Health inspection·May 20, 2021

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 3 Residents Affected - Some During an interview on 05/17/21, at 2:42 p.m., Resident 3 stated she had lost 100 pounds of water weight, and the wound on her buttock was getting better. During an interview and concurrent record review on 5/18/21, at 3:10 p.m., the Director of Nursing (DON) verified there was no completed Quarterly MDS assessment, which was due on 3/12/21, for Resident 3 Resident 59 During an observation and interview on 5/17/21, at 2:57 p.m., Resident 59 pointed at the pictures of Buddha and Hindu gods posted on his wall and stated he had no complaint. During an interview on 5/17/21, at 4 p.m., Licensed Staff A stated Resident 59 had not left the facility since he was admitted . During a record review on 5/18/21, at 8:45 a.m., the Daily Census Report indicated Resident 59 was admitted to the facility on [DATE]. The MDS report indicated the facility completed Resident 59's admission MDS assessment on 7/29/20 and had a late submission of a Quarterly MDS due on 10/30/20. There were no Quarterly MDS assessments completed for January 2021 and April 2021. During an interview on 05/18/21, at 2:05 p.m., Staff F stated Resident 59 liked to stay in his room, and Staff F was trying to find ways to connect with Resident 59 and his activity of interest. During an interview and concurrent record review on 5/18/21, at 3:38 p.m., the DON verified there were no completed Quarterly MDS assessments for January 2021 and April 2021 for Resident 59. Review of the facility policy and procedure titled MDS Assessments, Care Planning and Conference 5/06/2013, indicated, It is the policy of the [facility's name] to comply with regulatory standards pertaining with the MDS assessment, care planning and family conferences. The policy did not indicate completing Quarterly MDS and Significant Change MDS. Based on interview, and record review, the facility failed to ensure four of eight residents (Resident 3, Resident 59, Resident 6, Resident 2) received a quarterly assessment using a resident assessment instrument, Minimum Data Set (MDS). This failure had the potential for the facility to miss the critical indicators of gradual change in a resident's status affecting their quality of life and quality of care. Findings: Resident 2 During an observation and interview on 5/18/21, at 10 a.m., Resident 2 was sitting up in bed, eating breakfast. He stated he was pretty independent and took care of himself as well as looked out for other residents' well being. A wheelchair, walker and a cane were observed by his bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 2 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review on 5/19/21, at 4:45 p.m., the Daily Census Report indicated that Resident 2 was admitted to the facility 9/16/19. There was no admission Assessment found. A review of the MDS indicated diagnoses that included cancer, post traumatic stress disorder, pain and anxiety. During an interview and concurrent record review on 5/19/21, at 5:10 p.m., the DON verified there was no completed Quarterly MDS assessment for April 2021 for Resident 2. Resident 6 During an observation and interview on 5/17/21, at 3 p.m., Resident 6 was in bed, sitting up, with both lower legs elevated on a pillow. He declined to be interviewed and stated to get out. During an interview on 5/19/21, at 9:30 a.m., Licensed Staff I stated Resident 6 was difficult to provide care for due to his disabilities. She stated he had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both lower legs and had a history of pain. She stated due to his disabilities he could not tell you he was in pain, but he would demonstrate it by crying out loud. During a record review on 5/19/21, at 4:30 p.m., the Daily Census Report indicated the facility re-admitted Resident 6 to the facility on 7/1/20. The Assessment report indicated he complained of pain, was non-weight bearing, had contractures of his right upper arm, right lower leg and left lower leg. It indicated when he was in pain he cried, whimpered and grimaced. The record indicated Resident 6 had decreased appetite. Review of the document titled Facesheet, (a resident demographic) indicated he was originally admitted [DATE] for diagnoses that included cerebral palsy, autism, failure to thrive and protein malnourishment. A review of the MDS (Minimum Data Set-a resident assessment tool) indicated his admission weight was 83 pounds. During an interview and concurrent record review on 5/19/21, at 5 p.m., the DON verified there was no completed Quarterly MDS assessment for April 2021 for Resident 6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 3 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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** Based on observation, interview and record review, the facility failed to complete admission assessments and baseline care plans that were individualized, for sampled Residents 108, 109, 2, 6, 4 and 7 when: admission Assessments were not completed within 48 hours of admission for residents 108, 109, 2, and 6; and Resident 108 did not have a care plan for allergies to foods and medications; and Resident 4 did not have a care plan for pain; and Resident 7 did not have a care plan for ADLs (activities of daily living) that documented refusal of care. This failure had the potential for the facility to miss the critical indicators necessary to ensure continuity of care and communication among nursing home staff, resident safety, and interventions that would affect residents quality of life and quality of care. Findings: Resident 108 During an observation and interview on 5/17/21, at 3:29 p.m. Resident 108 was sitting up in bed. She stated she had fractured her left leg and it was severely swollen. She stated she had lots of allergies and discovered that she should not be eating grapefruit while on an anticoagulant (a medication that slows blood clotting) medication. During an observation on 5/18/21, at 11:10 a.m., Resident 108's left lower extremity appeared swollen, dusky and had evidence of blisters. She had oxygen administered at 2 liters per minute through a nasal tube. She stated she had been given grapefruit for several days and then experienced a severe allergic reaction that included shortness of breath, bleeding from her nose and face, swelling and extreme fatigue. She stated she has told dietary staff, nursing, her physician and the facility pharmacist that she did not want to have grapefruit, but the facility continued to serve it on breakfast trays for several days. During an interview with the Interim Director of Nursing, and concurrent record review, on 5/18/21, at 1:52 p.m., she was unable to locate an admission Assessment for Resident 108. She stated there should be one completed immediately upon admission. She was unable to locate any documentation or care plan to address the Resident's allergy/drug interaction with grapefruit. She stated everyone knew she would not get it and the kitchen no longer provided it. A review of the Medical Record chart indicated an allergy sticker on the front of the chart that did not list grapefruit. A review of the electronic medical record Progress Notes did not indicate any documentation about grapefruit or allergies. During an interview and record review with the Director of Nursing (DON) and Interim Director of Nursing on 5/18/21, at 2:01 p.m., they stated there was no documentation of a completed admission Assessment. DON stated an admission Assessment was everything, and without one a resident may not get care that allowed her to live her optimal life. She stated it was the basis for the day to day care plans for every resident. A record review of Resident 108's Facesheet, (a resident demographic) indicated she was admitted [DATE], at midnight, and her admission Assessment completion date was 5/18/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 4 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 Resident 109 Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with the DON and the Interim DON, on 5/18/21, at 2:01 p.m., they were unable to locate admission Screening Assessment documentation. The DON stated she did not see an admission Assessment, and it was everything. She stated they needed to be completed within 48 hours. She stated the admission Assessment provided important information about resident care, incisions, pain. She stated the risk to residents without an admission Assessment and subsequent care plans was that the resident may not get care that would allow her to live her optimal life. Residents Affected - Some During a record review on 5/19/21, at 1:55 p.m., Resident 109's Facesheet, indicated Resident 109 was admitted on [DATE]. A document titled, Assessment Report, indicated the admission Assessment was completed 5/4/21. Resident 2 During a record review on 5/19/21, at 2:15 p.m., a document titled Facesheet, indicated Resident 2 was admitted on [DATE]. During a record review and concurrent interview on 5/20/21, at 10:50 a.m., the Interim DON stated she could not find an admission Assessment for Resident 2. She stated there was completed admission Assessment documentation in the medical record. A facility document titled admission Documentation Requirements, dated 8/30/18, indicated Upon admission the nurse on duty is to complete the following: SNF/Swing admission Assessment. A facility document titled Resident Care Planning, dated 10/24/19, indicated Upon admission the nurse gathers data and inputs it into the Electronic Medical Record (EMR) system. The process of evaluation and re-assessment of the resident care plan will occur on a continuing basis as needed until the resident is discharged . However, each individual resident care plan will be reviewed and re-evaluated at least every month. Resident 6 During a record review and concurrent interview on 5/20/21, at 10:55 a.m., the DON and Interim DON stated Resident 6 was admitted [DATE], and the admission Assessment was completed 1/6/20. They stated the admission Assessment was not completed within 48 hours. Resident 4 During an interview and record review on 05/18/21, at 10:18 a.m., Interim Director of Nursing (IDON) verified Resident 4 had medication Norco 5 milligram/325 milligram for pain as needed and there was no Care Plan for Pain. During an interview on 05/19/21, at 2:19 p.m., Licensed Staff I stated Resident 4 was receiving Tylenol (pain medication) for headache, Voltaren (pain medication) for his joint pain, and Norco. Licensed Staff I verified there was no care plan for pain for Resident 4. When asked what to do when there was no Care Plan for pain, Licensed Staff I stated staff would ask Resident 4 if he has pain and see the Medication Administration Record if he has medication order for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 5 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 Resident 7 (Cross Reference F 676) Level of Harm - Minimal harm or potential for actual harm During an interview on 5/18/21, at 3 p.m., Interim Chief Nursing Officer stated she did not have a facility Policy and Procedure(P&P) for a Rehabilitative Nursing Assistance (RNA) Program because the facility did not have an RNA Program. She stated she did not have a specific P&P for Activities of Daily Living (ADL), and stated the P&P titled Certified Nursing Assistant (CNA) Documentation, dated 5/24/18 addressed ADLs. Residents Affected - Some Review Resident 7's of the Medical Record, the Physician Order, dated 8/26/20 at 2:21 p.m., indicated, Out of bed at every meal. Please do not let patient eat in bed. Review Resident 7's of the Medical Record, the Care Plan for ADL Function/Rehab potential, updated 5/17/21, indicated a planned approach to provide active and passive ROM (Range of Motion- measurement of the amount of movement around a specific joint or body part) and to encourage participation with ADLs. The Care Plan for Non-Compliance, dated 3/3/20, did not indicate Resident 7's refusal with getting out of bed with every meal. The Care Plan for Behavior and Cognitive loss, updated 5/17/21, did not indicate planned approaches for Resident 7's refusal of getting out of bed. Review of the facility policy and procedure titled Resident Care Planning dated 8/30/18, indicated, The purpose of the resident care planning is to develop coordinated and comprehensive plan in order to meet the resident individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 6 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 4 During an interview and record review on 05/18/21, at 10:18 a.m., Interim Director of Nursing (IDON) verified Resident 4 had medication Norco 5 milligram/325 milligram for pain as needed and there was no Care Plan for Pain. During an interview on 05/19/21, at 2:19 p.m., Licensed Staff I stated Resident 4 was receiving Tylenol (pain medication) for headache, Voltaren (pain medication) for his joint pain, and Norco. Licensed Staff I verified there was no care plan for pain for Resident 4. When asked what to do when there was no Care Plan for pain, Licensed Staff I stated staff would ask Resident 4 if he has pain and see the Medication Administration Record if he has medication order for pain. Resident 7 (Cross Reference F 676) During an interview on 5/18/21, at 3 p.m., Interim Chief Nursing Officer stated she did not have a facility Policy and Procedure(P&P) for a Rehabilitative Nursing Assistance (RNA) Program because the facility did not have an RNA Program. She stated she did not have a specific P&P for Activities of Daily Living (ADL), and stated the P&P titled Certified Nursing Assistant (CNA) Documentation, dated 5/24/18 addressed ADLs. Review Resident 7's of the Medical Record, the Physician Order, dated 8/26/20 at 2:21 p.m., indicated, Out of bed at every meal. Please do not let patient eat in bed. Review Resident 7's of the Medical Record, the Care Plan for ADL Function/Rehab potential, updated 5/17/21, indicated a planned approach to provide active and passive ROM (Range of Motion- measurement of the amount of movement around a specific joint or body part) and to encourage participation with ADLs. The Care Plan for Non-Compliance, dated 3/3/20, did not indicate Resident 7's refusal with getting out of bed with every meal. The Care Plan for Behavior and Cognitive loss, updated 5/17/21, did not indicate planned approaches for Resident 7's refusal of getting out of bed. Review of the facility policy and procedure titled Resident Care Planning dated 8/30/18, indicated, The purpose of the resident care planning is to develop coordinated and comprehensive plan in order to meet the resident individual needs. Based on observation, interview and record review, the facility did not develop and implement care plans for residents that were individualized, implemented and re-evaluated for Sampled Residents 109, 6, 4 and 7 when: Resident 109's hearing loss was not assessed and a care plan was not developed and implemented, Resident 6 did not have a care plan for weight loss, Resident 4 did not have a care plan for pain, and Resident 7 did not have an intervention for refusal of care and decline of Activities of Daily Living (ADL). These failures had the potential for resident decline and harm and negatively impact the resident's quality of life, quality of care and services. Resident 109 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 7 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 During an observation and interview on 5/17/21, at 3:54 p.m., Resident 109 stated I am hard of hearing and when people wore those masks it makes it worse. No signs indicated the resident experienced hearing loss. No hearing aids were observed. Resident 109 stated she asked people to remove her mask to help her hear what they are saying. During an interview on 5/18/21, at 1:52 p.m., the Interim Director of Nursing stated she did not think Resident 109 was hard of hearing. During an interview and concurrent record review, on 5/18/21, at 2:01 p.m., the Director of Nursing stated hearing loss should have been assessed on the admission assessment. A review of a document titled admission Assessment, indicated Resident 109 was admitted [DATE], and the assessment did not contain documentation of hearing assessment or hearing loss. A review of the paper chart for resident 109 did not indicate a care plan for hearing loss was initiated. Resident 6 During a interview on 5/18/21, at 12:20 p.m., Licensed Staff I stated Resident 6 always refused his puree diet. She stated the only thing he ate was his mother's cooking and even then he eats only 25%. She stated the only thing he liked was Ensure (a nutritional drink) because he had a sweet tooth. Resident 6 was admitted [DATE] with diagnoses that included Protein Malnourishment, Failure to Thrive, History of Pressure Ulcers (pressure sores develop, typically over bony areas of the body, due to prolonged pressure or laying on that area for an extended amount of time), Autism (a developmental disorder characterized by difficulties with social interaction and communication.) During a record review on 5/18/21, at 3:30 p.m., a document titled Dietary Notes, indicated on 1/2/20, Resident 6 weighed 78.6 pounds. A review of documented weights indicated an admission weight of 81 pounds. During an interview and concurrent record review with Registered Dietician, on 5/20/21, at 9:34 a.m., she stated Resident 6 had lost 2.5 pounds since January and was considered a 3% weight loss for someone who weighed 81 pounds. She stated the facility should be aware and should be monitoring his intake. Registered Dietician stated interventions for weight loss would include a care plan that offered smaller meals, provided meals of his preference, and provided a nutritional fortified drink with every meal. She stated each container of nutritional fortified drink would provide 16 grams of protein. She stated Resident 6 needed at least 37 grams of protein a day. She stated if he was only consuming 25 % of his meals and beverages he may or may not be getting what he needed to prevent weight loss. A review of documentation for percentage of meals consumed, indicated inconsistent documentation of meals that were consumed and/or how much was consumed. During an interview with the Interim Director of Nursing, on 5/20/21, at 10 a.m., she stated Resident 6 had gained weight, and he only has a fortified nutritional drink as a meal. She stated she was not sure what the plan was for Resident 6 and weight loss except to drink the fortified nutritional beverage. She was unable to state how the facility was monitoring his nutritional needs. During an interview with Licensed Staff L, he stated Resident 6 did not have weight loss. He stated the meals consumption was inconsistent in the electronic medical record because all he consumed was the fortified nutritional drink. He stated he was not certain what the plan was to prevent weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 8 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 loss for Resident 6. Level of Harm - Minimal harm or potential for actual harm A review of Resident 6's care plans indicated only a care plan titled Nutritional Status, last reviewed/revised 1/18/21. It did not indicate any new interventions related to the Registered Dietician's reported 3% body weight loss of 2.5 pounds. Residents Affected - Some A request for Resident 6's admission weight documentation and weights from January 2021 were not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 9 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 ensure one of eight residents (Resident 7) received care to prevent diminish resident's abilities in activities of daily living (ADL) when Resident 7 was not encouraged to get out of bed to eat. This failure resulted to Resident 7's decline of in ADL abilities. Residents Affected - Few Findings: During an initial observation on 5/17/21, at 2:26 p.m., Resident 7 was in bed and stated he was receiving good care. The Minimum Data Set (MDS-a resident assessment tool) indicated Resident 7 had changes in his ADL abilities. Review of the Quarterly MDS dated [DATE] and 3/08/21 indicated Resident 7 had a decline in the following ADL abilities: 1. Bed mobility (how resident move and change position while in bed). Resident 7 used to receive supervision and assistance from one person in 12/20 to receiving extensive assistance (resident involved in activity, staff provide weight-bearing assistance) from two persons in 3/21. 2. Transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position excluding to/from bath/toilet). Resident 7 used to be received limited assistance (resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight-bearing assistance) from one person to receiving extensive assistance from two persons. 3. Walk in room (how resident walks between locations in his/her room). Resident 7 used to receive limited assistance from one person to receiving extensive assistance from two persons. 4. Walk in corridor (how resident walks in corridor on unit.) Resident 7 used to receive limited assistance from one person to receiving extensive assistance from two persons. 5. Dressing (how resident puts on, fastens and takes off all items of clothing). Resident 7 used to be totally dependent (full staff performance of an activity with no participation by resident) from one person to being totally dependent from two persons. 6. Eating (how resident eats and drinks). Resident 7 used to receive supervision and set up of food only, to receiving limited assistance from one person. 7. Toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes). Resident 7 used to receive limited assistance from one person to being totally dependent from two persons. 8. Personal hygiene: how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). Resident 7 used to receive limited assistance from one person to being totally dependent from one person. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 10 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/17/21, at 3:43 p.m., Licensed Staff I stated Resident 7 refused to stand up and had a diagnosis of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During an observation on 05/18/21, at 12:05 p.m., Resident 7 was in bed and lunch food tray was on his table. Licensed Staff A was at the bedside speaking with Resident 7. During an interview on 5/18/21, at 2:05 p.m., Staff B stated Resident 7 did not like to get out bed, was not motivated and just watched television and sleeps. During an interview on 5/18/21, at 3 p.m., Interim Chief Nursing Officer stated she did not have a facility Policy and Procedure (P&P) for a Rehabilitative Nursing Assistance (RNA) Program because the facility did not have an RNA Program. She stated she did not have a specific P&P for Activities of Daily Living (ADL), and stated the P&P titled Certified Nursing Assistant (CNA) Documentation, dated 5/24/18 addressed ADLs. During an interview on 5/19/21at 1:15 p.m., Physical Therapist K stated Resident 7 refused to participate in therapy and received exercise program for him to do by himself. During Resident 7's record review on 5/20/21, at 9 a.m., with Physical Therapy Assistant (PTA), the Case Note authored by Physical Therapist K, dated 6/05/20, indicated Resident 7 refused 38 times and participated four times with physical therapy. Review Resident 7's of the Medical Record, the Physician Order, dated 8/26/20 at 2:21 p.m., indicated, Out of bed at every meal. Please do not let patient eat in bed. Review Resident 7's of the Medical Record, the Care Plan for ADL Function/Rehab potential, updated 5/17/21, indicated a planned approach to provide active and passive ROM (Range of Motion- measurement of the amount of movement around a specific joint or body part) and to encourage participation with ADLs. The Care Plan for Non-Compliance, dated 3/3/20, did not indicate Resident 7's refusal with getting out of bed with every meal. The Care Plan for Behavior and Cognitive loss, updated 5/17/21, did not indicate planned approaches for Resident 7's refusal of getting out of bed. Review of the facility policy and procedure titled Resident Care Planning dated 8/30/18, indicated, The purpose of the resident care planning is to develop coordinated and comprehensive plan in order to meet the resident individual needs. Finding: During an interview on 5/18/21, at 3 p.m., Interim Chief Nursing Officer stated she did not have a facility Policy and Procedure(P&P) for a Rehabilitative Nursing Assistant (RNA) Program because the facility did not have na RNA Program. She stated she did not have a specific P&P for Activities of Daily Living (ADL), and stated the P&P titled Certified Nursing Assistant (CNA) Documentation, dated 5/24/18 addressed ADLs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 11 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not provide professional standards of pain relief when effectiveness of pain medication administration was not assessed and documented for Sampled Residents 1, 4, 5, 6, 58, 108 and 109. Residents Affected - Some This failure had the potential for increased discomfort and potential resident harm due to incomplete monitoring of the effects of scheduled and as needed (PRN) pain medication orders which may have resulted in ineffective pain relief for residents. Findings: During an observation of Resident 6, on 5/19/21, at 9:15 a.m., he was whimpering and his lower legs were shaking. A Certified Nursing Assistant (CNA) was observed to come in and observe Resident 6 for pain and then went to Licensed Staff I to report Resident 6 was in pain. At 9:20 a.m., Licensed Staff I was observed to administer Tramadol, HCL (hydrochloride) 50 mg (milligrams) half tablet for pain to Resident 6. (Tramadol is a narcotic medicine used to treat moderate to severe pain.) During a record review and concurrent interview with the Interim Director of Nursing and Interim Chief Nursing Officer, on 5/19/21, at 3 p.m., no assessment of the effectiveness of the pain medication was located in Resident 6's medical record. Interim Director of Nursing stated staff should be assessing the effectiveness of pain medications to determine if the Resident's pain was relieved. The Interim Chief Nursing Officer stated pain should be assessed before and after pain medication administration. A review of pain medication administration for Resident 6 indicated for all scheduled and PRN pain medication administrations for the entire month of April and May indicated there was no assessment performed by licensed staff after administration of the pain medication. During a record review and concurrent interview with the Interim Director of Nursing and Interim Chief Nursing Officer, on 5/19/21, at 3 p.m., the medication administration records for Residents 1, 4, 5, 58, 108 and 109 were reviewed and the Interim Direct or Nursing could not find any pain administration assessments to determine if the Residents' pain was relieved. During a document review and concurrent interview with the Interim Director of Nursing, on 5/19/21, at 3:45 p.m., a document titled PATIENT CARE PLAN #19 PAIN & PAIN SYMPTOM RISK, reviewed 10/1/10, indicated APPROACH NEEDS / PREFERENCES, indicated Assess level of pain using pain rating scale, Administer pain medications as ordered, Monitor response using pain scale related to: Medications . Evaluate resident for break through pain & establish pain relief intervention. Interim Director of Nursing reviewed Residents 1, 3, 4, 5, 6, 58, 108 and 109 medical records that licensed staff who administered pain medication, evaluated pain relief and was unable to locate any documentation in any resident medical record. She stated staff should have documented evaluation of pain medication effectiveness. During a document review and concurrent interview with the Interim Director of Nursing, on 5/19/21, at 3:45 p.m., a facility Policy and Procedure (P&P) titled Medication Administration, dated 5/28/21, indicated It is the policy of the [Facility] to administer medications according to the acceptable standards of practice.When charting administration of any PRN medication, the nurse will document full details including the patient's symptoms, method, route and time of administration, effect of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 12 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 medication and signature. The Interim Director of Nursing stated the staff had not done that. Level of Harm - Minimal harm or potential for actual harm A facility P&P titled PAIN MANAGEMENT PROGRAM, reviewed 2017, indicated The patient's self report of pain is the single most reliable indication of how much pain that patient experienced. It is sufficient for a nursing diagnosis of altered comfort and development of an appropriate plan of care. Adequate treatment of pain is of such importance that it cannot be over-emphasized. Report ineffective medications/treatment to physician. Reassess and adjust medical plan of care as directed. Report the effective plan of care each shift. E. Reassessment: 1. Pain is rated with patient's routine vital signs (as the 5th vital sign) . Documentation: . C. Nursing Flowsheet: Describe assessment, re-assessments, , side effects, action taken, including prevention measure, interventions and outcome. Residents Affected - Some Review of a Nursing Reference titled, Medical Surgical Nursing Assessment and Management of Clinical Problems, 5th Edition, Mosby, indicated ASSESSMENT OF PAIN . The third step of the pain assessment process is doing follow-up assessments. Documentation of Pain Pain assessment information should be documented in a part of the medical record that is easy to access by all health care providers . Even the best pain measurement or assessment conducted by one nurse is of limited value, unless the information is shared with other nurses and health health professionals responsible for the care of the patient with pain. Review of a Nursing Reference titled NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr., indicated Chapter 17 Improving the Quality of Care Through Pain Assessment and Management . American Pain Society Current Guidelines . Reassess and adjust pain management, plan as needed. Monitor processes and outcomes of pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 13 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility did not ensure the safe and secure disposition of medications, including narcotics destruction, and diversion prevention, when an unsecured medication disposal bin was observed in the Medication Room. This failure had the potential for theft and diversion of medications and narcotics, when the container and pills contained within, were accessible and unsecured. Findings: During an observation and interview, in the Medication Room, on 5/18/21, at 10:19 a.m. with Licensed Staff G, there was a white plastic bin with a blue snap on lid that had a 3 inch yellow circular opening, with an attached cap, to access the interior. The white container sat unsecured to the countertop to the right of the two medication carts. Licensed Staff G stated if he had to dispose of any narcotics he would get it witnessed by another nurse, document, then dispose of it in the white bin with the blue top. He slid it across the countertop, and viewed the interior through the circular opening and stated he saw intact pills, glass vials, syringes and an intravenous bag (a plastic bag typically filled with fluid medicine that goes into persons vein). He stated the vials, bags and syringes should not be disposed of in the white container with the blue lid. He stated the contents were close to the top of the container and stated when it was full the pharmacist would come and get it. Licensed Staff G stated he did not know what the facility Policy and Procedure (P&P) was for narcotics disposal. During an observation and interview in the Medication Room, on 5/18/21, at 11:20 a.m., Licensed Staff H pointed to the white container with the blue top on the counter, to the right of the medication carts and stated narcotics are disposed of in this container. He was unable to state what the manufacturer's recommendations for use of the container was. He was unable to state what the facility P&P for narcotics destruction was. Licensed Staff H stated he did not know what the facility P&P for diversion of narcotics prevention was. He stated the white container with the blue top was unsecured and the pills viewed inside had the potential to be stolen. Licensed Staff H observed the labeling on the outside of the container and stated it didn't say how to secure or destroy the medications. During an interview on 5/18/21, at 11:54 a.m. the Interim Director of Nursing (DON) stated nothing other than pills or wasted liquid medications should go into the white container with the blue top. She stated when the container was full to the top, staff are supposed to close the lid. She stated the container stayed in the med room, which was locked, until the pharmacist or his unlicensed pharmacy assistant comes into the locked medication room and takes the container away. She stated when we need a new one we ask Pharmacy to bring us one. She stated she did not know the manufacturers instructions for use or the facility's P&P for narcotic diversion prevention. During an interview on 5/18/21, at 12 p.m., Licensed Staff J stated when he needs to dispose of narcotics he just puts them into a sharps container. He stated he didn't know the facility P&P for medication or narcotic disposal. He stated he was unaware of how the facility prevented medication diversion by staff. During an interview on 5/18/21, at 2:20 p.m., Licensed Staff H stated the manufacturer's recommendations for the white bin with the blue top was that it should not to be used to dispose of glass (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 14 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 - Few vials, intravenous bags or syringes. He stated the facility was not using the container according to manufacturer instructions and someone could access the undestroyed pills inside the container. During an interview and observation on 5/19/21, at 9:15 a.m., Licensed Staff I stated she didn't know the P&P for medication disposal. Licensed Staff I stated, if I drop a narcotic on the floor I put it in the white bin with the blue top. She stated when the bin got full, to the top, maybe the pharmacist would pick it up. According to the U.S. Department of Justice, Title 21 Code of Federal Regulations, 1317.75, Collection Receptacles should . (1) Be securely fastened to a permanent structure so that it cannot be removed; (3) The outer container shall include a small opening that allows contents to be added to the inner liner, but does not allow removal of the inner liner's contents. Review of a document titled Proper Disposal of DEA Controlled Substances, not dated, indicated When disposing of by destruction, the drug must be rendered non-retrievable. Non-retrievable means to permanently alter the controlled substance ' s physical or chemical condition through irreversible means, making it unavailable and unusable In a clinical setting, this means controlled substances should not be simply placed into a sharps container or non-hazardous pharmaceutical waste container. That ' s because these methods could allow the controlled substance to be poured out and used, making them retrievable. for all practical purposes. Review of a document titled General Pharmacy Operations, dated 5/28/20, indicated 4. Space, Equipment and Storage: . D. Drugs are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. Review of a facility P&P doc titled Medication Storage, dated 5/28/20, indicated The purpose of this policy and procedure is to describe the storing methods for medications.6. Medication on the nursing units which must be discarded are placed into a special blue and white incinerator waste disposal container designed especially for this purpose. These are collected by a Housekeeping Department staff member and taken to locked storage in the Engineering Manager's shop. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 15 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility did not ensure resident medications were stored according to Policy and Procedure, manufacturer's recommendations, and National Standards when the medication storage room and the pharmacy storage and ambient room temperatures were not monitored. This failure had the potential risk for resident harm or death if medication integrity was compromised and then administered to residents. Findings: During an observation and interview in the Medication Room, on 5/18/21, at 10:19 a.m. with Licensed Staff G, an observation indicated two shelves above the medication carts contained pre-packed medications. Licensed Staff G stated they were stored up there because there was no room in the medication cart. An observation of the all the drawers in the medication cart indicated bottles of supplements, over the counter medications, ointments, eye drops and pre-packed medication packets. He stated the medication refrigerator contained insulin (a diabetic medication that helps lower blood sugar), and was monitored by a centralized electronic monitoring system. He was unable to state what the temperature range should be in the refrigerator. An observation of an LED read out, on the front of the refrigerator indicated a reading of 05. He stated he did not know what that was. He stated if the refrigerator went out of range, the system would notify a manager who would then investigate and correct. He stated insulin needed to stay within a certain temperature range or it would be compromised and would not work effectively to lower blood sugar for the diabetic patient and might result in harm. He stated he was not aware if the room temperature was being monitored by anyone. Licensed Staff G stated he did not know what the facility Policy and Procedure (P&P) was for temperature monitoring. During an observation and interview of the Medication Room, on 5/18/21, at 11:46 a.m., Licensed Staff H stated only the medication refrigerator temperature was monitored. He was unaware if the temperature of the Medication Room was monitored. During an interview in the Medication Room, on 5/18/21, at 3:15 p.m., Licensed Staff H stated Only the medication refrigerators have a centralized monitoring system. He stated the medication room and the pharmacy storage rooms do not have ambient room temperature monitoring. He stated he did not know what the facility P&P was for temperature monitoring. During an observation and interview in the Pharmacy Storage Room, on 5/18/21, at 3:30 p.m., an Automated Medication Dispensing Machine, and attached medication refrigerator, were observed. Observation indicated there was no ambient temperature gauge or monitoring system in the area. Licensed Staff H stated only the Automated Medication Dispensing Machine and medication refrigerator were monitored for temperature. He stated the risk to residents was if the temperature went to high or low and compromised the integrity of the medications and it potentially would not have the desired effect for residents taking the medications. During an interview with Staff C, on 5/20/21, at 9:20 a.m., he stated if a medication refrigerator would go out of range he would receive an alert on his phone and would investigate. He stated there was no ambient room temperature monitoring in the Medication Room or the Pharmacy Storage Room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 16 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a document titled General Pharmacy Operations, dated 5/28/20, indicated 4. Space, Equipment and Storage: . D. Drugs are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. Review of a document titled Medication Storage, dated 5/28/20, indicated The purpose of this policy and procedure is to describe the storing methods for medications. 3. Medications shall be stored at appropriate temperatures: . b. Room temperature shall be between . 59 degrees Fahrenheit and . 77 degrees Fahrenheit. Event ID: Facility ID: 555516 If continuation sheet Page 17 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 observation, interview, and record review, the facility failed to ensure the food safety requirements were met when: Residents Affected - Many 1. The meats were stored above ready to eat foods. 2. One of three Dietary Staff (Dietary Staff E) handled clean dishes after touching dirty dishes using the same gloves. This failure had the potential for food-borne illness outbreak affecting vulnerable residents. Findings: 1. During an initial kitchen tour observation on 5/17/21, at 1:43 p.m., Dietary Staff D verified there were meats on the top shelves of the freezer, and below the shelves were cookie dough, ice cream, and other food. During an interview 5/19/21, at 9:18 a.m., Dietary Staff D stated the arrangement of how foods were stored in the freezer were done according to the manager's [instruction]. Dietary Staff D verified there was ice cream and tortillas at the bottom of freezer shelves and meats on the top shelves. During an observation on 5/19/21, at 11a.m., Dietary Staff E placed strawberries on each ice cream cup, covered them, and stored them on the freezer shelves below the meat packages. During an interview on 5/20/21, at 9:44 a.m., when asked what the best practice was for storing meat in the freezer, Dietitian F stated, if it's meat and there's other food items, meat should be in the lowest level. Review of the facility policy and procedure titled Food Preparation and Storage dated 10/24/2019, indicated, Meats should be loosely wrapped, and stored on the lowest shelves to prevent contamination of other food products with dripping blood. 2. During an observation on 5/19/21, at 10:05 a.m., Dietary Staff E was wearing gloves and prewashing cups, and then took a tray of clean cups from the dishwasher using the same gloves. Dietary F continued to prewash dirty dishes before putting them in the dishwasher, then removed clean dishes from the dishwasher and put dishes in the cupboards wearing the same gloves. During an interview on 5/19/21, at 2:40 p.m., Dietary Staff E stated she would change her gloves and do handwashing after touching dirty dishes. When mentioned about the earlier observation of not changing gloves between touching dirty to clean dishes, Dietary Staff E stated she always changed gloves and did handwashing. During an interview on 5/20/21, at 9:44 a.m., when asked about the expectation for wearing gloves, Dietitian F stated when grabbing dirty dishes, the staff can use gloves, once done washing, staff can remove gloves and then do hand washing. Review of the facility policy and procedure titled Sanitation and Safety Standards for Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 18 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 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 Employees dated 12/05/2019, indicated the dietary employees must wash hands frequently before touching clean equipment and dishes. 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: 555516 If continuation sheet Page 19 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to consistently Identify quality deficiencies and develop and implement action plans to correct identified quality deficiencies. Residents Affected - Few This failure had the potential to negatively impact residents standard of care and quality of life by not identifying and quickly addressing resident care issues. Finding: During an interview and record review with Administrator, on 5/20/21, at 10:45 a.m., he stated he had 15 years experience as an Administrator. He stated the Quality Assessment and Performance Improvement (QAPI) committee met quarterly, and had a project to address getting the meal trays back to Dietary (kitchen) in a timely fashion. Administrator stated he could not remember if there was any monitoring or audits, Performance Improvement Projects to monitor, or Minimum Data Set (MDS) (A resident assessment tool) completion issues. Administrator stated the Director of Nursing Services went out on medical leave March 10 and the facility had hired an Interim DON. He stated the Interim DON was expected to complete the residents Minimum Data Set (MDS) and provide oversight for all functions in the Skilled Nursing Facility. He stated he did not know if the MDS was completed in a timely fashion. He stated he did not know if the residents' care plan accuracy or reviews and/or admission assessments were monitored for being completed on time, or if Rehabilitation Nursing Assistant effectiveness, survey readiness review or staffing and management for day to day operations was reviewed. After he acquired the minutes from the QAPI meetings, he stated the QAPI committee met monthly, and after a review of the attendance sheets for February, March and April, he stated the QAPI had reviewed the following issues: Dietary trays left in resident rooms, monitored pills left on trays, Infection control data for MRSA (Methicillin-resistant Staphylococcus aureus - a bacteria) testing recommendations were made, Pharmacy bedside scanning for medications. Administrator stated the facility did not monitor survey readiness, MDS completion, care plan completion, staffing strategies for management coverage, storage of medications, narcotics disposal, and diversion prevention, and Rehabilitation Nursing Assistant (RNA) program. A review of the facility document titled 2019 Quality Assurance & Performance Improvement (QAPI) Plan for Southern Humboldt Community Healthcare District (SHCHD) Skilled Nursing Facility (SNF), indicated Guiding principal #3: At SHCHD QAPI includes all employees, all departments, and all services provided. Services Rendered-We strive to meet each resident's goals of care . Administration-We align all business practices to ensure every patient has individualized care. Feedback, Data Systems, and Monitoring-SHCHD will put in place systems to monitor care and services. The QAPI team at SHCHD will decide what data to monitor routinely. Areas to consider may include, but not be limited to, the following examples: . Care plans, including ensuring implementation and evaluation of measurable interventions, State survey results and deficiencies, Results from MDS resident assessments. Business and Administrative processes (e.g., .caregiver turnover, caregiver competencies, and staffing patterns .) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 20 of 21 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 555516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Medical Director attended the Quality Assessment and Performance Improvement (QAPI) committee meetings. This failure had the potential to not properly identify deficient practices that other committee members might be aware of. Residents Affected - Few Findings: During an interview and record review with Administrator, on 5/20/21, at 10:45 a.m., he stated he had 15 years experience as an Administrator. He stated the QAPI committee met quarterly. After review of the QAPI minutes, he stated the QAPI committee meets monthly, the last meeting was 4/8/21, and after a review of the attendance sheets for February, March and April, he stated the Medical Director and two staff representative did not attend. He stated he did not know there was a requirement for mandatory attendance by the medical director or by staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555516 If continuation sheet Page 21 of 21