Health inspection·April 7, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some development r/t [related to] decline in independent functional mobility following her fall at home and L [left] hip FX [fracture]. The care plan indicated the following interventions to prevent pressure injuries: administer medications as ordered ., administer treatments as ordered ., provide dressing to protect coccyx [tail bone area] from breakdown ., follow facility policies/protocols for the prevention/treatment of skin breakdown ., monitor nutritional status ., monitor any changes in skin status ., obtain and monitor lab as ordered ., treat pain as per orders, and attempt alternative methods if resident refuses treatment. A review of this care plan indicated it was revised twice: once on 4/22/21 (no new interventions added) and again on 3/17/23, with the indication that Resident 31 had developed two stage II pressure injuries, one on each buttock, and added the following interventions: clean left and right of coccyx wound areas with normal saline, pat dry and apply foam dressing ., medpass 2.0 (a dietary supplement) twice a day for wound healing ., monitor wound for healing and infection ., multiple vitamins/minerals daily ., vitamin C two times a day ., and zinc tablet one time a day. During an interview on 4/7/23, at 1:16 p.m., the Director of Nursing (DON) reviewed Resident 31's record and stated this was the facility's care plan for the prevention of pressure injuries for Resident 31. A review of Resident 31's Skin Evaluation dated 3/14/23, at 4:10 p.m., indicated Resident 31 had two pressure injuries: one stage 2 pressure injury (a shallow open ulceration of the skin) on the right buttock and one stage 2 pressure injury on the left buttock. During an interview on 4/7/23, at 1:16 p.m., the DON stated 3/14/23 was the date when the facility first detected these or any pressure injuries on Resident 31 since her admission on [DATE]. A review of Resident 31's care plans indicated care plan dated 3/15/23 titled open area on right coccyx and indicated the following interventions: lol air loss mattress ., notify physician and family ., continue application of dressing, multivitamins, vitamin C, zinc, med pass and monitor changes. A review of Resident 31's Skin Evaluation dated 4/3/23, at 3:54 p.m., indicated Resident 31 had developed a third pressure injury. Resident 31 had one stage 2 pressure injury on the right buttock and two stage 2 pressure injury on the left buttock. A review of Resident 31's care plans indicated no new care plan or care plan revisions to address this third pressure injury During an interview and record review on 04/07/23, at 1:16 p.m., the DON was asked about Resident 31's current pressure injuries and her risk factors for developing pressure injuries. The DON was also asked to review Resident 31's care plans and indicate when the care plans for the prevention of pressure injuries were created and updated. The DON stated she was unfamiliar with Resident 31 health conditions and clinical record. The DON stated the Nursing Supervisor was the best staff to interview about Resident 31 health conditions and review her clinical record. The stated care plans should be revised quarterly and upon change in conditions, such as development of a pressure injury. DON then left the interview to call the Nursing Supervisor. During an interview on 4/7/23, at 1:43 p.m., the Nursing Supervisor was asked about Resident 31's pressure injuries. The Nursing Supervisor stated Resident 31 first developed two and then a third one. The Nursing Supervisor was asked about Resident 31's risk factors for developing pressure injuries. The Nursing Supervisor stated Resident 31's skin was very moist because of incontinence, her sensory perception was limited, and immobility was a problem for her. The Nursing Supervisor was asked if, when and how care plans were created to mitigate these risk factors and prevent pressure injuries. The Nursing Supervisor stated she could not review Resident 31's care plans because of computer access problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 2 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy and procedure for care planning titled MDS Comprehensive Care Planning, Revised August 2022, indicated: The skilled nursing facility (SNF) must develop and implement an individual, written comprehensive person-centered care plan for each resident . that includes measurable objectives to be accomplished, the professional discipline responsible for each element of care and time frames to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. A comprehensive care plan must be . a. Developed within seven days after the completion of the comprehensive assessment . b. Reviewed and revised by the IDT after each assessment including both the comprehensive and quarterly review assessments. It will be evaluated and updated as necessary by the nursing staff and other professional disciplines involved in the care of the residents at least quarterly and more often if there is a change in the resident's condition. RESIDENT 37 A review of Resident 37 facesheet indicated she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disease causing uncontrollable movements, balance and coordination problems) and repeated falls. A review of Resident 37's Morse Risk for Falling Assessment, dated 4/12/22, indicated Resident 37 was at a High Risk for Falling due to the following fall risk factors: history of falls, multiple diagnoses, impaired gait and overestimation of personal limits. A review of Resident 37's clinical records indicated the Morse Risk for Falling Assessment was repeated for Resident 37 an additional eight times, on 4/13/22, 4/27/22, 6/15/22, 7/4/22, 7/18/22, 9/30/22, 10/7/22 and 1/6/23. The same assessment conclusion of High Risk for Falling remained unchanged in all these assessments. During an interview and record review on 4/7/23, at 11:30 a.m., the DON stated Resident 37 had seven documented falls since admission on [DATE], as indicated by a review of IDT [Interdisciplinary Team] Post Event Reports. The DON stated the IDT Post Event Reports indicated Resident 37 fell on: 4/27/22 (resident found of the floor next to the bed); 6/15/22 (resident found of the floor next to the bed); 7/4/22 (resident found of the floor next to the bed); 7/26/22 (fell to the floor while attempting to self-transfer from bed to toilet); 11/28/22 (found on the floor); 3/20/23 (resident slid from wheelchair to the floor) and 4/3/23 (resident found on the floor). During a further review of Resident 37 records and interview with the DON, on 04/07/23, at 11:30 a.m, three additional falls were identified: progress note dated 9/30/22 indicated Resident 37 fell when she slid from wheelchair to the floor on 9/30/22; fall prevention care initiated on 4/12/22 indicated Resident 37 fell on [DATE] while attempting to get up from the bed independently; and fall prevention care plan initiated on 4/1/23 indicated Resident 37 had an unwitnessed fall on 3/31/23. In total, a review of Resident 37's records indicated she fell 10 times during her 12-month admission to the facility. A review of Resident 37's care plans indicated three fall prevention related care plans initiated during admission. The first fall care plan was initiated on 4/12/22 and was titled [Resident 37] is at high risk for falls r/t personal hx [history] of mechanical fall . It contained the following interventions: anticipate and meet resident's needs (initiated on 4/12/22); ensure call light is within reach and encourage to use, ensure prompt response to requests for assistance (initiated on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 3 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4/12/22); educate resident about safety reminders (initiated on 4/12/22); encourage resident to participate in activities (initiated on 4/12/22); ensure resident is wearing appropriate footwear or non-skid socks (initiated on 4/12/22); follow fall facility protocol (initiated on 4/12/22); ensure use of electronic alarms in bed and chair (initiated on 4/20/22); provide safe environment (initiated on 4/20/22); provide ultra-low bed and ensure bed is in the lowest position (initiated on 6/17/22), physical therapy/occupational therapy to evaluate, treat and train resident (initiated on 3/20/23); and review wheelchair and check adjustment (initiated in 11/29/22). In total, Resident 37's fall care plan dated 4/12/22 was revised with additional interventions a total of four times, on 4/20/22, 6/17/22, 11/29/22, and 3/20/23. The second fall care plan was initiated on 4/13/22 and titled [Resident] has declined in her physical mobility r/t to recent fall at home . and had the following interventions initiated on 4/13/22: resident is weight bearing; requires stand by assistance; uses front wheeled chair; provide assistance with mobility; PT/OT [Physical Therapy/Occupational Therapy] evaluation and treatment; and required set up assistance of one staff. The third fall care plan was initiated on 4/20/23 and titled [Resident] uses tab alarms in bed and chair to prevent injury due to .attempts to transfer .unassisted . and the following interventions initiated on 4/20/23: anticipate and intervene for causes of falls; ensure consent for alarms; evaluate alarm quarterly; provide safe environment, glare free light, even floors free of spills and clutter; call light and personal items within reach; and bed in low position. A review of Resident 37's care plans indicated a fourth fall care plan titled Resident had unwitnessed non injury fall on 3/31/23 and had the following interventions: notify MD; notify family; neurological checks for 72 hours; monitor for signs and symptoms of complications for 72 hours; maintain fall precautions and remind resident not to remove tab alarm for safety. During an interview and record review on 04/07/23, at 11:30 a.m., the DON confirmed Resident 37 had fallen 10 times during her stay at the facility. The DON also confirmed the fall care plans and revisions indicated above. The DON stated fall care plans should be revised at least quarterly and after each fall. A review of facility policy and procedure titled Falls Prevention and Management Program, Revised ., indicated: As part of the skilled nursing facility's culture of safety, the falls prevention and management program serves to improve or maintain the quality of life of residents. Staff, in conjunction with the attending physician, consultant pharmacist, therapists and others, will properly assess a resident's risk for falling, provide adequate interventions to minimize that risk and try to prevent a resident from falling, and then evaluate the effectiveness of those interventions. The nursing function in a fall prevention program includes, but is not limited to: . Developing a plan of care to minimize a resident's fall risk and identify modifiable risk factors for falls . Being able to identify causative factors should a fall occur, then accelerate the care plan with new interventions to prevent further falls . If falling recurs despite initial interventions, staff will implement additional or different interventions or document why the current approach remains relevant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 4 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 staff failed to assess and document a large bruise on one of 13 sampled residents, Resident 12. This failure could potentially result in an unrecognized safety issue for the resident when the cause of the bruise was unknown. Residents Affected - Few Findings: During an observation and concurrent interview on 4/3/23 at 11:38 a.m., Resident 12 had a dark purple bruise on her right forearm that was approximately 2.5 inches by 4 inches. Resident 12 stated she got the bruise when Unlicensed Staff A was helping her to the bathroom. When asked if the bruised area was painful, Resident 12 stated, This arm always hurts, but yes. During a record review on 4/4/23 at 11 a.m., Resident 12's electronic medical record indicated she was admitted to the facility on [DATE] with medical diagnoses that included respiratory failure, bacterial pneumonia (lung infection), sepsis (blood infection), and difficulty in walking, among others. Resident 12's MDS (minimum data set, an assessment tool) dated 3/8/23 indicated her BIMS score was 15 (Brief Interview for Mental Status, a score of 15 indicates cognitively intact). Review of Resident 12's nurses' daily and weekly charting revealed no documentation of a large bruise on her right forearm or that she had reported any injury during toileting. During an interview on 4/5/23 at 4:16 p.m., Unlicensed Staff A stated she had not been working with Resident 12 too much, but she did when her coworker was on dinner break. Unlicensed Staff A stated she had asked her coworker how Resident 12 transfers, she answered Resident 12 needed minimal assistance, and she said Resident 12 had many bruises. Unlicensed Staff A stated she did not know how Resident 12 got the large bruise on her forearm. During a record review and concurrent interview on 4/5/23 at 4:24 p.m., Licensed Staff B stated residents' skin assessments were done once a week. Licensed Staff B stated she had not noticed a bruise on Resident 12's forearm, but she had not been at work for about five days. Licensed Staff B checked Resident 12's care plan and orders in the electronic medical record, and stated she could not find any documentation of a large bruise on Resident 12's right forearm. Licensed Staff B verified that if anyone had noted the bruise, it would be on Resident 12's care plan and there would be an order for monitoring of the site. During a record review and concurrent interview on 4/6/23 at 1:46 p.m., when queried, Licensed Staff C stated she saw the bruise on Resident 12's right forearm this morning (4/6/23). Licensed Staff C stated the doctor was notified (about the bruise), family was notified, and they were monitoring the bruise. Licensed Staff C stated they had asked the CNAs (certified nursing assistants) to be more gentle with Resident 12 as her skin was very fragile. When asked if Resident 12 had stated how she got the bruise, Licensed Staff C stated she had just looked at the bruise but did not ask Resident 12 about it. Licensed Staff C opened a progress note in Resident 12's electronic medical record, written by Licensed Staff B on 4/6/23. The note indicated Resident 12 had a bruise on her right arm that measured 8.5 cm (centimeters) by 6.5 cm, and that Resident 12 stated it probably happened when she transferred from the toilet to her wheelchair. During an interview on 4/7/23 at 11:11 a.m., Director of Nursing (DON) stated she did Resident 12's head-to-toe skin assessment on admit. DON stated she was busy stabilizing Resident 12's respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 5 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 - Few condition and did not document the diffuse bruising on her arms. DON stated the weekly assessment the nurses conducted on the residents had a complete skin assessment. DON stated the form called COMS Skin Only was where the nurses would document an injury like the one on Resident 12's arm. DON stated, If we didn't then that's bad on us. Review of facility job description for Licensed Vocational Nurse, last updated 5/2021, indicated under Responsibilities section, Identifies changes in patient status and reports to the appropriate health care professional. Documents resident response to care in clinical record. Review of facility job description for Registered Nurse, last updated 5/2021, indicated under Responsibilities section, Responds to information or data indicating acute risk to resident; initiates and documents action to reduce or correct the risk. Review of facility policy and procedure Skin Integrity & Management, last revised 8/2022, When a resident is identified to have a non-pressure skin discoloration and/or skin breakdown, the licensed nurse will contact the attending physician. The licensed nurse assigned to the resident will assess, evaluate and initiate a change of condition nursing documentation to last for at least seventy-two hours every shift. Documentation will be completed for any non-pressure skin discoloration and/or skin breakdown. The weekly nursing summary will include a description of skin condition for all residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 6 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 0679 Provide activities to meet all resident's needs. 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 provide an activities program that supported the choice of activities of four of 13 sampled residents (Residents 17, 19, 35 and 38) when the facility did not have sufficient activities staff to take these residents out for fresh air and outdoor activities. This failure resulted in Residents 17, 19, 35 and 38 being deprived of fresh air and outdoor activities which they reported were very important to them. Residents Affected - Some Findings: During an observation and interview on 4/3/23, at 9:50 a.m., Resident 19 was alert and oriented and stated she was bored and idle at the facility. Resident 19 stated: We sleep a lot because there is nothing do. Resident 19 stated she enjoyed being out for fresh air and enjoyed outdoor activities but stated such activities were not offered by the facility. Resident 19 stated she only left the facility for fresh air or outdoor activities if family took her. Resident 19 stated when she asked staff to take her out for fresh air staff stated they did not have time or enough staff to do so. During a group interview on 4/4/23, at 1:30 p.m., four alert and oriented residents (Residents 17, 19, 35 and 38) indicated they enjoyed fresh air and outdoor activities, such as walking around the campus, but stated these activities were not offered or available to them because the facility required staff to escort and accompany them when out and there was insufficient staff to do so. As a result, the residents stated, they stayed indoors all the time. Resident 17 stated, on behalf of the other residents, That is our biggest complaint. A review of Resident 17 Minimum Data Set (MDS) (a clinical assessment tool) dated 5/27/22 indicated, under Section F, Preference for Customary Routine and Activities, in response to the question How important is it to go outside to get fresh air when the weather is good?, Resident 17 indicated it was Very important. (the options were Very important, Somewhat important, Not very important and Not important at all.). A review of Resident 19 Minimum Data Set (MDS) (a clinical assessment tool) dated 3/3/23 indicated, under Section F, Preference for Customary Routine and Activities, in response to the question How important is it to go outside to get fresh air when the weather is good?, Resident 19 indicated it was Very important. A review of Resident 35 Minimum Data Set (MDS) (a clinical assessment tool) dated 10/1/22 indicated, under Section F, Preference for Customary Routine and Activities, in response to the question How important is it to go outside to get fresh air when the weather is good?, Resident 35 indicated it was Very important. A review of Resident 38's Minimum Data Set (MDS) (a clinical assessment tool) dated 5/26/22 indicated, under Section F, Preference for Customary Routine and Activities, in response to the question How important is it to go outside to get fresh air when the weather is good?, Resident 38 indicated it was Very important. A review of the historical weather for area where the facility is located, for the period of 4/3/23 to 4/6/23, indicated fair weather, zero precipitation and temperature ranges from 36° (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 7 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Fahrenheit (F) (lows) to 61° F (highs). (https://www.wunderground.com/history/daily/us/ca/santa-[NAME]). During an interview on 4/7/23, at 9:50 a.m., the Activities Director (AD) provided the schedule of activtiies for January to April 2023. A review of the sechedules indicated no outdoor activities. The AD was asked if residents were taken outdoor for fresh air and outside activities. The AD stated yes if the weather was good and if there were sufficient activities staff to take the residents out, since they needed to be escorted by staff or family when out. The AD was asked the number staff in the activities department. The AD stated there were 2.5 full time activities staff, as follows: one full-time Activities Director, one full-time Activities Assistant (AA E) and one part-time Activities Assistant (AA F). The AD stated the activities department was short of one full-time activities assistant in order to be fully staffed. A review of the Facility Assessment (a report created by the facility indicating the resources it needs to meet resident needs), dated 1/17/23, indicated, for an average daily census (total number of residents at the facility) of 42.7 residents (census during the survey from 4/3/23 to 4/7/23 was 49 residents), the facility required, during two-week pay periods, an average of 378 activities staff hours. During an interview on 4/7/23, at 11:15 a.m., the Administrator provided the time sheets of activities staff (AD, AA E and AA F) for the 15 day period from 3/23/23 to 4/6/23. A review of these time sheets indicated the AD, AA E and AA F worked a total of 209 hours in the facility, or 55% of the activities staff hours (378 hours) indicated by the facility assessment. A review of facility policy and procedure titled Activity Program, revised June 2020, indicated: Activities program designed to meet the needs of each resident are available on a daily basis. Weather permitting at least one acitivity a month is held away from the community. Weather permitting outdoor activities are held on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 8 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to administer one medication to one Resident (Resident 26) per MD orders. This failure had the potential to cause Resident 26 to have dizziness, lightheadedness, drowsiness, and or a runny/stuffy nose. Residents Affected - Few Findings: During a medication pass observation on 4/6/23 at 5:27 p.m., Licensed Nurse B popped two tablets of Tamsulosin HCL Capsule 0.4mg (milligram) (medicine to treat Benign prostatic hyperplasia (BPH) causes male prostate to increase in size, causing feeling need to urinate ) into a medicine cup and added applesauce. Licensed Nurse B stated there were two tablets. Licensed Nurse B administer two tablets to Resident 26. During a reconciliation of medication pass by reviewing MD orders on 4/7/26 at 9:00 a.m. MD order for Tamsulosin HCL Capsule 0.4mg dated 4/19/22 indicated to give one capsule by mouth two times a day related to Benign Prostatic Hyperplasia (with lower urinary tract symptoms). During a review of Resident 26 medical record, Medication Administration Record on 4/7/26 at 9:08 a.m., Licensed Nurse B charted she gave one tablet Tamsulosin HCL to Resident 26. During an interview on 4/7/23 at 9:15 a.m., the Director of Nursing she stated, My expectation is that there are no medication errors. During a review of the Facility Job Description for Registered Nurse dated May 2021(Licensed Nurse B was RN) indicated the staff Registered Nurse (RN) . Responsibilities: Administers medications safely and accurately, following existing departmental procedures. During a review of the Facility Policy titled Medication Administration General Guidelines (California specific), dated 2007 indicated Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy further indicated 3. Prior to administration, the medication and dosage schedule on the Resident's MAR is compared with the medication label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 9 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the floors of the walk-in refrigerators and freezer were clean. This failure resulted in food storage areas that were not sanitary. Residents Affected - Many Findings: During an observation and concurrent interview on 4/3/23 at 9:02 a.m., the floor of the Prep Fridge had an accumulation of food debris. On the floor under the bottom shelves were a whole onion, a pickle slice, a wrapped butter pat, and a bottle of lime juice. Management Staff D verified these items under the shelves and stated the floors of the walk-in refridgerators and freezer were supposed to be cleaned every night. When queried, Management Staff D stated it looked like it was probably not cleaned last night. Continuing the observation, the floors of the Protein Fridge and walk-in freezer also had accumulated food debris. Management Staff D stated the floors looked like they were not swept like [they] were supposed to. During an interview 4/6/23 at 9:03 a.m., Registered Dietitian (RD) stated the kitchen leadership did daily kitchen inspections and monthly kitchen audits that were more in depth. When queried, RD stated she would review the audits and see if there had been any pattern of issues with floors not getting proper cleaning. RD stated she had not noticed issues with cleanliness of the floors during her daily visits to the kitchen. During a subsequent interview RD stated her review of the most recent audits did not reveal any issues with the cleanliness of the floors. Review of the document Master Cleaning Schedule for the kitchen, last revised 9/2022, indicated the Walk-In Refrigerator Floors were to be cleaned daily. Review of the Food and Drug Administration (FDA) Food Code, last revised 2022, Chapter 6 Physical Facilities, subsection 6-5 Maintenance and Operation, 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 10 of 11 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly store its kitchen waste when the facility's recyling dumpster was propped open and had lids that did not properly close, and the trash compactor was left open. This failure could lead to infestation with insects or rodents. Residents Affected - Many Findings: During an observation of the trash area and concurrent interview on 4/5/23 at 10:33 a.m., the trash compactor door was open with trash visible inside. Management Staff D stated the door should not be open and closed it. One of the two recycling dumpsters had its lid propped open with a large Styrofoam block. Management Staff D verified it should not be propped open and removed the Styrofoam block. The dumpster's lids sagged and were too short to close the dumpster properly. Management Staff D verified the lids did not close properly and stated they were probably worn from years of being opened and closed. Review of the Food and Drug Administration (FDA) Food Code, last revised 2022, Chapter 5: Water, Plumbing and Waste, subsection 5-5 Refuse, Returnables, and Recyclables revealed, 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555268 If continuation sheet Page 11 of 11