Health inspection·October 16, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the allegation. Certified Nurse Assistant H confirmed receiving a call in her personal cell phone. Certified Nurse Assistant H stated she told Resident 76 and Resident 16 she had received a phone call from her son, but claimed she was taking her break when she received the phone call, and stated she immediately told the person on the line to call back tomorrow and hung up. Certified Nurse Assistant H stated staff was not allowed to have cellphones in the building, but reiterated that when she answered it, she was taking a break. During the interview, part of Certified Nurse Assistant H's cellphone was visible peeking out of her shirt's front pocket. Certified Nurse Assistant H stated she was taking a break and was walking towards the cafeteria when she was approached for the interview, therefore, she needed her cellphone because she kept her credit card inside the cell phone case. The cell phone had a pink protective case. During a second interview on 10/11/19 at 9:40 a.m., Resident 76, retold the same story, and stated Certified Nurse Assistant H was not taking a break when she was observed using her personal cell phone. Resident 76 stated Certified Nurse Assistant H took her breaks during the last hour of her work shifts, therefore, Certified Nurse Assistant H was not on break during the incident. Resident 76 also stated, How are we going to heal with people like that? During an interview on 10/14/19 at 3:51 p.m., the Director of Nursing (DON) stated Certified Nursing Assistants were not allowed to use personal cell phones while working, or in resident areas. During an interview on 10/14/19 at 3:30 p.m., the Director of Staff Development (DSD) stated Certified Nursing Assistants were not allowed to use cell phones during work hours, and if they needed to use cell phones, they could do so in the break room or outside the facility. She also stated Certified Nursing Assistants were highly discouraged from carrying their cell phones with them and were not allowed to use their cell phones in resident care areas. In addition, the DSD stated it was not appropriate to tell residents, I am too busy to help you, and explained they should ask the residents to give them a minute, and find another Certified Nursing Assistant to assist them. The facility policy titled, Resident Rights, last revised on 10/04/2016, indicated, As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside or outside the facility. A facility document titled, Good to Great, indicated under the headline Personal Communications, Personal telephone calls, texting or any other form of personal electronic communication are prohibited during work hours. This includes the use of personal electronic devices for personal reasons. Incoming urgent calls to our offices will be directed to you. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 2 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 12) had the right to make choices about aspects of his life that were significant to him regarding his smoking status. This failure resulted in nicotine withdrawal, anger, frustration, and strain on family dynamics. Findings: During an interview with the administrator and the Director of Nurses (DON), on 10/8/19, at 10 a.m., they stated the facility was non-smoking. They both stated the facility did not have any residents that smoke. During the group meeting, on 10/10/19, at 3:30 p.m., two residents identified as active smokers. Resident 78 stated he had a friend walk him out of the facility and they go smoke in the friend's car. Resident 78 stated he was told the facility was a non-smoking facility. Resident 78 confirmed he was not provided any alternate method to treat his nicotine addiction. Resident 12 stated he was told the facility was non-smoking. Resident 12 stated he had cigarettes when he got to the facility and the admitting staff took his cigarettes and supplies and stored them. Resident 12 stated his niece visited him at the facility and would sign him out and drive him to the store to buy more cigarettes. Resident 12 stated his niece let him smoke in her car. During an observation, on 10/10/19, at 5:05 p.m., Resident 12 was trying to exit the facility through the double doors in front of the conference room. The administrator stopped in the hall to talk with Resident 12. Resident 12 stated he was pissed off because his niece was supposed to bring cigarettes, and take him out for a smoke. Resident 12 attempted to push the doors open. The administrator offered Resident 12 an ice cream, or if he wanted to attend an activity. Resident 12 declined both offers and wheeled himself towards his room. During a review of the clinical record for Resident 12, on 10/10/19, at 5:50 p.m., the History and Physical section indicated Resident 12 was a smoker. The doctors note indicated Resident 12 smoked a few cigarettes daily and had done so for many years. During an interview with the DON, on 10/11/19, at 9:27 a.m., she confirmed the facility was a non-smoking facility. The DON stated the admissions coordinator would not accept a smoker for admission. The DON stated the facility always completed the smoking assessment at the time of admission. The DON reviewed Resident 12's assessment and confirmed he was assessed as an active smoker. The DON was unable to provide documentation to show Resident 12's smoking status was addressed on his care plan. The DON reviewed Resident 12's medical record and was unable to provide documentation to show how the facility was going to treat his nicotine withdrawal. The DON stated she did not know Resident 12 was a smoker. The DON stated no one told her Resident 23 was a smoker. During an interview with Resident 12, on 10/11/19, at 11:43 a.m., Resident 12 stated not smoking was hard. Resident 12 stated he was craving a cigarette right at that moment. Resident 12 stated he was trying to get ahold of his niece to take him for a ride to smoke. Resident 12 stated facility staff had his cigarettes, so he had no options. Resident 12 shook his head and stated it was very hard. Resident 12 stated he called his brother at his work to find his niece. Resident 12 stated he needed help to go out to smoke. Resident 12 explained he had to depend on family, and it was causing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 3 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few family stress because he was nagging his brother and niece for support. Resident 12 stated not smoking was messing up his entire day. Resident 12 stated he always started his day with coffee and a cigarette, and at the facility it was just coffee. Resident 12 stated he was jonesing for a cigarette and then he thinks about smoking all day, it was really hard. Resident 12 confirmed no one at the facility offered him a nicotine patch or gum to reduce the cravings. Resident 12 stated the withdrawal was making him stressed and anxious, he stated sometimes his skin felt like it was crawling. During an interview with the administrator, on 10/11/19, at 5:30 p.m., he stated he was working with the hospital to find a safe place for smoking. The administrator stated on 7/1/19 the management company took over facility and it had always been a non-smoking. The administrator could not provide any documentation that showed the facility had taken steps to reduce the nicotine cravings for smokers. The facility policy and procedure titled: Resident Rights, dated 10/16, indicated residents had the right to make choices about aspects of their life in the facility that are significant to them. The hospital policy and procedure titled: Smoking Policy, dated 2/16, indicated upon admission to the acute hospital, patients would be asked if they were current smokers. The policy indicated patients would be offered a nicotine substitute unless contraindicated. The policy indicated residents in the skilled nursing facility were exempted from the policy and had the right to smoke in the area designated by signage or off-campus. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 4 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 - Some 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** Resident 125 During an interview with Resident 125, on 10/8/19, at 5:09 p.m., he stated he had been at the facility for about a week. Resident 125 stated he completed antibiotic treatment the day prior. Resident 125 stated he liked to be in his room and did not attend group activities. Resident 125 had not received in room activities. Resident 125 stated the plan was to discharge to home within the week. During a review of the clinical record for Resident 125, the admission record indicated Resident 125 was admitted to the facility on [DATE]. During a review of the clinical record for Resident 125, the care plan section indicated a baseline care plan was started on 10/2/19. the interventions section for each focus was not filled in. The computer generated interventions had blank space to fill in resident-specific information. The interventions for the diet focus had no documentation of the diet Resident 125 needed. The interventions failed to include the amount of assistance Resident 125 required. During an interview with Certified Nurse Assistant T (CNA T), on 10/8/19, at 6:11 p.m., she stated she had worked at the facility for three weeks. CNA T stated she was familiar with Resident 125's care needs. CNA T reviewed the care plan for Resident 125, and identified the focus for level of assistance required for activities of daily living (ADL). CNA T reviewed the interventions the ADL focus and confirmed the interventions did not specify what assistance Resident 125 needed. CNA T reviewed the care plan and was unable to provide documentation to show how Resident 125 transferred from one position to another. During an interview with the Director of Nursing (DON), on 10/16/19, at 2:13 p.m., she reviewed the care plan for Resident 125. The DON was unable to provide documentation that showed what type of pain Resident 125 had. She was also unable to find what helped with Resident 125's pain or what made it worse. The DON was unable to provide documentation that showed Resident 125's food preferences. The DON was unable to provide documentation that showed Resident 125's level of assistance needed for ADLs. The DON was unable to provide documentation that showed Resident 125's discharge goal or the interventions to support that goal. The DON confirmed the baseline care plan had not been completed. The DON confirmed the interventions were not resident-specific. The DON stated Resident 125 discharged on 10/15/19. The facility policy titled, Comprehensive Person-Centered Care Planning, last revised in July of 2019 indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a residents medical nursing, mental and psychosocial needs that are identified in the comprehensive assessment .Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. Based on interview and record review, the facility failed to create a baseline care plan for two of twelve sampled residents (Resident 74 and Resident 125), upon admission. This failure had the potential to result in ineffective, poor-quality care to the residents involved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 5 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 Findings: Level of Harm - Minimal harm or potential for actual harm Resident 74 Residents Affected - Some Resident 74 was admitted to the facility on [DATE] with medical diagnoses including Malignant Neoplasm of Female Breast (Breast Cancer), according to the facility Face Sheet (Facility Demographic). During initial screening, Resident 74 was getting ready for a dressing change to her left breast. With Resident 74's permission, the dressing change was observed on 10/08/19 at 10:15 a.m. An extensive red, wet, and open wound was observed covering most of Resident 74's left breast. During record review on 10/15/19 at 9:15 a.m., no baseline care plan was found for Resident 74. During an interview on 10/15/19 at 11:05 a.m., Medical Records Staff F stated she was unable to find a baseline care plan for Resident 74. During an interview on 10/15/19 at 11:46 a.m., the Director of Nursing (DON) confirmed she could not find a baseline care plan for Resident 74. The DON stated she believed they (facility staff) were required to initiate a baseline care plan for new residents. The DON also stated admitting nurses were responsible for creating baseline care plans for new admissions. A Nursing Plan of Care for the wound on Resident 74's left breast was created on 10/07/19, four days after admission. This Nursing Plan of Care indicated, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short .Educate resident/family/caregivers of causative factors and measures to prevent skin injury .Encourage good nutrition and hydration in order to promote healthy skin .Follow facility protocols for treatment of injury .Occupational, Physical Therapy evaluation and treatment per physician orders. There were no other interventions to care for the wound, in the Nursing Plan of Care. There were no specific, resident-centered interventions in the plan of care that addressed the dressing changes or other treatments or medications ordered for Resident 74's wound. Physician orders dated 10/08/2019 indicated, Left breast open area: cleanse with NSS (Normal saline) & gauze, pat dry, swipe periwound (tissue surrounding a wound) with skin prep (a protective film on skin), apply moist gauze to wound bed then cover with dry gauze, & cover with a form drsg (dressing) qd (daily) & PRN (as needed). This information was not included in the Plan of Care initiated on 10/07/19 for the breast wound. Prescribed Pain medication was not included in the Plan of Care for the breast wound. A Nursing Plan of Care for pain management was initiated on 10/3/19 (day of admission), but was not client specific and did not indicate what specific pharmacological or non-pharmacological interventions relieved Resident 74's pain. The Nursing Plan of Care had standardized interventions including, Able to (SPECIFY: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain) .Administer analgesia as per orders. During an interview on 10/15/19 at 10:48 a.m., the Director of Nursing (DON) confirmed the Nursing Plan of Care for Resident 74's breast wound was not resident centered and did not provide the necessary information to take care of the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 6 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1 During a review of the clinical record for resident 1, the care plan indicated on 9/19/19 she had a 5% weight loss. The goal section indicated a desired body weight of 105-116 pounds. The intervention indicated provide assistance with no specifics of what assistance Resident 1 needed. An additional intervention indicated (set up, limited, extensive, total). provide assistance or cueing with meals as needed, with nothing circled that identified which level of assistance Resident 1 needed. Another intervention indicated weekly weights times 4 weeks and then monthly if stable. The intervention date indicated created on 7/15/19. During a review of the clinical record assessments section indicated a Nutritional interdisciplinary team update dated 9/19/19, at 12:06 p.m., On 07/10/2019, the resident weighed 111.3 lbs. On 10/03/2019, the resident weighed 102 pounds which was a 8.36 % weight loss. During an interview with the Director of Nursing (DON), on 10/16/19, at 11:20 a.m., she reviewed Resident 1's care plan interventions. The DON confirmed Resident 1 continued a nutritional supplement without reassessment of the intervention. Resident 1 continued to lose weight and did not switch to a high protein supplement. The DON reviewed the medical record and confirmed the intervention of weekly weights not implemented from care plan. Review of the care plan tasks indicated less than 50% consumed then alert the kitchen. The DON was unable to provide documentation the kitchen was alerted for the seven out of ten meals that were less than 50%. The DON had no explanation for why Resident 1's weight was not being monitored. The DON stated Resident 1's treatment did not meet her expectation for implementation of a care plan. Based on interview and record review, the facility failed to create comprehensive, resident-centered care plans for three of twelve sampled residents (Resident 74, Resident 77 and Resident 1). This had the potential to result in failure to meet the residents' preferences and goals, and address the residents' medical, physical, mental and psychosocial needs. Findings: Resident 74 Resident 74 was admitted to the facility on [DATE] with medical diagnoses including Malignant Neoplasm of Female Breast (Breast Cancer), according to the facility Face Sheet (Facility Demographic). A Nursing Plan of Care for the wound on Resident 74's left breast was created on 10/07/19, four days after admission. This Nursing Plan of Care indicated, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short .Educate resident/family/caregivers of causative factors and measures to prevent skin injury .Encourage good nutrition and hydration in order to promote healthy skin .Follow facility protocols for treatment of injury .Occupational, Physical Therapy evaluation and treatment per physician orders. There were no other interventions to care for the wound, in the Nursing Plan of Care. There were no specific, resident-centered interventions in the plan of care that addressed the dressing changes or other treatments or medications ordered for Resident 74's wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 7 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0656 Level of Harm - Minimal harm or potential for actual harm Physician orders dated 10/08/2019 indicated, Left breast open area: cleanse with NSS (Normal saline) & gauze, pat dry, swipe periwound (tissue surrounding a wound) with skin prep (a protective film on skin), apply moist gauze to wound bed then cover with dry gauze, & cover with a form drsg (dressing) qd (daily) & PRN (as needed). This information was not included in the Plan of Care initiated on 10/07/19 for the breast wound. Prescribed Pain medication was not included in the Plan of Care for the breast wound. Residents Affected - Some During an interview on 10/15/19 at 10:48 a.m., the Director of Nursing (DON) confirmed the Nursing Plan of Care for Resident 74's breast wound was not resident centered and did not provide the necessary information to take care of the wound. Resident 77 Resident 77 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lower End of Femur (Thigh Bone), according to the facility Face Sheet (A facility demographic). During an interview on 10/08/19 at 2:47 p.m., Resident 77 stated that her pain level was a 9 from a scale from 0 to 10 (0 being no pain, 10 being the worst pain experienced). She stated her pain level had not been controlled since admission. Resident 77's Nursing Plan of Care for pain, dated 10/07/19, indicated, Administer Analgesia as per orders .Identify, record and treat resident's existing conditions which may increase pain or discomfort. The Plan of Care did not specify pharmacological or non-pharmacological interventions that were specific and effective in treating and managing pain for Resident 77. During an interview on 10/14/19 at 4:11 p.m., the MDS (Minimum Data Set-An Assessment tool) Coordinator confirmed Resident 77's Nursing Plan of Care to treat pain was not resident centered or client specific. The facility policy titled, Comprehensive Person-Centered Care Planning, last revised in July of 2019 indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a residents medical nursing, mental and psychosocial needs that are identified in the comprehensive assessment .Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 8 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 - Few 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 revise and update a comprehensive care plan for one of twelve sampled residents (Resident 5), after he suffered a fall at the facility. This failure could have resulted in further falls, with possible injuries to Resident 5. Findings: Resident 5 was admitted to the facility on [DATE] with medical diagnoses including Congestive Heart Failure (A condition in which the heart can't pump enough blood to meet the body's needs) and Glaucoma (A condition of increased pressure within the eyeball, causing gradual loss of sight), according to the facility Face Sheet (A facility demographic). A Nursing Plan of Care initiated upon admission on [DATE] to prevent falls indicated, Be sure call light is within reach and encourage to use it to call for assistance as needed .bed in lowest position .Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c (wheelchair) .Keep needed items, water, etc, in reach. Despite these interventions, Resident 5 suffered a fall on 9/18/19. A change of condition note dated 09/18/19 at 14:06 p.m. indicated, Around 1315 (1:15 p.m.) Resident (Resident 5) was found on the floor sitting on his feet in front of the toilet bowl. Per resident he tried to transfer himself from wheelchair to toilet but missed the seat. The Nursing Plan of Care to prevent falls was revised on 09/18/19 after the fall, but only contained the following interventions, Bed in lowest position .Continue interventions on the at-risk plan .Monitor/document/report to MD for s/sx (symptoms): Pain, bruises, Change in mental status .Vital signs per orders. There were no new interventions to prevent further falls. During an interview on 10/11/19 at 3:09 p.m., the Director of Nursing (DON) confirmed the care plan did not have new interventions to prevent further falls for Resident 5, and stated it was a requirement to include new interventions in care plans for falls, after a resident had suffered a fall. An undated facility document titled, Falling Star Program Enrollment, provided by the Director of Nursing (DON) on 10/16/19 at 10:30 a.m. indicated, Resident who had a fall in the past 90 days in the facility will be enrolled in facility falling star program .Frequent rounds (at least hourly) will be done to check resident. There was no documentation that Resident 5 was enrolled in the Falling Star Program until 10/14/19 at 8:24 a.m. (26 days after the fall). On 10/14/19 at 8:24 a.m. an interdisciplinary fall committee note documented Resident 5's enrollment in the program. The facility policy titled, Fall Management last revised on 7/2019, indicated, Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk .When a resident sustains a fall, a physical assessment will be completed by a licensed nurse .Resident's care plan will be updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 9 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 follow its policies or professional standards of practice, when: Residents Affected - Many 1) Licensed staff did not document neurological assessments for one resident (Resident 10) after two unwitnessed falls, 2) A Licensed staff administered a medication brought from home, to a resident (Resident 76), without physicians' orders, 3) A Licensed staff requested an out of stock medication from a resident's family member (Resident 76) instead of calling pharmacy for it, 4) A Licensed nurse administered a medication without verifying that the medication was not expired, and 5) The pharmacist did not identify irregularities when six out of twevle sampled residents (Resident 1, 2, 7, 28, 76, and 77) did not get their medication. cross reference F tag 755. These failures had the potential to result in poor quality care, diversion of drugs, and harm to the residents of the facility. Findings: 1) Resident 10 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Left Femur (Thigh bone), and Diabetes Mellitus, according to the facility Face Sheet (Facility Demographic). First Fall: A Change of Condition Note documented on [DATE] at 11:27 a.m. indicated, On 8.5.2019 at around 0900 (9:00 a.m.), Patient (Resident 10) had an Unwitnessed fall .Patient found in a sitting position next to her wheelchair. Patient is alert and oriented to person, place and situation and disoriented to time, patient reoriented to time. Patient asked, what happened, patient stated I was trying to to (sic) the bathroom to pee, I thought I can stand up and walk on my own but I was wrong. Assessment is done. No documentation was found indicating Resident 10 had neurological monitoring done after the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 10 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0658 Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 11:08 a.m., the Director of Nursing (DON) stated she could not find neurological assessments for Resident 10 after the unwitnessed fall on [DATE]. The DON stated the expectation was to document neurological assessments for 72 hours after an unwitnessed fall. Second Fall: Residents Affected - Many A Change in Condition Note dated [DATE] at 8:23 a.m., indicated, Patient (Resident 10) had unwitnessed fall at 0430 (4:30 a.m.) [DATE]; was found sitting on floor between bed and chair .Patient has history of transferring without waiting for assistance. Recommend round q 1 (every hour) assess for needs, bed alarm on when patient is in bed. A document titled, NEUROLOGICAL ASSESMENT FLOWSHEET, dated [DATE] indicated the assessment was only performed from 4:45 a.m. to 6:00 a.m. (one hour and fifteen minutes) after the fall. The rest of the document was left blank. During an interview on [DATE] at 10:15 a.m., the DON confirmed neurological assessments had not been documented for 72 hours for Resident 10 after the fall on [DATE]. When asked for a reason in regards to the incomplete documentation, the DON stated, I don't know. I can't speak for the nurses. They were the ones doing it. The facility policy titled, Charting and Documentation, last revised in July of 2017 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional l or psychosocial condition, shall be documented in the resident's medical record .Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. The facility policy titled, Fall Management, last revised in July of 2019 indicated, When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record .Follow-up documentation will be completed for a minimum of 72 hours following the incident. 2) Resident 76 was admitted on [DATE] with medical diagnoses including Low Back Pain and Repeated Falls, according to the facility Face Sheet. A Physician's order dated [DATE] at 2:27 p.m., indicated, Dexamethasone (A medication that blocks inflammation) tablet 4 MG (Milligrams) Give 1 tablet by mouth one time a day for GLIOBLASTOMA (Brain cancer) until [DATE] 23:59 (11:59 p.m.). A Nursing Note for Resident 76 documented by Licensed Nurse E on [DATE] at 11:23 a.m. indicated, Husband provided 6 tabs of 1 MG Dexamethasone. Resident 76's Medication Administration Record for October, 2019, indicated the medication Dexamethasone Tablet 4 MG was administered to Resident 76 from [DATE] through [DATE]. The record indicated Licensed Nurse E documented having administered the medication to Resident 76 on [DATE]. During an interview on [DATE] at 11:54 a.m., Licensed Nurse E stated the facility was out of the prescribed medication Dexamethasone for Resident 76 on [DATE]. Licensed Nurse E stated Resident 76's husband brought a previously opened bottle of Dexamethasone from home, labeled with the resident's name, to the facility. Licensed Nurse E stated she administered the Dexamethasone brought from home on [DATE] to Resident 76 without verifying with pharmacy to ensure it was the right medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 11 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a second interview on [DATE] at 12:06 p.m., Licensed Nurse E stated she did not verify if there was a physician's order to authorize the administration of Dexamethasone brought from home, before she administered the medication to Resident 76 on [DATE]. Physician Orders active as of [DATE] did not indicate Dexamethasone 4 mg tabs brought from home were authorized for facility administration. During an interview on [DATE] at 11:30 a.m., the DON was asked to provide evidence that medications brought from home were authorized by Resident 76's physician, for administration at the facility. The DON provided evidence that Resident 76's physician authorized for the administration of a medication brought from home, but this medication was not Dexamethasone. There was no evidence that the physician authorized for the administration of Dexamethasone brought from home. The facility policy titled, MEDICATION BROUGHT TO THE FACILITY BY A RESIDENT OR RESPONSIBLE PARTY, last revised in August of 2014, indicated, Use of medications brought to the facility by a resident or responsible party is allowed only when the following conditions are met: 1) The medication name, dosage form, and strength have been verified by: consulting a tablet identification reference (e.g., Physician's Desk reference), or calling the dispensing pharmacy for a physical description of the medication. 2) The medication was ordered by the resident's physician and entered in the resident's medical record for bedside storage and self-administration by the resident. 3) Resident 76 was admitted on [DATE] with medical diagnoses including Low Back Pain and Repeated Falls, according to the facility Face Sheet. A physician order dated [DATE] at 2:27 p.m., indicated, Dexamethasone (A medication that blocks inflammation) tablet 4 MG Give 1 tablet by mouth one time a day for GLIOBLASTOMA (Brain cancer) until [DATE] 23:59 (11:59 p.m.). During an interview on [DATE] at 11:54 a.m., Licensed Nurse E stated the facility was out of the prescribed medication dexamethasone for Resident 76 on [DATE]. She also stated she checked the automatic dispensing unit, but the medication was not available. Licensed Nurse E stated she forgot to call the facility contracted pharmacy to restock it, and instead asked Resident 76's husband if he could bring it from home. A Nursing Note documented by Licensed Nurse E on [DATE] at 11:23 a.m. indicated, Husband provided 6 tabs of 1 MG Dexamethasone. During an interview with the DON on [DATE] at 12:05 p.m., she stated when the facility was out of a particular medication, or had a new order and the medication was not available at the facility, nurses had to verify if the automatic dispensing unit had the medication, or call pharmacy, before obtaining the medication from the resident's home. The facility policy titled, MEDICATION BROUGHT TO THE FACILITY BY A RESIDENT OR RESPONSIBLE PARTY, last revised in August of 2014, indicated, Use of medications brought to the facility by a resident or responsible party is allowed only when the following conditions are met .The medication was ordered by the resident's physician and entered in the resident's medical record for bedside storage and self-administration by the resident. The facility policy titled, PROVIDER PHARMACY REQUIREMENTS, last revised in August of 2019, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 12 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many indicated, pharmaceutical service is available to provide residents with prescription and nonprescription medications, services and related equipment and supplies .The provider pharmacy agrees to perform he following pharmaceutical services, including but not limited to: 7) providing routine and timely pharmacy service as contracted and emergency pharmacy service 24 hours per day, seven days per week. 4) Resident 75 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Neck of Left Femur (Thigh bone), Difficulty in Walking and Need for Assistance with Personal Care, according to the facility Face Sheet. During medication administration observation on [DATE] at 9:04 a.m., Licensed Nurse P prepared the morning medications for Resident 75. One of the medications being prepared for administration was a 500 mg (Milligrams) tablet of Calcium Magnesium Potassium (Electrolytes-important minerals in the body that carry an electric charge), brought by the resident from home. The tablet came in a bottle labeled as an over-the-counter medication, without Resident 75's name on it. The expiration date on the bottle could not be determined, as it had been erased. Prior to the administration of the medication, Licensed Nurse P was asked if she could verify the expiration date of the medication. Licensed Nurse P took the bottle, and asked Resident 75 for the expiration date. Resident 75 told her that she had purchased the bottle three months prior, so it was still good. Licensed Nurse P was observed administering the 500 mg tablet of Calcium Magnesium Potassium to resident 75 on [DATE] at 9:13 a.m., without having been able to verify the expiration date of the medication. During an interview with the DON on [DATE] at 10:01 a.m., she stated Licensed Nurses were not allowed to administer medication if the expiration date was not readable. The DON stated if a medication with an undetermined expiration date was brought from home by a resident or family member, Licensed Nurses had to ask the resident to bring another bottle. The educational nursing book titled, Kozier & Erb's FUNDAMENTALS of Nursing Concepts, Process, and practice 8th Edition, published in 2008 by A.B., S.S., B.K. and B.E., indicated, Check Three Times for Safe Medication Administration .Check the expiration date of the medication .Rationale: Outdated mediations are not safe to administer (pg. 854). 5) During an interview with the DON, on [DATE], at 4:33 p.m., she confirmed pharmacist did not identify a concern or irregularity when six residents (Resident 1, 2, 7, 28, 76 and 77) went multiple times without medication administration due to pharmacy not providing medication. The DON reviwed the Monthly Regimen Reviews and was unable to find documentation to show irregulatities relatedf to missed doses of medication for any of the identified residents. The facility policy and procedure titled: Medication Regimen Review, dated 8/17, indicated irregularities would be identified and reported monthly. The policy further indicated the pharmacist would use federally-mandated standards of care during their review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 13 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff implemented the fall prevention program for one of twelve sampled residents (Resident 10). This failure had the potential to result in further falls, with possible injuries to Resident 10 Findings: Resident 10 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Left Femur (Thigh bone), and Diabetes Mellitus, according to the facility Face Sheet (Facility demographic). First Fall: A Change of Condition Note documented on 08/05/19 at 11:27 a.m. indicated, On 8.5.2019 at around 0900 (9:00 a.m.), Patient (Resident 10) had an Unwitnessed fall .Patient found in a sitting position next to her wheelchair. Patient is alert and oriented to person, place and situation and disoriented to time, patient reoriented to time. Patient asked, what happened, patient stated I was trying to to (sic) the bathroom to pee, I thought I can stand up and walk on my own but I was wrong. Assessment is done. The Nursing Plan of Care for falls was revised after the fall on 08/05/19, and only one new intervention was added, 8/5/19 fall: Huddled with Charge nurse and CNAs (Certified Nursing Assistants) to keep reminding (Resident 10) the use of call light. Resident 10 also had a Nursing Plan of Care for impaired cognitive function and impaired thought processes that indicated, [Resident 10] is forgetful. Second Fall: A Change in Condition Note dated 10/02/19 at 8:23 a.m., indicated, Patient (Resident 10) had unwitnessed fall at 0430 (4:30 a.m.) 10/2/2019; was found sitting on floor between bed and chair .Patient has history of transferring without waiting for assistance. Recommend round q 1 (every hour) assess for needs, bed alarm on when patient is in bed. The Nursing Plan of Care for falls was revised after the fall on 10/02/19, and the following intervention was added, 10/2/19 fall: Restart falling star program for 90 days, educate on importance to use call light and encourage to take less naps during the day to increase better sleep at night. An undated facility document titled, Falling Star Program Enrollment, provided by the Director of Nursing (DON) on 10/16/19 at 10:30 a.m. indicated, Resident who had a fall in the past 90 days in the facility will be enrolled in facility falling star program .Frequent rounds (at least hourly) will be done to check resident. A facility document titled, Documentation Survey Report v2 dated 10/06/19 indicated Resident 10 was visually checked at 11:53 a.m., 3:57 p.m., 3:58 p.m., and 5:00 p.m. by Certified Nursing Assistants during the period of time between 9:00 a.m. and 5:00 p.m. There was no evidence that Resident 10 was visually checked at least hourly, as the Falling Star Program required. These gaps in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 14 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation were present throughout the month of September and part of October, 2019, in Resident 10's document titled, Documentation Survey Report v2. Resident 10's Medication Administration Record (MAR) indicated Licensed Nurses rounded on Resident 10 for morning and evening shifts on 10/06/19 but did not indicate the specific times when Resident 10 was visually checked for safety. This type of documentation was present from 10/01/19 through 10/16/19 in the MAR, in which the specific times when Resident 10 was checked was not documented, therefore, hourly roundings could not be verified. During an interview with the MDS Coordinator on 10/15/19 at 3:52 PM, she was asked how the facility verified that staff visually checked Resident 10 at least every hour. The MDS Coordinator stated Licensed Nurses were responsible for ensuring residents on the Falling Star Program were checked every hour by Unlicensed Staff, but confirmed there was no way to verify if this was actually being done. During an interview on 10/15/19 at 4:17 p.m., Certified Nurse Assistant T, Resident 10's assigned Nursing Assistant, stated there was no requirement to document the visual checks performed on Resident 10 every hour. Certified Nurse Assistant T also stated she was not sure how often residents on the Falling Star Program were required to be visually checked, but assumed it was every twenty to thirty minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 15 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 10, a [AGE] year-old female, was admitted to the facility on [DATE] with medical diagnoses including Fracture of Left Femur (Thigh bone), and Diabetes Mellitus, according to the facility Face Sheet (A facility demographic). Residents Affected - Few During dining observation on 10/08/19 at 12:56 p.m., in the main dining room of the facility, Resident 10 was observed during delivery of her lunch tray. Resident 10 received her meal, but did not receive any drinks with her meal. Resident 10 alerted the Activities Supervisor that she needed a drink, and requested the drink of her choice, which the Activities Director requested by phone to dietary personnel. The drink was delivered to Resident 10 approximately ten minutes after she received her lunch meal. The kitchen failed to include drinks for Resident 10 while preparing her lunch tray, and level of care staff failed to catch this omission during the delivery of the lunch tray. During a second interview on 10/09/19 at 10:23 a.m., Resident 10 confirmed she did not receive any drinks on 10/08/2019 for lunch. Resident 10 stated she was on a thin liquid diet and could drink regular water. During an interview on 10/08/19 at 4:31 p.m., with Registered Dietician (RD) 1 and RD 2, RD 1 stated that depending on the Resident 10's diet orders, she should receive some beverage with her meals. RD 1 stated tray meals were checked by kitchen personnel and Licensed Staff in the dining area. During an interview on 10/14/19 at 12:10 p.m., the Director of Nursing (DON) stated residents were expected to receive drinks with their meals unless they had a Physician's Orders indicating otherwise. The DON also stated she did not think Resident 10 was on fluid restrictions. Physician orders active as of 10/01/2019 indicated, CCHO (Controlled carbohydrate) diet PUREED texture, THIN LIQUIDS consistency. There was no Physician's Order for fluid restrictions. The education nursing book titled, Medical-Surgical Nursing Critical Thinking in Client Care, by P.L. and K.B., published in 2008, indicated, The older adult may become dehydrated without being aware of the need to increase fluid intake .Fluid volume deficit, or dehydration, is a common reason for hospitalization of people over age [AGE] .Older adults have a significant number or risk factors for fluid volume deficit .In addition, the older adult has fewer intracellular reserves, contributing to rapid development of dehydration. Without intervention, mortality from dehydration can exceed 50% in the older adult population. Based on observation, interview, and record review, the facility failed to provide adequate nutrition and hydration services for 2 out of 8 sampled residents (Resident 1 and 10). For Resident 1, the facility failed to identify, implement, and monitor interventions, consistent with the resident's assessed needs and facility policy, which resulted in a severe unplanned weight loss of 8.36% within a three month timeframe from 7/10/19 to 10/3/19. For Resident 10, the facility failed to provide fluid on the lunch meal tray, which had the potential to result in dehydration. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 16 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0692 Level of Harm - Actual harm Residents Affected - Few 1. During a review of the clinical record for Resident 1, the admission Record, dated 10/16/19, at 11:53 a.m., indicated Resident 1 was admitted to the facility on [DATE]. The record indicated Resident 1 was admitted for the primary diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions). The record further indicated Resident 1 was diagnosed with anxiety, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Rheumatoid Arthritis (a disease in which the body's immune system attacks its own tissue, including joints and internal organs. It causes painful swelling and over time can cause bone erosion and joint deformity) and Type 2 Diabetes (a disease that affects how the body uses glucose, the main type of sugar in the blood). During a dining observation, on 10/8/19, at 1 p.m., Resident 1 was served her meal in her room. Facility staff delivered the meal tray, positioned the meal within reach, and exited the room. During an observation, and concurrent interview with Resident 1, on 10/16/19, at 9:25 a.m., in the resident's room, she stated breakfast was ok today. Resident 1 was sitting up in bed, she appeared to have no natural teeth. There was no dentures container within her reach. Resident 1's fingers, on both hands were abnormally bent at the joints, in the opposite angle of how each joint would naturally bend. During an interview with Certified Nurse Assistant J (CNA J), on 10/16/19, at 9:45 a.m., she stated she had worked at the facility for two months. CNA J confirmed she was Resident 1's regular CNA, and was familiar with her needs. CNA J said Resident 1 always ate in her room. CNA J stated Resident 1 needed a lot of encouragement to eat. CNA J stated she delivered the meal tray and positioned everything so Resident 1 could reach it. CNA J confirmed she opened and prepped some components on the tray. CNA J explained, she knew Resident 1 would not eat her oatmeal, so she did not set it up. CNA J stated sometimes Resident 1 would eat her eggs, so she made sure they were within reach and ready to eat. CNA J stated she would check on Resident 1 often, and encourage her to eat. CNA J stated she would check on Resident 1 after passing trays, and remind her breakfast is getting cold. Then, after she did something else she would check in again. CNA J stated Resident 1 would say she was hungry but did not eat. CNA J confirmed she would get Resident 1 an alternate, such as soup, if she did not eat. When asked what percentage of breakfast did Resident 1 eat, CNA J stated 75%. CNA J described 75% as most of the pancakes with syrup. She confirmed Resident 1 did not eat any oatmeal, did not drink any milk or nutritional supplement. CNA J stated she used to weigh the residents she provided care for, but recently the facility changed who was responsible for weights. CNA J knew Resident 1 had new silverware that was easier to grip with her meals. CNA J stated she had not been alerted to any change in Resident 1's health status, she did not know Resident 1 had lost weight. CNA J stated there had been no change in the care she needed to provide. During an interview with Licensed Nurse E (LN E), on 10/16/19, at 11 a.m., she confirmed she was the nurse caring for Resident 1. LN E stated she had worked at the facility for approximately 2 months, and had provided care for Resident 1 on a regular basis. LN E stated there was no change in Resident 1's condition, and there were no alerts in regards to her care. LN E was not aware Resident 1 was losing weight. LN E stated Resident 1 required setup assistance with meals, and ate independently. LN E confirmed there were no orders for weekly weights for Resident 1. LN E stated no concerns for Resident 1 had been reported to her. During an interview with the Director of Nursing (DON), on 10/16/19, at 11:08 a.m., she stated there were no concerns that she was aware of for Resident 1. The DON was not sure if the Interdisciplinary Team had reviewed Resident 1's care yet. The DON confirmed over 5% weight loss in thirty days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 17 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0692 Level of Harm - Actual harm Residents Affected - Few would be a change in condition per the facility policy. The DON stated the expectation would have been a Change of Condition Report in the resident's electronic health record. The DON reviewed the clinical record for Resident 1 and was unable to find documentation of a change in condition. In addition, the DON stated nursing staff would chart every shift for three days, in relation specifically to the change. The DON reviewed the clinical record for Resident 1 and was unable to find documentation of shift reports specific to weight loss for 3 days. The DON stated the expectation could be for nursing or the weights committee to update the care plan, if indicated. The DON reviewed the care plan for Resident 1, the has nutritional problem or potential nutritional problem focus that was initiated on 7/10/19. Of the fourteen interventions, the DON could provide one that had been revised. The DON stated the brand of the supplement was added on 7/30/19. The DON stated weights would be taken weekly, until the weight stabilized, then monthly. The DON reviewed the Orders section, and was unable to find an order to take weights at any frequency. When asked if the review of care for Resident 1 was an accurate reflection of how the facility responded to resident weight loss, the DON stated no, not at all. During an interview with Registered Dietician 2 (RD 2), on 10/16/19, at 12:29 p.m., she stated Registered Dietician 1 (RD 1) was available by phone. RD 2 called RD 1 for interview. RD 1 stated she was familiar with Resident 1 and her care needs. RD 1 confirmed she was aware Resident 1 was losing weight. RD 1 stated she met with the interdisciplinary team a few times and spoke to the therapy department regarding Resident 1's weight loss. RD 1 stated the kitchen would put extra butter on her meal trays, and adaptive silverware was added two days ago. RD 1 stated all residents were seen at the time of admission to assess their nutritional needs and make recommendations to the physician. RD 1 stated if a resident was losing weight they were added to the RD workload to monitor and assist from a dietary perspective. RD 1 stated a different RD would have met with Resident 1 on 10/12/19 for a quarterly review and evaluation. RD 1 stated their department faxed recommendations to the physicians for their review. RD 1 confirmed her department did not monitor for the outcome of their recommendations. RD 1 stated the physician's decision to agree, disagree, or modify a recommendation would go to the nursing department, the same as any other physician orders. RD 1 and RD 2 both confirmed the recommendation to change Resident 1's supplement should have been sent by the facility, not the Dietay Department, because it was a team recommendation. When asked how often should the facility weigh a resident who had unintentional weight change, RD 1 stated weekly until the weight stabilized. RD 1 confirmed monthly weights would be reinstated. RD 1 stated if a resident she was monitoring did not have a weekly weight in the electronic health record she would follow up with the charge nurse or the DON. RD 1 explained the weights were taken and recorded on paper, then input into the record. RD 1 stated if the weights were not done, she would weigh the resident herself. RD 1 was asked; under what circumstance would a resident not have their weight taken at all? RD 1 stated the only example she could think of was if a resident was receiving end of life care and refused to be weighed. RD 1 went on to say the facility should provide education and encourage the resident to be weighed. RD 2 stated the kitchen was sending [brand] nutritional supplements out to Resident 1 at 10 a.m., and 2 p.m. RD 1 confirmed the brand RD 2 provided was not the same as the one recommended by the weights committee. She also confirmed the two supplements had different nutritional composition. Both RD1 and RD2 were asked if there were any additional actions taken by the dietary department to support Resident 1's goal of weight maintenance, neither had anything to add. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 111.3 pounds on 7/10/19 at 4:32 p.m. During a review of the clinical record for Resident 1, the Order Summary report, dated 10/16/19, at 11:59 p.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 18 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0692 indicated one active dietary order, started on 7/13/19. Resident 1 was ordered a controlled carbohydrate diet with mechanical soft food texture. Level of Harm - Actual harm Residents Affected - Few During a review of the clinical record for Resident 1, the Nutrition Evaluation and RDN Review report, dated 7/13/19, at 11 2:0 a.m., indicated the reason for review was admission. The report indicated no supplements were ordered for Resident 1. The report indicated Resident 1's usual weight was 120-125 pounds. The Weight History/Consideration section indicated Resident 1 had not noticed any weight change in the six months prior to the assessment. The report indicated the author calculated Resident 1 had a 7% weight loss from her usual weight. The Dining Information section indicated Resident 1 fed herself and need assistance. The Meal Intake section indicated 60% for the last 5 meals. The report listed loss/gain as the only observed weight trend. The report indicated Resident 1's ideal body weight was 108-132 pounds. The report indicated Resident 1's desirable body weight range was 105-116 pounds. The report identified concerns with Resident 1's nutrition status. Specifically, Resident 1 was not eating enough to meet her nutrient needs. The Recommendations per Registered Dietician section indicated: supplement, weekly weights, provide diet of choice, offer preferences, dietary education, swallow evaluation by speech therapy and verify the diet order was accurate. During a review of the clinical record for Resident 1, the Care Plan, initiated on 7/10/19, indicated Resident 1 had a nutritional problem or potential nutritional problem related to chronic pain, rheumatoid arthritis and dementia. The goal was Resident 1 would maintain adequate nutritional status as evidenced by maintaining her weight. During a review of the clinical record for Resident 1, the Care Plan, the nutritional problem or potential nutritional problem section, dated 7/15/19, Indicated the facility had identified 14 interventions to support Resident 1 maintaining her weight. if eats less than 50%, offer meal replacement was listed as a nursing intervention. No charting or monitoring tools were attached to that intervention. The facility was unable to provide documentation to show how the implementation of the intervention was assessed. Weekly weights for four weeks and then monthly if weight was stable was an identified intervention. Resident 1 was weighed 9 times out of 13 opportunities. Additionally, monitor and report to the physician any signs or symptoms of decreased appetite or unexpected weight loss was an intervention. The facility was able to provide documentation of one fax to the physician requesting a second supplement per day due to weight loss. At the time of exit, no additional evidence showing communication with the physician was provided. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 106.7 pounds on 7/17/19 at 7:19 p.m. During a review of the clinical record for Resident 1, the Orders section, indicated [brand] nutritional supplement one time a day was started on 7/18/19. The supplement was ordered to be given at 5 p.m. During a review of the clinical record for Resident 1, the Care Plan, nutritional problem or potential nutritional problem intervention section, indicated one new intervention. Give supplement as ordered was added to Resident 1's care plan. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 102.5 pounds on 9/18/19 at 11:26 a.m. During a review of the clinical record for Resident 1, the physician communication form, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 19 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0692 Level of Harm - Actual harm Residents Affected - Few 9/19/19, indicated the Interdisciplinary team contacted Resident 1's physician in regards to her weight loss. The form indicated, Resident 1 has a documented weight loss of 9.5# x 1 month (8.5%) and loss of 7.5# x 6 days. The form indicated the facility was going to reweigh the resident. The form indicated Resident 1's average intake over the week prior was 55%. The form indicated the facility requested to give Resident an additional nutritional supplement daily. The form indicated the physician agreed with the recommendation. During a review of the clinical record for Resident 1, the Orders section, indicated [brand] nutritional supplement one time a day in the morning was started on 9/27/19. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 104 pounds on 9/25/19 at 6:35 p.m. During a review of the clinical record for Resident 1, the LN-Nutrition Interdisciplinary Team Update report, dated 9/26/19, at 3: 25 p.m., indicated a most recent weight of 104 pounds. The report indicated Resident 1 had 7.1% weight loss. The report indicated Resident 1 had an average meal intake of 38%. The progress section indicated weight loss most likely due to poor oral intake. The report recommendation was to discontinue the current nutritional supplement and replace with a different brand supplement that contained 350 calories and 20 grams of protein. During a review of the clinical record for Resident 1, no change noted to the record. The facility was unable to provide documentation the LN-Nutrition Interdisciplinary Team Update report, dated 9/26/19, had been communicated to the physician. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 104 pounds on 9/25/19 at 6:35 p.m. Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 102 pounds on 10/3/19 at 2:32 p.m. During a review of the clinical record for Resident 1, a Registered Dietician Note, dated 10/5/19, at 1:48 p.m., indicated Resident 1's weight continued to trend down. The note indicated poor oral intake as a probable cause. The note indicated Resident 1 had eaten less than 50% eight times in ten meals reviewed. The note indicated the RD would continue to monitor Resident 1. During a review of the clinical record for Resident 1, the LN-Nursing Summary-Weekly report, dated 10/6/19, at 3:08 a.m., indicated Resident 1 was able to eat independently. The report indicated Resident 1's oral intake was an average 75% or more for the previous week. The report indicated Resident 1's weight was stable at 102 pounds. The report included a section to document what action had been taken to stabilize Resident 1's weight. That section was left blank. Licensed Nurse N electronically signed the report as complete on 10/6/19. During a review of the clinical record for Resident 1, the LN-Nursing Summary-Weekly report, dated 10/12/19, at 10:33 p.m., indicated Resident 1 was able to eat independently. The report indicated Resident 1's oral intake was an average 75% or more for the previous week. The report indicated Resident 1's weight was stable at 102 pounds. The report indicated the weight was taken on 10/3/19. The report included a section to document what action had been taken to stabilize Resident 1's weight. That section was left blank. Licensed Nurse N electronically signed the report as complete on 10/13/19. During a review of the clinical record for Resident 1, the POC Response History report, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 20 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0692 Level of Harm - Actual harm 10/16/19, provided a 30-day look back window. The report was for CNA task Amount Eaten. The question indicated in the report was, what percentage of the meal was eaten. From 10/12/19 look back 7 days, documentation indicated Resident 1 ate 76%-100% or more of her meal 3 times. The report indicated Resident 1 ate 0%-25% of her meal 4 times during the same timeframe. Residents Affected - Few During a review of the clinical record for Resident 1, the POC Response History report, dated 10/16/19, provided a 30-day look back window. The report was for CNA task Amount Eaten. The question indicated in the report was, what percentage of the meal was eaten. From 10/5/19 look back 7 days, documentation indicated Resident 1 ate 76%-100% or more of her meal 3 times. The report indicated Resident 1 ate 0%-25% of her meal 4 times during the same timeframe. The report further indicated there was one meal Resident 1 refused. During an interview with the Director of Nursing (DON), 10/16/19, at 11:20 a.m., she reviewed the electronic health record for Resident 1. The DON reviewed the care plan interventions and confirmed weekly weights had not been implemented. The DON reviewed the CNA task charting for amount eaten. The DON stated the Nursing Summary report answers should match. The DON confirmed the two documents had conflicting information in regards to how much Resident 1 was eating. The DON reviewed both weekly nursing reports, and stated they were wrong, Resident 1's weight was not stable. The DON was unable to provide any documentation that a physician had evaluated Resident 1 for weight loss. The DON was unable to provide any documentation that a nurse had assessed Resident 1 for weight loss. The DON had no additional evidence or explanation for the lack of assessment and monitoring in regards to Resident 1's weight. During a review of the physical chart for Resident 1, the physician's progress note section, indicated Resident 1 had been seen by a physician on 10/6/19. The chief complaint recurrent headaches. The review of systems section indicated general: Appetite is satisfactory. No significant weight change. The report was electronically signed on 10/7/19 at 3:23 p.m. The facility policy and procedure titled, Nutrition and Weight Loss Policy, dated 7/19, indicated it was the policy of the facility to ensure that all residents maintained acceptable parameters of nutritional status. The policy indicated weight changes would be communicated to the doctor and the resident or resident representative. The policy further indicated the doctor or designee would assess and identify medical conditions, causes and problems related to the resident's nutritional status and needs. The procedure section indicated any resident weight that varied from the previous reported period by five percent in thirty days would be evaluated by the nutrition committee to determine cause and interventions required. The procedure indicated any resident at nutritional risk would be weighed weekly and reviewed during the weekly the nutrition committee meeting. The purpose section indicated the resident's response to interventions would be monitored and evaluated to discontinue or justify continuation of the approach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 21 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed its policies to provide pain management for two of twelve sampled residents (Resident 76 and Resident 77). This failure resulted in 1) Resident 76 suffering from intolerable pain, up to a level 10, on a pain scale from 0 to 10 (0 being no pain, 10 being the worst pain experienced in one's lifetime) and crying for two weeks from back pain, and 2) Resident 77 suffering from severe pain, up to a level 9, on a pain scale from 0 to 10 for four days from a left femur (Thigh bone) fracture, which made her unable to participate in physical therapy, and become depressed. Residents Affected - Few Findings: 1) Resident 76 Resident 76 was admitted to the facility on [DATE] with medical diagnoses including Low Back Pain, Neuralgia (Intense, typically intermittent pain along the course of a nerve) and Pain in Thoracic Spine (Pain caused by joint dysfunction where the ribs attach to the spine), according to the facility Face Sheet (Facility demographic). Resident 76's MDS (Minimum Data Set-An assessment tool) dated 9/30/19 indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 14, which indicated her cognition was intact. Resident 76's MDS also indicated she required assistance with bed mobility and transfers. During an interview on 10/08/19 at 10:56 a.m., Resident 76 stated that for the last two weeks, the facility had not been able to obtain her pain medication, therefore, she had to call her husband to bring her pain medication from home. Resident 76 explained she had undergone several back surgeries that caused her intolerable pain, and she needed Oxycodone (A narcotic pain medication used to treat moderate to severe pain) 30 mg tablets to keep her pain under control. Resident 76 stated her pain level was a 10 on a scale from 0 to 10 during the interview and was observed crying. A Nursing Note for Resident 76 dated 09/30/19 at 2:01 p.m., indicated, Pt (Patient) c/o (complains) 10/10 pain. pain not controlled by current meds. A Nursing Note dated 10/08/19 at 1:00 p.m. indicated, PT (patient) continues to state pain 10/10. During a second interview on 10/09/19 at 8:57 a.m., Resident 76 stated Oxycodone 30 mg was the medication prescribed by her pain medication doctor to control her pain, and it was effective if administered as prescribed, every four hours. She stated she was told by facility staff that the facility contracted pharmacy had to drive her pain medication from Bakersfield, and as a result it took a long time to get it. Resident 76 also stated her pain level was greater than a 10, on a scale from 0 to 10, enough to where she thought she was going to throw up. Resident 76 stated her husband was bringing Oxycodone 30 mg tabs to the facility in a plastic zip lock bag, for medication administration by Licensed Staff. She stated she told everybody at the facility about her pain issues. Resident 76 stated her pain was so bad she could not sleep at night, and the facility would not give her anything to sleep. A Physician's Order, dated 09/29/19 at 6:20 p.m., indicated, oxycodone HCI Tablet 30 MG Give 30 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 22 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0697 by mouth every 4 hours as needed for PAIN MANAGEMENT. Level of Harm - Actual harm During a phone interview on 10/09/19 at 9:40 a.m., Resident 76's husband confirmed he brought Oxycodone 30 mg tablets from home for Resident 76's pain management at the facility. He stated he brought five tablets on three different occasions (for a total of 15 tablets) and gave them to Licensed Nurses at the facility. Resident 76's husband stated nothing was returned to him so he assumed Licensed Nurses used all the Oxycodone tablets he brought to the facility. Residents Affected - Few During an interview on 10/09/19 at 2:07 p.m., the Director of Nursing (DON) stated Oxycodone 30 mg tablets were not in the facility's emergency kit during Resident 76's admission, and it had taken the facility contracted pharmacy longer than four hours for delivery. Other medications were administered to Resident 76 to control the pain but were ineffective. During an interview on 10/10/19 at 1:02 p.m., Licensed Nurse P, Resident 76's assigned nurse, confirmed administering Oxycodone 30 mg tablets brought to Resident 76 from home. Licensed Nurse P stated the medication came in a bottle labeled with the resident's name, description and dose. Licensed Nurse P stated she called the facility contracted pharmacy by phone to verify the medication brought from family was indeed Oxycodone 30 mg tablets. Licensed Nurse P stated after receiving verification from pharmacy, based on the description of the tablet, and obtaining a physician's order, she administered the medication Oxycodone 30 mg tablets to Resident 76. During an interview on 10/11/19 at 11:54 a.m., Licensed Nurse E confirmed Resident 76's husband brought three Oxycodone 30 mg tablets in a zip lock bag on 9/30/19, completely unlabeled, for administration. Licensed Nurse E stated she was the staff member who accepted the tablets, and had the husband sign a document indicating the type and dosage of medication brought from home for accountability purposes. She disproved Licensed Nurse P's statement on 10/10/19 at 1:02 p.m. that the Oxycodone 30 mg tablets from home came in a labeled bottle. Licensed Nurse E stated it usually took six hours for pharmacy to deliver pain medication not available at the facility. A facility document titled, Controlled Substance Accountability Sheet, dated 09/30/19, indicated Resident 76's husband brought three tablets of Oxycodone 30 mg to the facility, and they were accepted by Licensed Nurse E. A medication dispensing record provided by the DON on 10/16/19 at 9:45 a.m. indicated pharmacy delivered only two tablets of Oxycodone 30 mg to the facility on [DATE]. Resident 76's Medication Administration Record indicated these two 30 mg tabs of Oxycodone were administered to Resident 76 that same day (on 10/02/19), leaving her out of her prescribed medication again. According to the medication dispensing record, the pharmacy did not deliver more Oxycodone 30 mg tablets until 10/08/19 (six days later). For 6 days, Resident 76 received only two oxycodone 30 mg tabs from the facility contracted pharmacy, and fourteen tablets from other sources, presumably from medication brought from home. Resident 76's Medication Administration Record indicated Resident 76's pain level was an 8 out of 10 on 10/03/19, 10/04/19, 10/06/19 and 10/08/19. Resident 76's pain level was a 10/10 on 10/07/19. During an interview on 10/14/19 at 12:05 p.m., the DON stated medications that came in a zip lock bag, unlabeled, from home, were not acceptable for facility administration. During an interview on 10/11/19 at 9:42 a.m., Resident 76 stated she had been crying at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 23 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0697 Level of Harm - Actual harm Residents Affected - Few facility as a result of having a pain level of 10 out of 10. She stated it took a couple days to get her pain under control, but it had finally been managed. She confirmed her husband brought the Oxycodone 30 mg tablets from home in an unlabeled clear plastic zip lock bag, and they were accepted by the facility for administration. Resident 76 stated she was in misery (A cause of great distress or discomfort) for two weeks, often crying in pain. When asked if she had suffered as a result of this issue, Resident 76 stated, More than suffering. Resident 77 Resident 77 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lower End of Femur (Thigh bone) and Neuralgia, according to the facility Face Sheet. Resident 77's pain level had been documented as an 8 out of 10 on 10/07/19 and 10/08/19, in her Medication Administration Record. During an interview on 10/08/19 at 2:47 p.m., Resident 77 stated her pain level was a 9, on a scale from 0 to 10. She stated her pain level had not been controlled since admission, and the morning of 10/08/19 she was unable to do her physical therapy as a result of the intolerable pain. Resident 77 stated she had pain from a fracture to her left femur (thigh bone). Resident 77 stated staff informed her that facility physicians would not prescribe medication for her, and she had not seen a physician herself. During an interview on 10/08/19 at 4:43 p.m., Licensed Nurse P, nurse assigned to Resident 77, stated she called the physician that morning (10/08/19) to notify him that Resident 77's pain was not in control, and to request pain medication. The physician gave an order for Norco (Hydrocodone-Acetaminophen-A narcotic analgesic used to treat moderate to severe pain). Licensed Nurse P stated she immediately faxed and called pharmacy at 10:18 a.m., to obtain permission from pharmacy to withdraw the narcotic from the facility's emergency kit. Licensed Nurse P stated that in order to obtain a controlled medication from the emergency kit, pharmacy authorization was required. Licensed Nurse P explained that by 2:00 p.m. she had not received authorization from pharmacy to withdraw the medication from the emergency kit, therefore, she called back to follow up. Licensed Nurse P stated pharmacy put her on hold, and when she finally spoke to a pharmacy representative, was told they had just received her request in regards to Resident 77's Norco order. Licensed Nurse P stated she did not get approval from pharmacy until approximately 3:00 p.m. A Physician's Order dated 10/08/19 at 10:18 a.m., indicated, Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for prn (as needed) pain. During a phone interview on 10/08/19 at 5:01 p.m., Pharmacy Technician U, employed by the facility contracted pharmacy, confirmed receiving a request for Norco the morning of 10/08/19, for Resident 77. She stated pharmacy, Got behind, and she did not know why the medication's withdrawal from the emergency kit was not approved earlier for facility use. Resident 77's Medication Administration Record indicated Norco (Hydromorphone-Acetaminophen) 5-325 mg, was administered for the first time to Resident 77 on 10/08/19 at 3:36 p.m., more than six hours after it was ordered by the physician. During an interview on 10/09/19 at 2:09 p.m., the DON confirmed Resident 77 had a new prescription for pain medication because her pain was not being controlled. The DON stated she had to call the pharmacy's general manager on 10/08/19 at around 3:00 p.m. to get the pharmacy's approval to obtain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 24 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0697 the medication from the emergency kit. Level of Harm - Actual harm Resident 77's Nursing Plan of Care for pain, initiated on 10/07/19, did not list specific pharmacological or non-pharmacological interventions to help alleviate or manage Resident' 77's pain. The care plan was not resident centered and had standardized pain interventions, including, Identify, record and treat resident's existing conditions which may increase pain and discomfort .Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Residents Affected - Few During an interview on 10/11/19 at 9:34 a.m., Resident 77 stated she suffered in horrible pain for several days and was starting to get depressed. During an interview on 10/14/19 at 12:30 p.m., the DON stated they were having issues with pharmacy. She stated pharmacy was not sending them controlled pain medications in a timely manner and made them wait on the phone a long time to speak to a representative. She also stated when pharmacy had to send medications out of stock at the facility, it took pharmacy four hours to deliver it, unless it was sent by satellite, in which case the medication was delivered a bit faster. The DON stated the facility's administrator knew about this issue. The facility policy titled, PROVIDER PHARMACY REQUIREMENTS, last revised in August of 2014, indicated, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: 7) Providing routine and timely pharmacy service as contracted and emergency pharmacy service 24 hours per day, seven days per week. The facility policy titled, Recognition and Management of Pain, last revised in July of 2017 indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility policy titled, Pain Management, last revised in July of 2019, indicated, it is the policy of this facility that pain management is achieved through individualized recognition, assessment, treatments and monitoring of resident's needs through an interdisciplinary and holistic approach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 25 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessment and implementation of bedrails for 16 residents (sampled and unsampled) met required standards of care. This could have resulted in accidents, feelings of entrapment, installation of restraints, and harm to the residents of the facility. Findings: Resident 10 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Left Femur (Thigh bone), and Diabetes Mellitus, according to the facility Face Sheet. During an observation on 10/08/19 at 11:20 a.m., Resident 10 was observed in bed, sleeping, with bilateral bed rails in the up position (bedrails by head of the bed). The DON was asked to provide the bed rail assessment performed on Resident 10 prior to the implementation of the bed rails. An undated facility document titled, Bed Rail Safety Assessment, for Resident 10, indicated she was evaluated for the need for bed rails. This report indicated bed rails were recommended for Resident 10 to promote bed mobility. The bed rail assessment report for resident 10 did not indicate having evaluated Resident 10's communication abilities, sleep habits or the ability to toilet self safely. A facility document titled, LN-Restraint/Enabling Device/Safety Device Evaluation, dated 7/25/19 at 7:47 p.m. indicated, Indicate below, ALL Measures you have tried before Implementing Recommended Device. A checkmark was documented for the following options, New Admit/0 Previous Measures .1/2 or ¼ Side Rails (Right Side) .1/2 or ¼ Side Rails (Left Side), indicating no previous measures have been tried before implementing the use of bed rails. During an interview on 10/14/19 at 12:00 p.m., the DON confirmed all residents using bed rails, including Resident 10, were being evaluated for the use of bed rails using the same standard document titled, Bed Rail Safety Assessment, which did not consider communication as one of the assessment areas. She confirmed the facility had another form titled, Bed Rail Safety Evaluation, to assess for bed rail safety, which evaluated communication abilities, but stated facility staff were not using that form on any residents, and would start using it now. The DON also stated not all residents were using bed rails, since it depended on their individual assessments. The DON also confirmed no previous or alternate methods had been used on Resident 10, prior to installing bed rails. During an observation on 10/14/19 at 12:33 p.m., 16 residents were observed using some form of bed rails. The facility policy titled, Bedrail Assessment, last revised in July of 2019 indicated, It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 26 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for three of twenty-four residents (Resident 16, Resident 76 and Resident 75). This failure resulted in Resident 16 having to suffer from incontinence (Lack of voluntary control over urination or defecation) and feeling uncomfortable sitting in her own bowel movement, and in Resident 76 having to wait for up to two hours for pain medications. This failure also had the potential the keep the residents uncommunicated about their needs, potentially placing them at risk for neglect and harm. Findings: Resident 16 Resident 16, was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lower End of Right Femur (Thigh bone), according to the facility Face Sheet (A facility demographic). Resident 16's MDS (Minimum Data Set-An assessment tool) dated 09/23/2019, indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 15, which indicated her cognition was intact. Resident 16's MDS also indicated she required extensive assistance with ambulation, bed mobility and toilet use. During an interview on 10/08/19 at 10:47 a.m., Resident 16 stated call lights took 45 minutes to 1 hour to be answered, especially at night time, because the facility had less staff. Resident 16 stated she had suffered incontinent episodes for having to wait so long for assistance with toilet use. She stated not feeling well sitting in her own bowel movement. Resident 16 stated she had told facility staff about it, but staff told her they were short-staffed, and were doing the best they could. Resident 16 stated the longest she had to wait for her call light to be answered was 1 hour. Resident 76 Resident 76 was admitted to the facility on [DATE] with medical diagnoses including Low Back Pain and Repeated Falls, according to the facility Face Sheet. Resident 76's MDS dated [DATE] indicated her BIMS score was 14, which indicated her cognition was intact. Resident 76's MDS also indicated she required assistance with bed mobility and transfers. During an interview on 10/09/19 at 8:57 a.m., Resident 76 stated she had to wait up to 2 hours for staff to respond to call lights. She stated she pressed her call light when she needed her attends to be changed, or was in need of pain medication. She also stated pain medication took a long time to be given. Resident 75 Resident 75 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Neck of Left Femur, Difficulty in walking and Need for Assistance with Personal Care, according to the facility Face Sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 27 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0725 Resident 75's BIMS dated 10/03/19 was scored 15, which indicated her cognition was intact. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/09/19 at 8:39 AM Resident 75 stated call bells took ½ hour to be answered on the weekends. Residents Affected - Some During an interview on 10/14/19 at 3:30 p.m., the Director of Staff Development (DSD) stated an appropriate call light response time was 3 minutes. The facility policy titled, Call Light/Bell, last revised in July of 2019 indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff .Answer the light/bell within a reasonable time .Respond to the request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 28 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Resident 76 Residents Affected - Some Resident 76, was admitted to the facility on [DATE] with medical diagnoses including Low Back Pain, Neuralgia (Intense, typically intermittent pain along the course of a nerve) and Pain in Thoracic Spine (Pain caused by joint dysfunction where the ribs attach to the spine), according to the facility Face Sheet (Facility demographic). Resident 76's MDS (Minimum Data Set-An assessment tool) dated 9/30/19 indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 14, which indicated her cognition was intact. Resident 76's MDS also indicated she required assistance with bed mobility and transfers. During an interview on 10/08/19 at 10:56 a.m., Resident 76 stated that for the last two weeks, the facility had not been able to obtain her pain medication, therefore, she had to call her husband to bring pain medication from home. Resident 76 explained she had undergone several back surgeries that caused her intolerable pain, and she needed Oxycodone (A narcotic pain medication used to treat moderate to severe pain) 30 mg tablets to keep her pain under control. Resident 76 stated her pain level was a ten on a scale from 0 to 10 and was observed crying during the interview. During a second interview on 10/09/19 at 8:57 a.m., Resident 76 stated Oxycodone 30 mg was the medication prescribed by her pain medication doctor to control her pain, and it was effective if administered as prescribed, every four hours. She stated she was told by facility staff that the facility contracted pharmacy had to drive her pain medication from Bakersfield, and as a result it took a long time to get it. She also stated her pain level was past a 10, on a scale from 0 to 10, enough to where she thought she was going to throw up. Resident 76 stated her husband was bringing Oxycodone 30 mg tabs to the facility in a zip lock bag for medication administration by Licensed Staff. A physician order, dated 9/29/19 at 6:20 p.m., indicated, oxycodone HCI Tablet 30 MG Give 30 mg by mouth every 4 hours as needed for PAIN MANAGEMENT. During a phone interview on 10/09/19 at 9:40 a.m., Resident 76's husband confirmed bringing Oxycodone 30 mg tablets from home for Resident 76's pain management at the facility. He stated he brought five tablets on three different occasions (for a total of 15 tablets) and gave them to the facility's Licensed Nurses. Resident 76's husband also stated no Oxycodone tablets were returned to him so he assumed the facility's Licensed Nurses used them all for Resident 76's management of pain. During an interview on 10/09/19 at 2:07 p.m., the Director of Nursing (DON) stated Oxycodone 30 mg tablets were not in the facility's emergency kit during Resident 76's admission, and it had taken the facility contracted pharmacy longer than usual to bring the medication, which normally took four hours for delivery. During an interview on 10/11/19 at 11:54 a.m., Licensed Nurse E confirmed Resident 76's husband brought three Oxycodone 30 mg tablets in a zip lock bag on 9/30/19, completely unlabeled, for administration. Licensed Nurse E stated she was the staff member who accepted the tablets, and had the husband sign a document indicating the type and dosage of medication brought from home for accountability purposes. Licensed Nurse E stated it usually took six hours for the pharmacy to deliver pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 29 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0755 medication not available at the facility. Level of Harm - Minimal harm or potential for actual harm A medication dispensing record provided by the DON on 10/16/19 at 9:45 a.m. indicated pharmacy delivered only two tablets of Oxycodone 30 mg to the facility on [DATE]. Resident 76's Medication Administration Record indicated these two 30 mg tabs of Oxycodone were administered to the resident that same day (on 10/02/19), leaving her out of her prescribed medication again. According to the medication dispensing record, the pharmacy did not deliver more Oxycodone 30 mg tablets until 10/08/19 (six days later). For 6 days, Resident 76 received only two Oxycodone 30 mg tabs from the facility pharmacy, and fourteen tablets from other sources, according to Resident 76's Medication Administration Record, presumably from medication brought from home. Residents Affected - Some Resident 76's Medication Administration Record indicated Resident 76's pain level was an 8 out of 10 on 10/03/19, 10/04/19, 10/06/19 and 10/08/19. Resident 76's pain level was a 10/10 on 10/07/19. During an interview on 10/11/19 at 9:42 a.m., Resident 76 stated that she was in misery for two weeks, often crying in pain. When asked if she had suffered as a result of this issue, Resident 76 stated, More than suffering. 2) Resident 77 Resident 77, was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lower End of Femur (Thigh bone) and Neuralgia, according to the facility Face Sheet. Resident 77's pain level had been documented as an 8 out of 10 on 10/07/19 and 10/08/19, in her Medication Administration Record. During an interview on 10/08/19 at 2:47 p.m., Resident 77 stated her pain level was a 9, on a scale from 0 to 10. She stated her pain level had not been controlled since admission, and the morning of 10/08/19 she was unable to do her physical therapy as a result of the intolerable pain. Resident 77 stated she had pain from a fracture to her left femur (thigh bone). During an interview on 10/08/19 at 4:43 p.m., Licensed Nurse P, nurse assigned to Resident 77, stated she called the Physician the morning of 10/08/19 to notify him that Resident 77's pain was not in control, and to request pain medication. According to Licensed Nurse P, the Physician gave an order for Norco (Hydrocodone-Acetaminophen-A narcotic analgesic used to treat moderate to severe pain). Licensed Nurse P stated she immediately called pharmacy at 10:18 a.m., and faxed the Physician's order, to obtain permission from pharmacy to withdraw the narcotic from the facility's emergency kit. Licensed Nurse P stated that in order to obtain a controlled medication from the emergency kit, pharmacy authorization was required. Licensed Nurse P explained that by 2:00 p.m. she had not received authorization from pharmacy to withdraw the medication from the emergency kit, therefore, she called back to follow up. Licensed Nurse P stated pharmacy put her on hold, and when she finally spoke to a pharmacy representative, was told they had just received her request in regards to Resident 77's Norco order. Licensed Nurse P stated she did not get approval from pharmacy until approximately 3:00 p.m. A physician order dated 10/08/19 at 10:18 a.m., indicated, Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for prn pain. During a phone interview on 10/08/19 at 5:01 p.m., Pharmacy Technician U employed by the facility contracted pharmacy confirmed receiving a request for Norco the morning of 10/08/19, for Resident 77. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 30 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She stated pharmacy, Got behind, and she did not know why the medication's withdrawal from the emergency kit was not approved earlier for facility use. Resident 77's Medication Administration Record indicated Norco (Hydromorphone-Acetaminophen) 5-325 mg, was administered for the first time to Resident 77 on 10/08/19 at 3:36 p.m., more than six hours after it was ordered by the Physician. During an interview on 10/09/19 at 2:09 p.m., the DON confirmed Resident 77 had a new prescription for pain medication because her pain was not being controlled. The DON stated she had to call the pharmacy's general manager on 10/08/19 at around 3:00 p.m. to get the pharmacy's approval to obtain the medication from the emergency kit. During an interview on 10/14/19 at 12:30 p.m., the DON stated they were having issues with pharmacy. She stated pharmacy was not sending them controlled pain medications in a timely manner and made them wait on the phone a long time to speak to a representative. She also stated when pharmacy had to send medications out of stock at the facility, it took pharmacy four hours to deliver it, unless it was sent by satellite, in which case the medication was delivered a bit faster. The DON stated the facility's Administrator knew about this issue. 3) Resident 7 During an interview with DON, on 10/14/19, at 4:11 p.m., she reviewed the electronic medical record for Resident 7. The DON reviewed the progress notes section, and confirmed Resident 7 had many Medication Administration Notes. The Medication Administration Notes section indicated Entacapone (a medication used to treat the end-of-dose 'wearing-off' symptoms of Parkinson's disease between doses of a primary treatment medication) tablet 200 milligrams (mg), give one tablet four times a day for Parkinson's disease. A note dated 8/9/19, at 2:13 p.m., indicated medication not given see nurse note. The DON stated she did not know why the medication was not given. Further review of the notes indicated the next two scheduled doses were also not given. The DON was unable to provide documentation to show the facility called the pharmacy when they were unable to provide medication as ordered. During an interview with DON, on 10/14/19, at 4:15 p.m., she reviewed the electronic medical record for Resident 7. A note dated 9/8/19, at 9:03 p.m., indicated Entacapone medication not given see nurse note. The DON stated she did not know why the medication was not given. The DON was unable to provide documentation to show the facility called the pharmacy when they were unable to provide medication as ordered. During an interview with DON, on 10/14/19, at 4:17 p.m., she reviewed the electronic medical record for Resident 7. A note dated 9/19/19, at 11:34 a.m., indicated Entacapone medication not given see nurse note. The DON stated she did not know why the medication was not given. The DON was unable to provide documentation to show the facility called the pharmacy when they were unable to provide medication as ordered. During an interview with DON, on 10/14/19, at 4:19 p.m., she reviewed the electronic medical record for Resident 7. A note dated 9/23/19, at 4:04 p.m., indicated Entacapone medication not given see nurse note. The DON stated she did not know why the medication was not given. Further review of the notes indicated the next seven scheduled doses were also not given. The DON confirmed Resident 7 did not receive his medication for two days. The DON was unable to provide documentation to show any effort the facility made to secure the medication when the pharmacy was unable to provide medication as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 31 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0755 ordered. Level of Harm - Minimal harm or potential for actual harm During an interview with DON, on 10/14/19, at 4:23 p.m., she reviewed the electronic medical record for Resident 7. A note dated 8/12/19, at 4:43 p.m., indicated Metolazone (a medication that increases the amount of urine made as a way to get rid of excess water) not given see nurse note. The DON stated she did not know why the medication was not given. Residents Affected - Some During an interview with DON, on 10/14/19, at 4:25 p.m., she reviewed the electronic medical record for Resident 7. A note dated 8/15/19, at 5:09 a.m., indicated nystatin powder, apply to treat fungal infection, not given see nurse note. The DON stated she did not know why the medication was not given. The DON was unable to provide documentation the doctor was informed when this medication was not available to give. During an interview with DON, on 10/14/19, at 4:27 p.m., she reviewed the electronic medical record for Resident 7. A note dated 8/20/19, at 3:23 p.m., indicated Sinemet (a medication used as a primary treatment for Parkinson's disease) not given see nurse note. The DON stated she did not know why the medication was not refilled in time to be available to give. During an interview with DON, on 10/14/19, at 4:30 p.m., she reviewed the electronic medical record for Resident 7. A note dated 9/9/19, at 4:32 p.m., indicated Eliquis (an anticoagulant used to treat and prevent blood clots and to prevent stroke) medication not given see nurse note. The DON stated she did not know why the medication was not available from pharmacy. During an interview with DON, on 10/14/19, at 11:54 a.m., she confirmed the facility should always have the medication needed for their residents. The DON stated if the medication was not available to give she expected the nurse to call the doctor. The DON stated the doctor could prescribe an alternate medication, or change the order for a one-time dose to be given when the medication arrived from pharmacy. The DON stated the facility would also need to call the pharmacy and get an updated delivery time. The DON stated the facility could have the medication delivery from a secondary location. The DON stated the facility would rather use personal medications than nothing. The DON confirmed personal medication would be a last resort. The DON stated Parkinson's disease (a disorder that affects the brain and spinal cord, causing gradual loss of the ability to control body movements) was a serious medical condition and treatment was very important residents must have their dose. 4a) Resident 21 During an interview with the DON, on 10/14/19, at 4:32 p.m., she reviewed the electronic medical record for Resident 21. The DON confirmed Resident 21 was admitted to the facility on [DATE]. The DON reviewed the progress notes section, and confirmed Resident 21 had many Medication Administration Notes. The Medication Administration Notes section indicated Lomotil (a medication given to treat diarrhea) tablet, give two tablets four times a day. The notes indicated medication not available, doctor notified. The note was repeated every administration time from 8/29/19 through 9/4/19 at 12:02 p.m. The DON confirmed Resident 21 was not given her medication as ordered, since the time of admission. The DON was unable to provide documentation to show the facility had made any effort to get Resident 21's medication. The DON stated she did not know why the pharmacy did not deliver Resident 21's lomotil. When asked why the facility did not try to get the medication by other means, the DON stated she did not know. The DON was unable to provide documentation that the doctor had changed Resident 21's medication orders or was aware Resident 21 was not getting medication as prescribed. Review of the orders section of the medical record indicated a verbal order was carried out on 9/4/19 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 32 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discontinue lomotil for Resident 21. There was no reason indicated on the order. The DON reviewed the order and confirmed the reason for discontinuing treatment was left blank. The DON reviewed Resident 21's medical record and was unable to provide any documentation that indicated a rationale for discontinuing treatment. 4b) During a review of the electronic medical record for Resident 21, the Medication Administration Note, dated 8/29/19, at 10:04 p.m., indicated latanoprost solution, eye drops for the treatment of glaucoma, medication not available. No documentation to indicate doctor was made aware. No documentation to indicate facility attempted to get Resident 21's eye drops prior to the next administration time. During a review of the electronic medical record for Resident 21, the Medication Administration Note, dated 9/2/19, indicated latanoprost solution for the treatment of glaucoma, medication not available. No documentation to indicate doctor was made aware. No documentation to indicate facility attempted to get Resident 21's eye drops prior to the next administration time. During a review of the electronic medical record for Resident 21, the Medication Administration Note, dated 9/3/19, indicated latanoprost solution for the treatment of glaucoma, medication not available. No documentation to indicate doctor was made aware. No documentation to indicate facility attempted to get Resident 21's eye drops prior to the next administration time. During an interview with the DON, on 10/14/19, at 2:58 p.m., she reviewed the medical record for Resident 21. The DON reviewed the Medication Administration Notes that indicated latanoprost solution for the treatment of glaucoma, medication not available, and stated she did not know why the medication was not available. The DON was unable to find documentation the doctor was made aware medication was not administered as prescribed. The DON was unable to find documentation that the facility made any attempt to obtain Resident 21's eye drops prior to the next scheduled dose. The DON confirmed that the pharmaceutical services and medication administration did not meet her expectation. 4c) During an interview with the DON, on 10/14/19, at 3:03 p.m., she reviewed the medical record for Resident 21. The DON reviewed the Medication Administration Notes. The Medication Administration Note, dated 9/23/19, indicated Resident 21's antidepressant medication was not available to give. The DON was unable to find documentation the doctor was made aware when the medication could not be given as prescribed. The DON reviewed notes dated 9/11/19 and 9/12/19 that indicated Resident 21's medication to treat diabetes was not available to give. The DON was unable to find documentation the doctor was made aware when the medication could not be given as prescribed. The DON was unable to provide documentation that showed the facility had made any effort to obtain Resident 21's medication. The DON stated she did not know why the pharmacy did not provide the medication in time to administer as prescribed. The DON confirmed not providing Resident 21 her medications as prescribed did not meet the facility expectations for resident care. 5) Resident 2 During an interview with the DON, on 10/14/19, at 4:35 p.m., she reviewed the medical record for Resident 2. The DON reviewed the Medication Administration Notes. The Medication Administration Note, dated 9/27/19, at 12:36 p.m., indicated Resident 2's omeprazole (a medication to treat acid reflux) was not available to give. The DON was unable to provide documentation that indicated the doctor was notified when the medication could not be given as prescribed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 33 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0755 6) Resident 1 Level of Harm - Minimal harm or potential for actual harm During an interview with the DON, on 10/15/19, at 3:05 p.m., she reviewed the medical record for Resident 1, dated 9/27/19, at 3:58 p.m. and 12:29 p.m., indicated fluticasone propionate (a nasal spray to treat seasonal allergies) not available to give. The DON was unable to find documentation that indicated the doctor was notified when the medication could not be given as prescribed. Review of the progress notes, dated 9/24/19 and 9/25/19, indicated ativan (a medication used to treat anxiety) not in stock waiting for pharmacy. The DON was unable to find documentation that the doctor was made aware when the medication could not be given as prescribed. The DON was unable to provide documentation to show the facility attempted to obtain the medication by other means when it was not available to give. Residents Affected - Some The facility policy and procedure titled: Medication Administration, dated 6/15, indicated if a medication with a current active order could not be located it should be removed from the emergency kit, if not available contact the pharmacy. The facility policy titled, PROVIDER PHARMACY REQUIREMENTS, last revised in August of 2019, indicated, pharmaceutical service is available to provide residents with prescription and nonprescription medications, services and related equipment and supplies .The provider pharmacy agrees to perform he following pharmaceutical services, including but not limited to: 7) providing routine and timely pharmacy service as contracted and emergency pharmacy service 24 hours per day, seven days per week. Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of six of twelve sampled residents (Resident 1, 2, 7, 21, 76, and 77) when: 1) Resident 76's controlled pain medication was not available to give for multiple days, 2) Resident 77's new controlled pain medication was not processed and authorized to give for an extended time, 3) Resident 7's medication was not available to give for 13 doses out of 224 opportunities, 4a) Resident 21's medication was not available for 28 doses out of 28 opportunities; 4b) Resident 21's medication was not available for 3 doses out of 61 opportunities; 4c) Resident 21's medication was not available for 1 dose out of 30 opportunities; 5) Resident 2's medication was not available for 1 dose out of 30 opportunities ; 6) Resident 1's medication was out of stock and not refilled by pharmacy in time to administer 1 scheduled dose. These failures resulted in severe pain for extended time, symptoms exacerbation, disease progression, and resident discomfort. Findings: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 34 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with facility policies for food service safety. These failures had the potential to cause food borne illness in a population with complex medical conditions. Findings: 1) During the initial kitchen tour, on 10/8/19, at 9:25 a.m., there was a container of cottage cheese the walk-in refrigerator, on the right side shelf, eye level. The container had a sticker on it that indicated use by 10/7/19. In the walk-in refrigerator, right side, one shelf below the cottage cheese, was a container of mushrooms. The container had a sticker on it that indicated use by 10/7/19. Observed a metal sheet tray with four plastic cups on it. The tray was on the bottom shelf on the left side of the walk-in refrigerator. Upon further inspection, three of the cups were filled with chunks of fruit in a yellow colored liquid. The fourth cup was a yellow smooth thick pudding like substance. All four of the cups were uncovered. In the walk-in refrigerator, on the left side, on the ceiling, were two blue plastic slotted vents. On the plastic circumference and on the slats of the vent was brown particulate. Each particle ranged from too small to visualize each individual piece to a speck the size of a grain of salt. During an observation and concurrent interview with Registered Dietician 2 (RD 2), on 10/8/19, at 9:49 a.m., she entered the walk-in refrigerator. RD 2 reviewed the use by stickers located on the containers of and mushrooms. RD 2 stated they should have been removed yesterday. RD 2 looked at the cups on the metal sheet pan and stated they were left over pear fruit cups, one pureed. RD 2 confirmed the cups were uncovered, and stated they should have a cover or lid. RD 2 looked up at the blue plastic slotted vents and stated there was dust on them. During an interview with RD 2 and Dietary Aide B, on 10/8/19, at 10 a.m., they stated the hospital maintenance department cleaned and maintained the walk-in refrigerator. Dietary Aide B confirmed kitchen staff did not clean the blue plastic slotted vents in the walk-in refrigerator. 2) During a record review, on 10/8/19, at 10:04 a.m., the temperature log binder indicated the kitchen documented the temperature of the food prior to plating the meal. Over multiple dates in October there were meal items at specific textures that had no documentation of temperature. On 10/5/19 no documentation to show temperature taken for beverages at lunch or dinner. On 10/6/19 no documentation to show temperature taken for beverages for all three meals. On 10/7/19 no documentation to show temperature taken for the alternative vegetable for dinner. During an observation, on 10/8/19, at 10:22 a.m., the weekly menus were posted on a cork board in the kitchen. The menus indicated the facility served egg salad, tuna salad, and chopped chicken salad. The menu indicated chicken salad sandwich was an option for the lunch meal on 10/8/19. During an interview with Dietary Aide B, on 10/8/19, at 10:30 a.m., she stated she made the chicken salad that was to be used at lunch. Dietary aide B stated the chicken used to make the salad was frozen then defrosted for 4 days in the refrigerator. Dietary Aide B was asked if she did anything after the chicken salad was made. Dietary Aide B stated yes, she would take the temperature of the chicken salad and record it. Dietary Aide B removed a binder from the shelf adjacent to the door of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 35 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many walk-in refrigerator. The binder was labeled Cooling Log. Inside the binder was a blank master page in a plastic protector. There were no copied pages and nothing documented. Dietary Aide B stated she made the chicken salad two hours ago, took the prepared temperature, but did not document it. Dietary Aide B had no explanation for the lack of documentation for the other prepared salads served by the kitchen. Dietary Aide B confirmed she knew the salads were Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food (food that requires time/temperature control for safety to limit the growth of pathogens such as bacterial or viral organisms capable of causing a disease or toxin formation). During an interview with RD 2, on 10/8/19, at 10:30 a.m., she stated the kitchen did not take temperatures of the prepared salads because everything used to make a salad was refrigerated. RD 2 stated canned tuna was put it in the refrigerator to get cold prior to making salad. The RD stated the kitchen did not document the time it took to make a prepared salad. When asked what would happen if the staff the was making a prepared salad got pulled to do something else during the preparation process, RD 2 stated that would not happen. RD 2 was unable to provide evidence prepared salads were always made in a safe amount of time with no interruptions. RD 2 confirmed the kitchen staff made tuna, egg and chicken salads on a regular basis without monitoring the prepared temperature or the preparation time. 3) During an interview with RD 2, on 10/8/19, at 10:40 a.m., she reviewed the temperature log binder. The temperature log sheet, dated 10/5/19, the lunch and dinner beverages were not temped. RD 2 stated she did not know why there was no temperatures for the beverages for lunch or dinner on the 10/5/19 log sheet. The temperature log sheet, dated 10/6/19, the beverages were not temped at all. RD 2 stated she did not know why there was no temperatures for the beverages on the 10/6/19 log sheet. RD 2 stated it was possible the beverages were not temped, or maybe staff took temperatures and did not write it down. 4) During an observation, on 10/8/19, at 12:08 p.m, in the activity room, there was a small refrigerator adjacent to the doorway. On the door of the refrigerator there was a sign that indicated refrigerator's rules. One rule indicated on the sign was, nothing to go into the freezer, does not keep adequate temperature. Inspection of the freezer revealed two six pack containers of ice cream sandwiches labeled for [Room and number/letter] . The ice cream sandwiches were soft and squishy when a light pressure was applied. Also in the freezer was a chocolate milkshake from a fast food chain. The container had no indication of who the drink was intended for, or when it was put in the freezer. The dome shaped lid had an opening in the top, about 1 inch in diameter. During an interview with the Activity Director (AD), on 10/11/19, at 10:16 a.m., she stated she was responsible for monitoring the refrigerator in the activity room. The AD confirmed she found the ice cream in the freezer, and It should not have been in there. The AD stated she reminded staff not to put anything in the freezer. The AD stated there was a label on the freezer door that indicated DO NOT USE. The AD stated she thought the expectation was clear, but resident ice cream and a milkshake in the freezer did not meet her expectations. The facility policy and procedure titled: Refrigerator/Freezer Storage, dated 4/19, indicated food that had exceeded its use by date would be discarded. The policy indicated all foods would be wrapped tightly in moisture proof containers that were labeled and dated with the use by date. The facility policy and procedure titled: Resident/Personal Food Storage, dated 11/16, indicated food brought in from the outside for storage would be stored units that would be monitored by staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 36 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 for food safety. 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: 555258 If continuation sheet Page 37 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the administration of supplemental oxygen was documented for one of twelve sampled residents (Resident 5). This lack of documentation could have prevented a comprehensive review of the Resident 5's supplemental oxygen needs and effective continuity of care. Findings: Resident 5 was admitted to the facility on [DATE] with medical diagnoses including Congestive Heart Failure (A condition in which the heart can't pump enough blood to meet the body's needs) and Glaucoma (A condition of increased pressure within the eyeball, causing gradual loss of sight), according to the facility Face Sheet (A facility demographic). During an observation on 10/08/19 at 10:40 a.m., Resident 5 was observed receiving supplemental oxygen at 2 liters per minute through a nasal cannula (A device consisting of a lightweight tube used to deliver supplemental oxygen or increased airflow to a resident in need or respiratory help) from an oxygen delivery system attached to the wall. The Director of Nursing (DON) was present during the observation. Physician's Orders dated 07/28/19 for Resident 5 indicated, 02 (oxygen) AT 2L/MIN (two liters per minute) VIA NASAL CANNULA PRN (as needed) SOB (shortness of breath)/WHEEZING/02 SAT < 90% (oxygen saturation less than 90%) as needed. Resident 5's Medication Administration Record for October of 2019, which included the order for supplemental oxygen administration, did not indicate supplemental oxygen was administered to Resident 5 on any days from 10/01/19 through 10/11/19. Staff did not sign for Resident 5's administration of supplemental oxygen on the Medication Administration Record. During an interview on 10/11/19 at 3:09 p.m., the Director of Nursing (DON) stated Licensed Staff were supposed to be documenting the use of supplemental oxygen for Resident 5. She stated she did not know why they had not been documenting it. During an interview on 10/15/19 at 10:13 a.m., Licensed Nurse E confirmed she had been assigned to Resident 5 on some days in October, 2019. She stated it was a requirement to document the administration of supplemental oxygen but could not explain why Licensed Staff were not documenting it on Resident 5's Medication Administration Record. The facility policy titled, Charting and Documentation, last revised in July of 2017 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: b. Medications administered; c. treatments or services performed .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 38 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident 5 was admitted to the facility on [DATE] with medical diagnoses including Congestive Heart Failure (A condition in which the heart can't pump enough blood to meet the body's needs) and Glaucoma (A condition of increased pressure within the eyeball, causing gradual loss of sight), according to the facility Face Sheet (A facility demographic). Residents Affected - Some During an observation on 10/08/19 at 10:44 a.m., Resident 5 was observed in bed, in his room. Resident 5's urinal was hanging from the bed rail. Resident 5's urinal was empty, but had dark brown areas that appeared to be mold, all throughout the inside of the white transparent plastic urinal. The urinal appeared overused and grossly contaminated. The Director of Nursing (DON) was present during the observation. The urinal was not labeled with Resident 5's name, room number, or the first day of use. The DON was asked when it was last changed or replaced, but she could not verify the date since the urinal was not labeled. The DON stated urinals were replaced as needed and confirmed Resident 5's urinal needed to be replaced. During an interview on 10/14/19 at 11:55 a.m., the DON was asked how often facility staff disinfected urinals. The DON stated this was not done every week but as needed. The DON was asked if they kept a log to review how often urinals were disinfected. The DON stated they did not keep a log of urinal disinfection dates. The facility policy titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, last revised in June of 2011 indicated, Discard resident-care items when damaged or so grossly soiled that a disinfection process is not effective in rendering the item clean. Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge .Disinfect measuring graduates/urinals weekly using EPA-registered and facility approved low-level disinfectant solution. Based on observation, interview and record review, the facility failed to implement an Infection Prevention and Control Program (IPCP) when: 1) Staff were observed not following contact precaution procedures when providing care for one resident (Resident 99) that was admitted to the facility with a confirmed infection and was at risk of transmitting the infection to other residents, 2) The facility failed to implement appropriate measures for the transport of contaminated linens, 3) A clogged pipe was accessed which allowed sewage to spill out onto the floor, and 4) One resident's urinal for use was noted to be grossly contaminated. These cumulative failures could cause the spread of infections and potentially lead to harm or death for a population of residents with complex medical conditions. Findings: 1) During an observation, on 10/11/19, at 3:37 p.m., the Director of Staff Development (DSD) and Licensed Nurse G (LN G) were initiating isolation precautions (actions implemented, in addition to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 39 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some standard precautions that are based upon the means of transmission [airborne, contact, and droplet] in order to prevent or control infections) for Resident 3's room. During an observation, on 10/11/19, at 3:39 p.m., on the door of Resident 3's room, was a red sign. The sign indicated always wear a gown and gloves on before entering the room and take off before leaving the room. The sign indicated contact precautions were required (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). During an observation, on 10/11/19, at 3:44 p.m., Certified Nurse Assistant F (CNA F) was in Resident 3's room with no gown or gloves on. LN G was in Resident 3's room, she was wearing a gown and gloves. As LN G moved in the room the outside of her gown brushed against CNA F's braided hair. There was no garbage can in the room so CNA F picked up an opaque plastic bag from the resident's area and walked it out to the hallway. CNA F had no gloves no gown and walked down the hall to an unknown location. At 3:47 p.m. CNA F returned to the floor and washed her hands at the nurse station. During an observation, on 10/11/19, at 3:53 p.m., CNA F entered Resident 3's room with no gloves and no gown. CNA F called out to CNA H, who was providing care for Resident 3, that she was going to get two pillows. CNA F turned in the room to walk out and paused. CNA F was escorted down the hall towards the hospital by the DSD. CNA F did not perform handwashing. At 3:54 p.m., CNA F walked from the hospital area down the hall to an unknown location, she did not stop to wash her hands. At 3:56 p.m., CNA F entered the main area by the nurse station holding pillows and pillow cases. CNA F called to CNA H, in Resident 3's room, and handed her the pillows and pillow cases. At that point CNA F washed her hands. During an observation, on 10/11/19, at 3:57 p.m., CNA F sat at a computer at the nurse station. CNA F's hair was in the same fashion. CNA F was wearing the same scrubs. No cover or protection observed. During an observation, on 10/11/19, at 4:02 p.m., CNA F stood up from the computer and followed the administrator, DSD, Director of Nursing (DON), and CNA H into an unoccupied resident room . At 4:08 p.m., CNA F returned to the computer at the nurse station from an unoccupied resident room. At 4:10 p.m., CNA F entered the staff break room and walked back out towards the clean utility room at 4:11 p.m. CNA F emerged from the clean utility room with folded linen in her hands. CNA F walked into Resident 6's room and pulled the privacy curtain to provide care for Resident 6. During an interview with the DSD, on 10/11/19, at 4:55 p.m., she confirmed contact precautions were in use for Resident 3. The DSD stated, prior to entering Resident 3's room everyone needed to put a gown on and gloves. The DSD stated there was a red bag inside a garbage can that was placed inside the room as close as possible to the doorway. The DSD stated the expectation was to leave everything in the room. The DSD stated the expectation was to wash hands in the room prior to leaving the room and again outside of the room before doing anything else. The DSD was asked what was the potential harm if proper use of personal protective equipment was not done. The DSD stated the infection could spread to the other residents and staff, anyone in the facility. The DSD stated if someone was observed contaminating their scrubs she would tell them to go change their clothing. The DSD confirmed they could spread infection if they continued to work in potentially contaminated clothing. The DSD confirmed the same expectation for prevention of cross contamination would apply to someone's hair. 2) During an interview with the administrator, on 10/9/19, at 2:42 p.m., he stated all linen was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 40 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some processed by the hospital's offsite professional laundry service. The administrator stated the hospital did not launder residents personal clothing. The administrator stated personal resident laundry was taken to a sister facility. The sister facility's staff laundered clothing in their laundry room and then the clean clothing was brought back to this facility. During an interview with the Infection Preventionist (IP), on 10/11/19, at 5:14 p.m., she stated the hospital processed the linen. The IP stated the hospital did not require any separation for different types on linen. The IP confirmed there was no separation process for the linen from the room on isolation precautions per hospital policy. The IP stated personal laundry was sent out via a utility van to a sister facility to launder. The IP stated the containers of soiled clothing were slid into the van and transported in the same container they were in on the nursing unit. The IP stated the clean clothing was brought back to the facility in plastic bags. The IP stated personal clothing from a resident on isolation precautions would be put in a red bag so the sister facility would know the clothing came from an isolation room. The IP was asked if she saw a potential infection control issue with the way the facility was processing resident's personal clothing. The IP replied, yes, there could be a possibility for infection control issues. The IP confirmed the sister facility was not a professional laundry service. The facility policy and procedure titled: Infection Prevention and Control Program -Linens, dated 8/29/17, indicated environmental services staff or designee would bag laundry that was to be picked up and processed by commercial means prior to pick-up. 3) During an observation on 10/10/19, beginning at 12:20 p.m., a man was kneeling down, wearing gloves, feeding a metal line down a six-inch, round hole tunneling under the floor. The hole, or opening, was located in a common walkway adjacent to the nurse's station. A yellow placard indicating caution, wet floor, had been placed in front of the hole. The only other object around the worksite was the machine the man used. The machine, located behind the man on his knees, had an engine that made a loud sound. The man was worked quickly. The man fed a cable into the opening, and removed the cable; over and over. As he removed the cable from the hole, the man pulled-off clumps of blackened, wet fabric that had accumulated on the surface of the cable. The man placed the fabric into a pile located to his right. A pool of dark water accumulated under the pile of blackened fabric. The fabric resembled discarded wet wipes. The sound of the machine filled the distant areas of the skilled nursing unit. A musty and stale smell of sewer came from the opening on the floor. When the man finished his work, small-to-large puddles of the dark liquid contaminated a four-foot-by-ten-foot area on the skilled nursing unit's floor. During a concurrent observation and interview on 10/19/19, at or around 12:20 p.m., Plumbing Technician V stated he was doing work on a clogged drain. An individual could get within one foot of the Plumbing Technician as he worked on the clogged drain, given the safeguards around the work area. Plumbing Technician V stated he was unclogging the facility's sewer line. During a concurrent observation and interview on 10/19/19, at or around 12:20 p.m., the Administrator stated the plumbing technician was working on a little back-up in the drain. The Administrator stated he was unaware plumbing work would be performed that day. The Administrator stated the hospital's facilities department could provide more information about who scheduled the service. During an interview on 10/19/19, at or around 12:35 p.m., Hospital Facilities Staff W stated he did not know whether the hospital had a written policy indicating the process for accessing a sewer line safely. Hospital Facilities Staff W stated the appropriate safeguards included physical barriers, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 41 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as well as a guard placed over the snake (a flexible auger cable, used to dislodge clogs in plumbing) to protect from spray. During a concurrent interview and document review on 10/19/19, at 1:00 p.m., Chief Engineer X stated the facility did not have a specific policy for accessing a sewer line safely. Chief Engineer X stated: If we don't have one, we will make one. Chief Engineer X stated staff historically put two barriers to the sides of the machine when working on a sewer line in the facility. Chief Engineer X stated the barriers were made from vinyl, held up by metal stands, and meant to protect the clinical environment from spray. Chief Engineer X stated the snake cable also had a guard, but the guard was meant to protect gloves from getting caught not to minimize spray. Chief Engineer X stated Plumbing Technician V removed two-to-three buckets of patient wipes during his work at or around 12:20 p.m. Chief Engineer X stated he did not inform administration for the skilled nursing facility unit about the plumbing work beforehand. Chief Engineer X stated the plumbing had clogs in the past due to patient wipes, but not in recent years. Chief Engineer X drew a sketch depicting the shape and location of the two barriers, in relation to the position of the machine, on each side of the auger cable and hole. Chief Engineer X stated the sketch indicated where staff should have placed barriers when the snake machine was operating to dislodge the clog in the skilled nursing facility unit's plumbing. During an interview on 10/10/19, at 2:50 p.m., the Director of Nursing (DON) stated her facility used flushable wipes for resident toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 42 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop clinical criteria protocols, implement infection surveillance protocols, or antibiotic use protocols which resulted in no infection surveillance reports for Resident 9,7 or 2, not all lab tests complete prior to prscribed antiobiotics for Resident 126, 20, and no end date for an antibiotic order for Resident 124. This failure also had the potiental for inconsistent and ineffective antibiotic stewardship (a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) services for all 24 residents in the facility. Residents Affected - Many Findings: During an interview with LN E, on 10/10/19, at 12:45 p.m., she stated she could not describe the facility antibiotic stewardship program. LN E stated she knew where to find the information and wanted to answer at a later time. LN E confirmed she had worked at the facility for two months. During an interview with LN E, on 10/10/19, at 2 p.m., she stated she could ask the Director of Staff Development (DSD). LN E stated the DSD had papers for Mcgeer's Criteria (a surveillance tool used for retrospectively counting true infections). LN E was not aware the facility utilized the Infection Surveillance assessment in the residents' electronic medical records. During an interview with LN P, on 10/11/19, at 4:25 p.m., she stated the had worked at the facility for three weeks. LN P confirmed she cared for a resident that had a change of condition during his stay. LN P also confirmed the changes assessed were indicative of an infection. LN E was asked to describe the nursing duties when a resident had a change in condition that was a possible infection. LN P stated the nurse completed the eInteract Change of Condition assessment in the resident's electronic medical record. LN P stated no other information was required for the facility. During an interview with the Director of Staff Development (DSD), on 10/11/19, at 4:34 p.m., the DSD stated she was also the Infection Preventionist (IP) for the facility. The DSD confirmed the floor nurses should know how to use the antibiotic stewardship program and where to find the information. During an interview with the DSD, on 10/11/19, at 4:50 p.m., she stated she had worked at the facility for two and a half months. The DSD stated she transferred from a floor nurse position to DSD/IP last month. The DSD stated the purpose of the antibiotic stewardship program was to: decrease the use of antibiotics with McGeer's criteria for signs and symptoms of potential infections. The DSD stated the criteria tool was located in the electronic medical record. The DSD stated the facility used the Infection Surveillance report, located in the assessments section. The DSD stated the floor nurses would start the Infection Surveillance report at the same time they completed the eInteract Change of Condition assessment for any change that included signs and symptoms of infection. The DSD stated there were no paper infection surveillance forms that she was aware of. During an interview with the Infection Preventionist (IP), on 10/15/19, at 10:14 a.m., she stated the facility infection assessment tool located in each resident's electronic medical record. The IP stated the expectation was to start the infection assessment when a resident had a change in their condition with symptoms that could be indicative of an infection. The IP confirmed the change in condition assessment and the infection surveillance assessment would be completed by the floor nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 43 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many staff. The IP stated she finalized the Infection Surveillance reports after a review of results from any diagnostic tests. The IP confirmed residents that potentially acquired an infection in the facility would have both assessments documented in their electronic medical record for review. During a review of the electronic medical record for Resident 9, the assessments section indicated an eInteract Change of Condition report was completed on 10/11/19, at 1:31 p.m. The report indicated the changes assessed were signs and symptoms of urinary tract infection (UTI). Further review of the electronic medical record indicated no Infection Surveillance report had been documented. During an interview with the Infection Preventionist (IP), on 10/15/19, at 10:51 a.m., she reviewed the electronic medical record for Resident 9 and confirmed the Infection Surveillance report was not done. During an interview with the Infection Preventionist (IP), on 10/15/19, at 10:59 a.m., she reviewed the electronic medical record for Resident 7. The orders section indicated an antibiotic was prescribed to treat an UTI on 9/5/19. The IP continued to review the record and was unable to find the eInteract Change of Condition assessment. Further review indicated the Infection Surveillance report was not done. During an interview with the Infection Preventionist (IP), on 10/15/19, at 11:02 a.m., she reviewed the electronic medical record for Resident 2. The orders section indicated an antifungal was prescribed to treat an infections caused by fungus on 10/7/19. The IP continued to review the record and was unable to find the eInteract Change of Condition assessment. Further review indicated the Infection Surveillance report was not done. During an interview with the Infection Preventionist (IP), on 10/15/19, at 11:05 a.m., she confirmed none of the three records reviewed met the facility expectations antibiotic stewardship. During an interview and concurrent record review with the IP, on 10/15/19, at 10:22 a.m., she reviewed the Infection Prevention and Control Program binder for the month of the August. The Infection Prevention and Control Surveillance Log indicated Resident 126 was admitted to the facility on [DATE]. The log indicated Resident 126 had yellow phlegm, shortness of breath and a dry throat on 8/5/19. The log indicated Pneumonia was the Organism on Culture. The log indicated no xray was done, and Resident 126 was given antibiotics. The log indicated Resident 126 had pain with urination on 8/16/19. The log indicated no lab work was done for Resident 126. Resident 126 was given antibiotics for the second time in August. The IP reviewed the log and confirmed neither condition met the criteria to prescribe antibiotics. The IP was unable to find documentation to the doctor to promote antibiotic stewardship. The IP reviewed the log and confirmed for the month of August every resident listed was prescribed antibiotics. The IP was unable to find Infection Surveillance reports for Resident 126, she stated she was a floor nurse in August. During an interview and concurrent record review with the IP, on 10/15/19, at 10:31 a.m., she reviewed the Infection Prevention and Control Program binder for the month of September. The Infection Prevention and Control Surveillance Log indicated the facility action plan was to ensure labs included culture and sensitivity reports. The log indicated Resident 20 had a urinalysis done on 9/5/19. The IP reviewed the lab result and confirmed the culture and sensitivity report was not done. Resident 20 was prescribed antibiotics. The IP was unable to find documentation to the doctor to promote antibiotic stewardship. The IP reviewed the log and confirmed for the month of August every resident listed was prescribed antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 44 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the Infection Preventionist (IP), on 10/15/19, at 11:10 a.m., she stated the facility had no other evidence to provide in regards to the antibiotic stewardship program. During an interview with the DON, on 10/15/19, 4:33 p.m., she stated she reviewed the antibiotic orders for Resident 124. The DON stated both orders, with no end date, did not follow the facility's antibiotic stewardship policy. The facility policy and procedure titled: Antibiotic Stewardship, dated 9/17, indicated the program would include action to implement recommended practices, tracking measures, reporting data, education for clinicians, and education for nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 45 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the gas stove in the kitchen was maintained in working order. This failure had the potential to cause injury or death to all 24 residents in the facility. Residents Affected - Few Findings: During an observation, on 10/10/19, at 12:08 p.m., [NAME] C used a long handled lighter to light the gas range. During an interview with [NAME] C, on 10/10/19, at 12:10 p.m., she stated she had worked in the kitchen for 20 years. [NAME] C confirmed the front left and right burner of the 6 burner gas range required an outside fire source. During an interview with RD 2, on 10/10/19, at 1:23 p.m., she stated the maintenance department completed all the service needs for the range. RD 2 stated the records for service or maintenance would be kept in the maintenance department. During an interview with the Plant Operations Supervisor, on 10/11/19, at 9:20 a.m., he stated his department did not complete the preventative maintenance for the range in the kitchen. The supervisor stated the kitchen cancelled all scheduled preventative maintenance as of 11/17. The supervisor stated his staff only respond to work orders for the kitchen range as they needed it. During an interview with RD 1, on 10/11/19, at 9:40 a.m., she confirmed the front right burner required an outside source to lite. RD 1 stated the kitchen used an intranet system to send an email request to plant services for the range. RD 1 was unable to provide documentation to show the kitchen requested routine preventative maintenance. During an interview with RD 1, RD 2, Staff L and Staff K, on 10/11/19, at 10:05 a.m., they confirmed the front right burner on the range was not in good working order. Staff L and Staff K confirmed neither staff had performed preventative maintenance on the range. When asked if the burners had a constant pilot or a thermocouple safety, facility staff and the RDs did not know. Staff L stated there might be a thermocouple on bottom of the stove. Neither staff L or K knew the procedure for testing a thermocouple, or how often the range required testing. The range operator's manual, dated 5/05, indicated standing pilot burner flame should be a clear blue flame with an inner cone at each burner port. The manual further indicated a thermocouple was included in ranges built after 2002. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 46 of 47 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement policies for smokers' safety. This failure had the potential to result in unsafe smoking practices, and nonsmokers subjected to second hand smoke. Residents Affected - Few Findings: During an observation on 10/8/19, at 9:15 a.m., the entrance to the facility had a sign that indicated no smoking. During an interview with the administrator and the Director of Nurses (DON), on 10/8/19, at 10 a.m., they stated the facility was non-smoking. They both stated the facility did not have any residents that smoke. The documents provided at entrance did not include a smoking policy. During the initial tour, on 10/8/19, no identified space for smoking was found. The administrator confirmed there was no designated smoking area due to the fact the facility was located on a hospital campus. During the group meeting, on 10/10/19, at 3:30 p.m., two residents identified as active smokers. Resident 78 stated he had a friend walk him out of the facility and they go smoke in the friend's car. Resident 78 stated he was told the facility was a non-smoking facility. Resident 78 confirmed he was never given a smoking policy. Resident 12 stated he was told the facility was non-smoking. Resident 12 confirmed he was never given a smoking policy. Resident 12 stated his niece visited him at the facility and would sign him out to drive him to the store to buy more cigarettes. Resident 12 stated his niece let him smoke in her car. Both residents confirmed there was not an area for residents and visitors to smoke safely and away from other residents. During an interview with the administrator, on 10/11/19, at 5:30 p.m., he stated he was not aware the facility needed to request permission from the state to have a non-smoking facility. The administrator stated he was working with the hospital to find a safe place for smoking. The administrator stated he was working on smoking policy and procedures similar to the ones he had at other facilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555258 If continuation sheet Page 47 of 47