sometimes food arrives late and she gets hungry. During a concurrent observation and interview on 12/14/23 at 8:25 a.m., Resident 50 stated he received his meal tray at 8:20 a.m. Resident 50 stated his tray was late, just like every day his meal tray was late. During a concurrent observation and interview on 12/14/23 at 1:01 p.m., the food was sampled by the facility Registered Dietician (RD) and the surveyor. The chicken was dry, chewy, bland and needed seasoning. The peas and the cauliflower were bland and lacked flavor as well. The food was all lukewarm, the chicken temperature was 132 F, the cauliflower and peas mixture were 120 F and the pasta with sauce was 128 F. The RD stated the cauliflower was warm, the peas were less warm and the chicken had cooled down. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated if food was bland, had no taste and cold, residents might not want to eat it. Unlicensed Staff O stated a meal tray arriving 1 hour late was not acceptable. Unlicensed Staff O stated residents might lose interest in their food which could result to weight loss. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated late meal tray affects food palatability, temperature and the flavor would be altered. Licensed Staff P stated it would affect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 28 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0804 how much resident would consume and could possibly lead to weight loss. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/15/23 at 10:56 a.m., the Director of Staff Development (DSD) stated meals should arrived at residents within specified time frames and not 1 hour or more late. The DSD stated late meal tray could result in food getting cold, resident getting upset, resident losing appetite which could possibly lead to weight loss and resident not receiving their optimal nutritional needs. Residents Affected - Many Based on the facility's policy and procedure (P&P) titled Food Preparation, undated, the P&P indicated food shall be prepared by methods that conserve nutritive value, flavor and appearance .poorly prepared food will not be served .may add increased amount of herbs and spices (not salt) since potency of produce may vary .prepare foods as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking .hot foods should be held prior to service at 140 F or above . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 29 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure 1. residents' food items were labeled with name and dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items. Residents Affected - Many Findings: During an observation on 12/13/23 at 1:40 p.m., resident's refrigerator was in the staff breakroom. The refrigerator side was broken. During a concurrent observation and interview on 12/13/23 at 1:47 p.m., Unlicensed Staff AA verified she put the jar of minced garlic for the resident in room [ROOM NUMBER] in the refrigerator. Unlicensed Staff AA stated there was no name to identify who this jar of minced garlic belonged to. Unlicensed Staff AA verified the jar of minced garlic was opened but not dated. Unlicensed Staff AA stated she was unable to read the jar of minced garlic expiration date. Unlicensed Staff AA stated resident's food items should be labeled with their name, should have date on when it was opened and should have a use by date. Unlicensed Staff AA stated residents' food brought in from outside should be labeled with their name instead of room number because resident could switch rooms. Unlicensed Staff AA stated residents' food brought in from outside should be open dated and should have a use by date for safety purposes because food could get spoiled and resident could get sick if they eat it. During a concurrent observation and interview on 12/13/23 at 1:59 p.m., Licensed Staff BB verified the box of cookie dough from the freezer did not have an expiration date and there was also no indication it was dated when they received it. Licensed Staff BB stated this should be dated when staff received it. Licensed Staff BB stated this cookie dough should have been discarded for safety purposes. During a concurrent observation and interview on 12/13/23 at 2:05 p.m., Dietary Aide 1 stated he cleans the refrigerator daily and would throw away expired food items. Dietary Aide 1 verified 1 small tub of jello in the refrigerator should have been discarded on 12/9/23. Dietary Aide 1 verified the 2 prebiotic squeeze snacks did not indicate who this belonged to. Dietary Aide 1 verified the fruit and yogurt blueberry pear squeeze snack expired on 8/30/23. Dietary Aide 1 stated these items should have been discarded for residents' safety. During an observation on 12/13/23 at 2:12 p.m., a carbonated drink was noted to be opened, there was no name on the drink only a room number. The carbonated drink did not indicate when it was opened and when it should be discarded. During a concurrent observation and interview on 12/13/23 at 2:15 p.m., there were 2 supplement drinks in the resident's refrigerator with no name to indicate who these belonged to. Licensed Staff BB and CC stated resident could have brought it from home. Licensed Staff CC stated these supplemental drinks should be discarded. During an observation on 12/13/23 at 2:19 p.m., a bottle of organic prune juice was in the resident's refrigerator with no name just a room number. During an interview on 12/13/23 at 2:31 p.m., the Registered Dietician (RD) stated residents' food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 30 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many coming from outside had to labeled with the residents name, dated when it was received or opened and dated when it should be discarded. If there was no discard date, the food item had to be thrown within 3 days of opening it. The RD stated the rule was if 3 days had passed since it was brought in, it had to be tossed out. The RD stated food items should be labeled with resident's name and not room number because residents could change rooms. The RD stated food items should also be labeled with use by date and expired food items should be discarded for residents' safety. The RD stated residents could get sick if they consume food that was potentially expired or contaminated. During an observation on 12/14/23 at 8:20 a.m., a smoothie squeeze pack was noted in the resident's refrigerator in the staff breakroom. The smoothie squeeze pack was not labeled with name and was expired since 9/30/23. A review of the facility's policy and procedure (P&P) titled Bringing in Food for a Resident, undated, the P&P indicated food and beverages should be labeled and dated to monitor for safety .food or beverages need to be marked with residents name .food or beverage items without manufacturers expiration date will be dated upon arrival at the facility and thrown away 2 days after the date marked or if frozen 30 days. A review of the facility's policy and procedure (P&P) titled Food for Residents from Outside Sources, undated, the P&P stated food brought in from outside the facility kitchen for residents' consumption will be monitored .if opened, food must be sealed, dated to the date opened and disposed of in 2 days after opening .frozen items will be disposed of in 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 31 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on observation, interview and record review, the Governing Body (a group of people that has the authority to exercise governance over an organization) failed to ensure to designate or appoint a California Licensed Nursing Home Administrator (NHA) (Administrator is responsible for establishing and implementing policies regarding the management of the facility) who would be legally responsible for establishing and implementing policies regarding the management and operation when: 1) The Administrator in training (AIT) claimed to be the Administrator of the facility, for over 6 weeks including during the recertification survey dated 12/11/23 - 12/14/23. 2) The AIT was licensed by the State of Montana and was currently scheduled to take the reciprocity administrator licensing exam on 12/14/23. 3) The current licensee Administrator for the facility was not present in the building to provide oversite since October 2023 and during the survey on 12/11/-12/14/23. The current administrator was supervising other two facilities which were more than two hours away from this facility, a facility that he was the designated licensee Administrator. This failure had the potential to result in mismanagement and misguided of the care of vulnerable residents and false information provided by the AIT that he was the Administrator to the vulnerable residents, staff, and visitors. Findings: (1) During a concurrent observation and interview on 12/11/23 at 9:15 a.m., at the initiation of the recertification survey, the Administrator in Training (AIT) greeted the surveyors. When asked if he was the Administrator, he answered yes. The AIT stated that he had been the Administrator for 6 weeks. AIT stated that he was previously the AIT at the other affiliated facility. (2) During a concurrent observation and interview on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated [the name of the licensee Administrator], which was not the AIT present. When asked the AIT, who was this licensee Administrator whose name was posted on the bulletin board, the AIT stated that he was the licensee Administrator but had not been there for over 6 weeks. When the AIT was asked where the licensee Administrator was, the AIT replied, he had not been there. The AIT was asked for a copy of his current Nursing Home Administrator (NHA) license and the phone number of the licensee Administrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 32 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A record review of AIT's Licensure provided by AIT titled Licensure as Nursing Home Administrator indicated that he was Licensed under the State of Montana active, expires at 12/31/2023. A concurrent interview and record review titled Master's or Reciprocity Application for Nursing Home Administrator Examination application on 12/14/23 at 2:30 pm. AIT stated that he applied for California Licensure for NHA. A review of an email provided by AIT from the NHA to confirm an approval for California Nursing Home Administrator State Examination for December 14, 2023, at 2 p.m. to 4 p.m. AIT stated that he was scheduled to take the test for California License for Nursing Home Administrator on 12/14/2023. When asked AIT, if he had a California Nursing Home Administrator License, AIT stated, No but he said that he was licensed in the State of Montana. AIT stated that he was in telephone contact with the Licensee Administrator regarding the current recertification Survey. During a concurrent interview and record review of the Quality Assurance Program Improvement (QAPI) on 12/15/23 at 4:3 p.m. in the large conference room, the attendance sheets dated 10/24/23 and 11/28/23 were signed by the AIT under Administrator. The licensee Administrator did not sign the attendance sheet dated 10/24/23 and 11/28/23. When the licensee Administrator (who arrived in the facility on 12/15/23) was asked about his signature in the attendance sheet for QAPI meeting, Licensee Administator stated, he was not in the facility anymore during that time. Licensee Administrator stated that he left the facility in the middle of October 2023. (3) During a telephone interview on 12/14/23 at 3:04 p.m., the Licensee Administrator stated that he was assigned to oversee other two facilities out of the area. Licensee Administrator stated that he was aware that there was a recertification survey happening in the facility and that AIT was in contact with him constantly. When asked the Administrator if the AIT should identify himself as the Administrator, Licensee Administrator stated, AIT should not have identified himself as the Administrator. When asked the Licensee Administrator if he was aware that AIT did not have a current California NHA license, Licensee Administrator answered yes. When asked Licensee Administrator, if he felt it was acceptable to assign or appoint a non-California Licensed NHA to your facility, Licensee Administrator did not respond. Licensee Administrator stated that he provided oversite of AIT over the phone. When asked Licensee Administrator if he was aware of the mileage difference between facilities that he oversees, Licensee Administrator stated, not sure. A review of the regulatory of Health and Safety code §483.70(d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with §483.75(f). [§483.70(d)(3) Governing body responsibility of QAPI program will be implemented beginning November 28, 2019 (Phase 3).] A review of the regulatory of Health and Safety Code §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. A review of the regulatory of health and Safety Code §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is required. (ii) Responsible for management of the facility; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 33 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0837 (iii) Reports to and is accountable to the governing body. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 34 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the Quality Assurance Committee (QAA) is composed of the required committee members, such as an active licensed Nursing Home Administrator (NHA) of California during the QAPI meeting dated 10/23 & 11/23. Residents Affected - Many This failure had the potential to result in mismanagement of the practices required by the Administrator to keep the vulnerable resident safe and healthy. Findings: During a concurrent observation and interview on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated [the name of the licensee Administrator], which was not the AIT present. When asked the AIT, who was this licensee Administrator whose name was posted on the bulletin board, the AIT stated that he was the licensee Administrator but had not been there for over 6 weeks. When the AIT was asked where the licensee Administrator was, the AIT replied, he had not been there. The AIT was asked for a copy of his current Nursing Home Administrator (NHA) license and the phone number of the licensee Administrator. A record review titled Licensure as Nursing Home Administrator under the State of Montana active, expires at 12/31/2023. A concurrent interview and record review titled Master's or Reciprocity (in exchange) Application for Nursing Home Administrator Examination application. AIT stated that he applied for Licensure for NHA. A record review titled email from the NHA to confirm an approval for California Nursing Home Administrator State Examination for December 14, 2023, at 2 p.m. to 4 p.m. for AIT. During an interview on 12/14/23 at 2:30 p.m., AIT stated that he was scheduled to take the test for License for Nursing Home Administrator. When asked AIT if he had a Nursing Home Administrator Licensed for California, AIT stated, No but he said that he was licensed in the State of Montana. AIT stated that he was in telephone contact with the Licensee Administrator regarding the recertification Survey. During a concurrent interview and record review of the Quality Assurance Program Improvement (QAPI) on 12/15/23 at 4:3 p.m. in the large conference room, the attendance sheets dated 10/24/23 and 11/23 were signed by the AIT under Administrator. The current licensee Administrator did not sign the attendance sheet dated 10/24/23 and 11/23 for QAPI/QAA.When the licensee Administrator (who arrived in the facility on 12/15/23) was asked about his signature in the attendance sheet for QAPI meeting, Licensee Administator stated, he was not in the facility anymore during that time. Licensee Administrator stated that he left the facility in the middle of October 2023. A review of the Health and Safety Code §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 35 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0868 (ii) The Medical Director or his/her designee; Level of Harm - Minimal harm or potential for actual harm (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and Residents Affected - Many (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 36 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 observations, interviews and record reviews, the facility failed to 1. ensure staff were offering and performing hand hygiene (HH, a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands) to the residents before or after meals for 12 out of 12 sampled residents (Residents 47, 22, 40 11, 48, 50, 24, 63, 52, 72, 2 and 28), when [NAME] 1 did not perform HH and continue to cook eggs after he wiped his gloved hand in front of his shirt, and ensure staff were following the facility's guideline for donning Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when staff did not wear gloves when she scooped ice in the ice machine located in the kitchen 2. ensure an oxygen tubing was dated when it was changed and ensure there was a humidifier (a medical device used to humidify supplemental oxygen that provides long-lasting moisture for utmost patient comfort during oxygen therapy) when a resident was using an oxygen concentrator (a medical device that you could use if you have a condition that affects your breathing) for one out of one sampled resident (Resident 380). Residents Affected - Many 3. ensure there were no flies in the kitchen, dining room, hallways and residents' room which could land on uncovered commode and urinals then land on residents' food, uncovered kitchen food and items, 4. ensure there was no urinal at a resident overbed table while he was eating his meal for one out of one sampled resident (Resident 48) and there were no food items on top of the commode for one out of one sampled resident (Resident 65). These failures could lead to cross contamination, accidental ingestion of contaminated food, gastrointestinal disease (diseases that affects the gastrointestinal (GI) tract, the passage that runs from the mouth to the anus) and infection. Findings: 1. During an observation on 12/11/23 at 12:21 p.m., Resident 47 received his lunch tray. There was no HH offered prior to eating his meal. During an observation on 12/11/23 at 12:22 p.m., Resident 22 received his lunch tray. There was no HH offered prior to eating his meal. During an observation on 12/11/23 at 12:23 p.m., Resident 40 received her lunch meal tray. There was no HH offered prior to eating her meal. During an observation on 12/11/23 at 12:25 p.m., Resident 60 received her lunch meal tray. There was no HH offered prior to eating her meal. During an observation on 12/11/23 at 12:47 p.m., Resident 11 left the dining room. There was no HH offered after eating her meal. The moist towelette (wipes used for cleaning hands) on her meal tray was left unopened. During an observation on 12/11/23 at 12:51 p.m., Resident 48 left the dining room. There was no HH offered after eating his meal. The moist towelette on his meal tray was left unopened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 37 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 During an observation on 12/12/23 at 12:22 p.m., Resident 50 was served his lunch meal tray. There was no HH offered by staff prior to eating his meal. During an observation on 12/12/23 at 12:26 p.m., Resident 63 ate his dessert with his hand. There was no HH offered prior to eating his meal. Residents' 24 and 63 had their moist towelette for HH opened but not used. During an observation on 12/12/23 at 12:27 p.m., Resident 52 had her moist towelette for HH opened but not used. During an observation on 12/12/23 at 12:30 p.m., Resident 72 had her moist towelette opened but not used. During an observation on 12/12/23 at 12:32 p.m., Resident 24 left the DR. There was no HH noted after her meal. During an interview on 12/12/23 at 12:34 p.m., Resident 22 stated staff did not consistently offer HH to residents. Resident 22 stated staff should offer HH to all residents especially those who were not able to perform HH by themselves, but the staff just doesn't. During an observation on 12/12/23 at 12:42 p.m., there was no HH offered to Resident 2 after eating his lunch. The moist towelette was not used. During an observation on 12/12/23 at 12:44 p.m., there was no HH offered to Resident 52 after eating her meal. During an observation on 12/12/23 at 12:53 p.m., there was no HH offered to Resident 28 after eating her lunch. During an observation on 12/12/23 at 12:55 p.m., Resident 28 wheelchair was pushed back to her room by Management Staff F. There was still no HH offered after eating her lunch. During an observation on 12/14/23 at 5:49 a.m., Dietary Aide 2 did not perform HH prior to donning gloves. During an interview on 12/14/23 at 6:19 a.m., the Dietary Manager (DM) stated the moist towelette were placed at residents' tray for HH before meals. During an observation on 12/14/23 at 6:25 a.m., [NAME] 1 scooped ice in the ice machine with no gloves. During an interview on 12/14/23 at 6:44 a.m., the RD verified staff should wear gloves whenever they were scooping ice in the ice machine. During an observation on 12/14/23 at 6:50 a.m., [NAME] 1 removed the glove mittens he was using and proceeded to take the temperature of the chicken with no HH. The glove mitten was dirty. During an observation on 12/14/23 at 7:03 a.m., [NAME] 1 was frying eggs. [NAME] 1 wiped his gloved hand in front of his shirt. The cook did not discard his gloves and did not perform HH. [NAME] 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 38 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 continued to fry the eggs. Level of Harm - Minimal harm or potential for actual harm During an observation on 12/14/23 at 7:15 a.m., Dietary Aide 3 did not perform HH prior to donning gloves. Residents Affected - Many During an observation on 12/14/23 at 11:59 a.m., Dietary Aide 4's beard net was worn where it was not adequately covering his facial hair. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff D stated staff should perform HH before and after gloving and HH should be offered to the residents before and after meals. Unlicensed Staff D stated if there was no HH offered to the residents before and after meals, residents would be at risk for infections and gastrointestinal infections. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated HH should be performed before and after gloving and HH should be offered to the residents before and after meals. Licensed Staff P stated if staff was cooking and he wiped his gloved hand on his shirt, he needs to remove his gloves, perform HH and then put on a new glove. Licensed Staff P stated not performing HH and not following the PPE protocol could result to potential contamination and GI infection. During an interview on 12/15/23 at 11:34 a.m., the Director of Staff Development (DSD) stated HH should be offered to the residents before and after meals and HH should be performed prior to donning and after doffing gloves. The DSD stated the cook should have performed HH and donned new gloves when he wiped his gloved hands in front his shirt. The DSD stated not adhering to HH protocol and not adhering to PPE protocol meant the facility policy was not followed and expectations were not met. The DSD stated not adhering to HH and PPE protocol could result to contamination and residents could get sick. During an interview on 12/15/23 at 12:46 p.m., the DON stated residents should be offered HH before and after meals, and staff should perform HH before donning and after doffing gloves. The DON stated there would be a risk of contamination if the HH and the PPE protocol was not followed. The DON was silent when asked what the risks for residents were when the HH and the PPE protocol was not followed. During an interview on 12/15/23 at 1:17 p.m., the RD stated there could be a possible cross contamination if HH were not being offered or done to all residents before and after meals. The RD stated this could result to food borne illness. Based on the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated hand hygiene indicated hand hygiene as the primary means to prevent the spread of healthcare associated infections .all personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors .hand hygiene was indicated immediately after glove removal . 2. During a concurrent observation and interview on 12/11/23 at 1:36 p.m., Anonymous Resident was using an oxygen concentrator with no humidifier and the oxygen tubing was not dated. Anonymous Resident stated her nose gets irritated, but staff don't do anything. During an observation on 12/14/23 at 8:16 a.m., Anonymous Resident oxygen tubing was still not dated and there was still no humidifier attached to the concentrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 39 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated oxygen tubing had to have an exact date when it was changed. Licensed Staff P stated not dating the oxygen tubing could lead to staff assuming it was recently changed even though it was not. Unlicensed Staff P stated this could cause bacteria to accumulate and could cause respiratory infections. Licensed Staff P stated if a concentrator was used, a humidifier should be added. Licensed Staff P stated not using a humidifier while on oxygen could lead to nasal passages irritation, nose bleeding and dry nose. During an interview on 12/15/23 at 11:34 a.m., the DSD stated the oxygen tubing orange sticker indicated the oxygen tubing was changed. The DSD stated the orange sticker still needed to have the date on when the oxygen tubing was changed. The DSD stated it was important to put on the date on when oxygen tubing was changed because debris could accumulate in the oxygen tubing and this could lead to respiratory infection. The DSD stated using a humidifier was important to keep nasal passages moist. The DSD stated if a humidifier was not used while on oxygen therapy, it could lead to dry nasal passages which could be painful, and could lead to nosebleed. The DSD stated residents would feel uncomfortable. The DSD stated residents then might not want to use oxygen which could lead to respiratory issues. During an interview on 12/15/23 at 12:46 p.m., the DON stated it was the facility's expectation to have a date on the orange sticker attached to the oxygen tubing to identify when it was last changed. The DON did not respond when asked what could happen or what the risks were for residents if an oxygen tubing were not dated to indicate when it was last changed. A review of the facility's policy and procedure (P&P) titled Oxygen Therapy- Mask and Nasal Cannula, undated, the P&P indicated humidifier bottle should be changed every 10 days and humidifier bottle must be dated. 3. During an observation on 12/11/23 at 11:17 a.m., a fly was noted in the kitchen. During a concurrent observation and interview on 12/11/23 at 1:05 p.m., Resident 50 stated there were flies in the dining room. Resident 50 stated he would slap the flies but he couldn't. Resident 50 stated the flies had been an issue because it can get into their food. During a concurrent observation and interview on 12/11/23 at 11:25 a.m., more flies were noted in the kitchen. The registered dietician (RD) stated they knew about the flies but they could not identify the source. The RD stated this was not the first time the kitchen had flies. During a concurrent observation and interview on 12/12/23 at 11:52 a.m., Resident 50 came in the dining room with red, hand shaped fly swatter. When asked what was that for, Resident 50 stated it was to kill the flies. Resident 50 stated the flies bothered him a lot as there were flies where he was eating. During an observation on 12/13/23 at 9:35 a.m., there was an uncovered thickener scoop left on top of the thickener bucket. During an observation on 12/13/23 at 9:36 a.m., the RD also saw the flies in the kitchen. The RD stated, I know. During an observation on 12/13/23 at 9:49 a.m., there were cut up eggs left uncovered in the kitchen where flies were noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 40 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 During a concurrent observation and interview on 12/13/23 at 9:56 a.m., Dietary Aide 1 was notified there was a fly that landed on the cut up eggs. Dietary Aide 1 responded by covering the cut up eggs with aluminum foil. Dietary Aide 1 did not throw the cut up eggs in the trash at that time. During a concurrent observation and interview on 12/14/23 at 6:20 a.m., there were flies noted on the uncovered butter and whisk. Dietary Aide 2 was notified, he stated oh yeah. Butter and whisk remained in the area between the oven and the stove. Dietary Aide 2 did not throw the butter nor remove the whisk in the area between the oven and the stove at that time. During an observation on 12/14/23 at 6:30 a.m., the butter and whisk that was touched by a fly was still in the area between the stove and the oven. During an observation on 12/14/23 at 7:10 a.m., [NAME] 1 transferred a scoop of brown sugar from a large tub to a little container. When done, cook 1 did not cover the large tub of brown sugar and the scoop. A fly was then noted on the brown sugar inside the tub, then it flew to the scoop that was left inside the uncovered brown sugar tub. During an interview on 12/14/23 at 7:37 a.m., the Director of Nursing (DON) asked how the facility survey was doing. She was notified there were flies in the kitchen, the dining room, and the hallways. The DON stated she didn't really knew about the flies, but she had heard it from the grapevine. During an interview on 12/14/23 at 12:12 p.m., the Maintenance Director stated he did not know why there were flies in the facility. The Maintenance Director stated it was important not to have flies in the kitchen for safety and hygienic purposes. The Maintenance Director stated flies could cause residents to get sick. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff D made a face and appeared disgusted when asked what could potentially happen if a fly landed on uncovered kitchen items for cooking or on residents' food. Unlicensed Staff D stated residents could get sick, there would be contamination as flies could have landed on a fecal matter before landing on uncovered kitchen items for cooking and residents' food. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated the facility had flies. Licensed Staff P stated flies could lead to GI infection. During an interview on 12/15/23 at 11:34 a.m., the DSD stated flies were an infection control issue. The DSD stated flies throw up, could land on food after they had landed on fecal matter or trash. The DSD stated the kitchen items and food use for cooking should be covered at all times to ensure flies does not land on cooking items and food. During an interview on 12/15/23 at 12:46 p.m., the DON stated flies in the facility could lead to vector borne illness and could possibly cause residents to get sick. During an interview on 12/15/23 at 1:17 p.m., the RD stated flies carried a risk and potential for food borne illness. A review of the facility's policy and procedure (P&P) titled Pest Control, revised 5/2008, the P&P indicated the facility shall maintain an effective pest control program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 41 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 4. During an observation on 12/14/23 at 8:27 a.m., Resident 48 was eating his breakfast, and a urinal with minimal amount of urine was at his overbed table along with his meal. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated there should be no urinals at the overbed table while resident was eating for infection control purposes. Unlicensed Staff O stated there should be nothing on top of a resident commode for infection control issues and dignity. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated urinals at the overbed table while resident was eating and putting food items on top of the commode was not acceptable and runs the risk for contamination. Unlicensed Staff P stated residents could get sick and could have GI infection. During an interview on 12/15/23 at 11:34 a.m., the DSD stated residents should not have a urinal at the overbed table while they were eating. The DSD stated if a resident was confused, resident might consume the fluid in the urinal, or the contents of the urinal might spill on residents' food. The DSD stated this was an infection control issue and residents could get sick. The DSD stated it was not okay to have a food item on top of the commode. The DSD stated putting food item on top of the commode was a risk for infection as commode was used for bowel and bladder elimination. The DSD stated food could land on the commode, if not adequately cleaned, residents could get sick with GI infection. A review of the facility's policy and procedure (P&P) titled Resident Rights, revised 2/2021, the P&P indicated residents have a right to a dignified existence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 42 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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, interviews and record reviews, the facility failed to ensure the kitchen walls were in good repair when holes on the walls were noted. This failure could result in rodents and pest accessing the kitchen area through these holes which could put residents at risk for harmful diseases. Residents Affected - Few During a concurrent observation and interview on 12/14/23 at 6:44 a.m., when asked about the multiple holes on the kitchen wall by the dish sanitizing machine, the Registered Dietician (RD) stated she could not identify what those holes were, but it could possibly be screw holes. When asked if those kitchen holes should be covered, she stated she does not know how deep those were, but she would notify maintenance today. The RD stated she conducted environmental rounds in the kitchen monthly. The RD stated she did not recall if she had noted these kitchen holes on her kitchen environmental rounds. During a concurrent observation and interview on 12/14/23 at 12:12 p.m., the Maintenance Director was shown the holes in kitchen wall by the dish sanitizing machine. The Maintenance Director stated these kitchen wall holes were not reported to him. The Maintenance Director stated it was important the kitchen wall holes were covered to ensure pest could not enter the kitchen through these holes for residents' safety and sanitary reason. The Maintenance Director stated the kitchen area was damp and had moisture, so it could attract pest. The Maintenance Director stated the holes on the kitchen walls would need to be covered. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated holes on the kitchen walls should be covered otherwise pest could get inside the facility through these holes and the facility could have issues with pest control. Unlicensed Staff O stated pest could contaminate residents' food and residents could get sick. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated holes on the kitchen walls should be covered so pest couldn't enter the facility through these holes. Licensed Staff P stated it was a safety issue as resident's food could be exposed to pests and could lead to residents getting sick. During an interview on 12/15/23 at 11:34 a.m., when asked about the holes on the kitchen wall, the DSD stated she would contact the Maintenance Director and would ask him to fill the holes on the kitchen walls. The DSD stated the holes on the kitchen walls should be covered because the facility would not want something from the outside to get inside and moisture could get in the holes in the kitchen wall and become a breeding point for pests. The DSD stated these could result to contamination, bacteria and germs could also breed in the food or kitchen items. A review of the facility's policy and procedure (P&P) titled Maintenance Services revised 12/2009, the P&P indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .maintaining the building in good repair and free from hazards . the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building was maintained in safe and operable manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 43 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0943 Level of Harm - Minimal harm or potential for actual harm Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility did not ensure training materials, resources, and policies and procedures explained all allegations of abuse must be reported in two hours. Residents Affected - Some This failure resulted in staff not knowing the correct timeline to submit an SOC341 (State of California Report of Suspected Dependent Adult / Elder Abuse) (This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult.), after they had become aware of an allegation of abuse. Finding: During an interview on 12/13/23, at 12:00 PM, CNA Q stated she would report allegations of abuse to charge nurse and the nurse would report and file an SOC 341. She stated the time to report is 24 hours. During an interview and record review with Director of Staff Development (DSD), on 12/14/23, at 11:15 a.m., she stated Abuse Prevention and Reporting was completed for every new hire and at annual in-services. She stated Abuse Reporting time frame was Two hours if harm and 24 hours if no harm. A review of the resources and documents used for Abuse Prevention and Reporting training indicated a document titled, Mandated Reporter California Long Term Care Ombudsman Association, not dated, indicated for allegations of Physical Abuse Serious Bodily Injury within 2 Hours Written Report SOC341 to: Licensing Agency. Physical Abuse No Serious Bodily Injury Within 24 hours: Written Report SOC341 to: Licensing Agency. Licensed Nurse O stated The Abuse Training Program information was here when I started and I did not know where it came from. During an interview and record review on 12/14/23, at 11:52 a.m., Unlicensed Staff N stated staff needed to report any abuse immediately or in two hours. He stated he was unsure but there was a resource binder at the nursing station with information on reporting abuse. Review of a document titled Mandated Reporter California Long-Term Ombudsman Association, dated 1/1/2013, Indicated Observes, has knowledge of, or reasonably suspects Physical Abuse in a Long-Term Care Facility, Serious Bodily Injury, Within 2 Hours: Written Report SOC341 to Licensing Agency. No Serious Bodily Injury Within 24 hours: Written Report SOC341 to Licensing Agency. Unlicensed Staff P stated the document was confusing. During an interview on 11/14/23 at 11:49 a.m., Licensed Nurse A stated she did not know when to report abuse to the Licensing Agency and asked Was it two hours? During an interview on 11/14/23 at 11:55 a.m., at 11:55 a.m., Licensed Nurse A stated reporting abuse should occur immediately or within 24 hours. She stated I don't know the difference for reporting abuse. During an interview on 11/14/23 at 12 p.m. Unlicensed Staff T stated Abuse reporting should be done in 36 hours? During an interview with Licensed Nurse K she stated all competency orientation documents included abuse training, and stated all staff were educated about filling out the SOC341. She stated if something happened they would have called the Director of Nursing, or Administrator. She stated an abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 44 of 45 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 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some allegation, if serious, would be reported in two hours or 24 hours if the abuse was non serious. She stated non serious was defined as when two residents with dementia have an exchange but then forget about it and there was no visible sign of injury. During a concurrent interview and record review, on 12/15/23, at 10:15 AM, CNA R stated she would report abuse to the abuse coordinator immediately. Review of a card in her badge carrier indicated to report abuse within 24 hours. She stated the card was given to her by the Director of Staff Development (DSD) as part of abuse training. During an interview and record review, on 12/15/23, at 11:10 a.m., Administrator In Training (AIT), stated he was the abuse coordinator for the facility and thought an Abuse allegation and a completed SOC341 should be reported immediately, or between two to 24 hours. He stated two hour reporting was for serious bodily injury and 24 hours was no visible resident injury. During a review of a document titled Mandated Reporter California Long-Term Ombudsman Association, dated 1/1/2013, it indicated Observes, has knowledge of, or reasonably suspects Physical Abuse in a Long-Term Care Facility, Serious Bodily Injury, Within 2 Hours: Written Report SOC341 to Licensing Agency. No Serious Bodily Injury Within 24 hours: Written Report SOC341 to Licensing Agency. Administrator in training stated he not aware of the requirement to report all allegations of abuse in two hours. He stated he did not know the regulation. He stated the risk of not reporting allegations of abuse in two hours to state agency was the risk being inconsistent with reporting and losing trust with resident's, resident families, and facility staff. He stated it resulted in staff confusion about required two hour reporting times. He provided a document titled, Abuse Reporting Requirements (name) Healthcare , dated 2017, indicated All alleged violations immediately but not later than 1) 2 hours-If the alleged violation involves abuse . Review of a document titled Policy: Abuse Reporting and Response, dated 9/2017, indicated The Center immediately reports all suspected and / or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follow: a. Immediately but not later than 2 hours . Review of a document titled (Place Building Logo here) Reportable Incident Investigation Tool, dated 07/2017, indicated Initial reporting: .Submit the appropriate state specific form (initial report) within the state's mandated reporting requirement (2 or 24 hours). Review of the State Operating Manual, dated 2017, indicated §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Request for a copy of the Federal Regulation about abuse reporting timeline was made to the facility, and not received before the end of survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 45 of 45