Health inspection·October 10, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lab orders earlier on the morning of [DATE]. Resident 1 was last viewed by direct care staff on [DATE] at approximately 7:00 am. Resident 1 was viewed by direct care staff the same morning at 7:30 am and found unresponsive. Medical Director (MD) was notified at 7:35 am that Resident 1 had died. During an interview on [DATE] at 12:26 pm, family member (FM) stated that Resident 1 sent him a text message on [DATE] stating he was not feeling well. FM stated Resident 1 communicated to him that he had vomited on [DATE] and [DATE]. During an interview on [DATE] at 2:14 pm, Licensed Vocational Nurse (LVN) A stated the phlebotomist (Phleb – someone who draws blood for analysis) went into Resident 1 ' s room the morning that he passed away and attempted to get blood drawn for laboratory (lab) orders. LVN A stated Phleb emerged from the room around 5 am and told her Resident 1 refused blood work and was in the bathroom. During an interview on [DATE] at 2:32 pm, Certified Nurse Assistant (CNA) B stated she last saw Resident 1 sleeping at 12:30 am, two hours after her shift started. CNA B stated she cannot recall when she checked on him next. CNA B stated that she did not know Resident 1 had died until she was told by another staff member at her next shift on [DATE] at 10:30 pm. During an interview on [DATE] at 2:41 pm, CNA C stated on [DATE] she received in hand off report that the morning Phleb could not get blood from Resident 1 because he was in his bathroom, and Phleb noted a bowel movement trail leading to bathroom door. CNA C stated that she also received in report that lab tech reported this to LVN A. CNA C stated, I ' m really confused about this because it ' s like no one went to check on him after the lab person reported seeing the bowel movement on the floor, and morning shift starts their rounds at 6:30 am. During an interview on [DATE] at 2:03 pm, CNA D stated Resident 1 ' s door is usually closed, and he did not open the door when he received hand-off report from CNA B. CNA D stated CNA B reported to him I checked on him [Resident 1], he ' s okay. CNA D stated he first saw Resident 1 around 7:15 am when another staff member asked him to wake up Resident 1 for morning medications. CNA D stated he noted feces on the floor that was dark and looked like blood going from the bathroom to Resident 1 ' s bed. CNA D stated Resident 1 had feces on his hands and feet and was cold to the touch. CNA D stated Resident 1 was not covered up and naked. CNA D stated a code blue was called, but since Resident 1 was Do-Not-Resuscitate, facility did not attempt life-saving measures. CNA D stated MD was notified of death around 7:45 am. During an interview on [DATE] at 11:12 am, Phleb with local laboratory stated she was at facility at 4:00 am to obtain a lab draw from Resident 1. Phleb stated she opened the door to Resident 1 ' s room and noted that he did not stir and wake up like he did when she came to draw labs in the past. Phleb stated she saw bowel movement all over the floor from the bathroom and back to his bed. Phleb stated she noticed Resident 1 had his back to her, was curled up in his bed in the fetal position, and his buttocks were exposed with Fecal matter covering his entire backside. He was not covered up. Phleb stated she wanted bowel movement cleaned up from the floor before she attempted a lab draw. Phleb stated she asked a staff member who was sitting for another room down the hall if there was someone who could assist with cleaning it up. Phleb stated staff member entered Resident 1 ' s room, emerged and stated she would tell his nurse and that he ' s refusing. Phleb stated she never verbally asked Resident 1 if he wanted a lab draw. Phleb stated she gave report to LVN A when she was ready to exit facility. Phleb stated she told LVN A regarding situation with Resident 1 and that she had relayed this information to another staff member. Phleb stated when she returned to facility on [DATE], she was questioned by the LVN A if Resident 1 had verbally refused. Phleb stated she repeated to LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 2 of 5 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 555535 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Valley Care Center 9000 Larkin Road Live Oak, CA 95953 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A that she never verbally asked Resident 1 if she could do a lab draw due to the situation in Resident 1 ' s room and his condition. During an interview on [DATE] at 12:24 pm, MD stated she was scheduled to evaluate Resident 1 on [DATE]. MD stated she ordered a post-mortem stool test, which was positive for blood. MD stated she would have expected staff to notify on-call provider of change in condition. MD stated there was no call logged from facility staff in her company ' s system. MD stated, Do not resuscitate does not mean do not treat. During a concurrent interview on [DATE] at 9:51 am, Director of Nursing (DON), stated facility expectation was resident door to remain open at all hours for visual checks. DON stated if a resident wanted door closed, resident preference needed to be documented in resident ' s care plan. DON confirmed this was not in Resident 1 ' s care plan. DON stated expectation was all direct care staff to check on residents during their shift every 2 hours and as needed. DON stated expectation was that staff needed to assess Resident 1 after Phleb notified staff of her observation and report any changes promptly to MD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 3 of 5 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 555535 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Valley Care Center 9000 Larkin Road Live Oak, CA 95953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide timely and accurate discharge planning for one of three residents (Resident 1) when Resident 1 was not given a 30-day notice of discharge and no physician order was received to initiate discharge planning. Residents Affected - Few This failure resulted in the potential of an unsafe discharge for Resident 1 and caused him anxiety. Findings: During a record review of document titled admission Record, Resident 1 was admitted on [DATE]. Resident 1 had a history of congestive heart failure (the heart cannot pump enough blood to meet the body ' s needs), chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe), type II diabetes (where the body cannot regulate blood sugar levels), and brain tumor. Resident 1 ' s Physician Orders for Life Sustaining Treatment (POLST) status was Do-Not-Resuscitate. Resident 1 ' s Brief Interview for Mental Status (BIMS, scores on a scale of 0-15 the mental ability of an individual with 15 being the highest) score was 15, cognitively intact. During a record review of document titled Care Plan 7/18/2024, Resident 1 had a functional decline requiring assistance with his Activities of Daily Living (ADLs). Resident 1 ' s level of care was appropriate to reside in the facility for residential care. During a record review of document titled Interdisciplinary Team (IDT) Conference Notes 8/8/2024 7:36 am, Resident 1 verbalized his desire to be discharged to family member (FM ' s) home out of state. Notes further indicated that discharge plan initiated for about 30 days pending updates from his son regarding housing. During a record review of document titled Social Service Notes 8/27/2024 2:30 pm, Resident 1 would be discharged to FM ' s home out of state. Resident 1 was excited about being discharged to FM ' s home and social services would plan. Note further stated facility offered to pay for Resident 1 to travel to FM's home out of state. This was the only discharge planning note in Resident 1 ' s documentation. During a record review of document titled Progress Notes 8/27/2024 10:30 pm, pharmacy stated it could not give additional medication refill request for Resident 1 ' s discharge because the rest was made with not enough notice. Resident gave less than 24-hour discharge notice. During a record review of facility policy titled Social Services 2001 MED PASS, the social services department ' s responsibilities include participating in the planning of the resident ' s .return to home and community .by assessing the impact of these changes and making arrangements for social and emotional support. During a concurrent interview with Certified Nursing Assistant (CNA) C on 9/25/2024 at 2:41 pm, CNA C stated Resident 1 told her his discharge plan was to go to a previously scheduled appointment later in the week, and after appointment, facility would put him in a hotel. CNA C stated Resident 1 told her he would then be put on a bus to FM ' s out of state home the following morning. CNA C stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 4 of 5 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 555535 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Valley Care Center 9000 Larkin Road Live Oak, CA 95953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 was worried about not having money to cover travel expenses and was confused as to why he was leaving. During a concurrent interview with Nurse Practitioner (NP) on 9/26/2024 at 12:15 pm, NP stated Resident 1 did not talk about being discharged because she had no idea he was being discharged until after he died. NP stated she saw Resident 1 on 8/26/2024. NP stated she evaluated Resident 1 due to complaints of shortness of breath and coughing. NP stated staff told her he had vomited four times the night prior. NP stated Resident 1 was refusing food because he would just throw it up. NP stated Resident 1 had abdominal pain and thought he might be constipated. NP stated if she had known Resident 1 was being discharged , she would absolutely not have agreed to discharge him based on his symptoms. During a concurrent interview with Director of Nursing (DON) on 10/10/2024 at 9:51 am, DON stated she was not a part of discharge planning for Resident 1. DON stated she had no idea social services was discussing putting Resident 1 on a bus for discharge. During a concurrent interview with Social Services Director (SSD) on 10/10/2024 at 11:00 am, SSD stated facility social services department was lacking. SSD confirmed there were no discharge planning notes for Resident 1. SSD confirmed there was no discharge date set during 8/8/24 IDT care conference. SSD stated there should have been discharge planning notes for Resident 1. SSD stated lack of staffing in facility social services department. SSD stated she notified DON and Admin that Resident 1 was not feeling well. SSD confirmed she did not document this. During a concurrent interview with Administrator (Admin) on 10/10/2024 at 11:23 pm, Admin stated he was the one who initiated discharge of Resident 1 because he heard Resident 1 wanted to be discharged . Admin stated discharge of Resident 1 was just a discussion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 5 of 5