Inspection·April 17, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of an outbreak line listing (tracking tool of infectious outbreaks) indicated on 04/15/2024 a possible resident outbreak of scabies on Station 1, a total of 18 residents. A review of WD progress note, dated 04/15/2024 and 04/29/2024 indicated excoriation on knee, forearm, thigh, lesion on back, wrist, hand, fingers dry skin. Clobetasol 0.05% to excoriated areas twice a day for 14 days. MD documented plan for biopsy if not improved. A review of skin/wound note, dated 05/08/2024 at 1:55 pm, indicated Resident 2 has a rash on bilateral chest, abdominal wall, bilateral hip and bilateral thigh red raised bumps, no fluid, resident was itching. MD was in house and assessed Resident 2. Director of Nursing (DON) and Infection Preventionist (IP) were notified. A review of infection note documentation, dated 05/09/2024 at 2:05 pm, indicated Resident 2 had a rash across chest, abdominal wall, bilateral hip, and thigh. Mild bumpy redness some scabs noted. Scraping (remove skin for testing) performed in house negative for scabies confirmed by unidentified second nurse. Continue ivermectin as ordered. Previous treatment of permethrin ineffective, tac cream (a topical corticosteroid used to reduce inflammation, itching, and redness) ineffective, hydrocortisone (a steroid medication can treat skin conditions) ineffective, environmental sciences instructed to deep clean room. A review of a website resource of the CDC an institution should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies even if characteristic signs or symptoms of scabies are absent. Skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. A review of Resident 2's physician order dated 05/10/2024, indicated ivermectin (an anti-parasitic medication used to treat scabies) 12 milligrams (mg) given for one time only. A review of alert charting dated 05/12/2024 at 11:49 pm, 05/13/2024 at 11:38 pm, 05/14/2024 at 11:25 pm, and 05/15/2024 at 1:18 pm Resident 2 was still itching all over body. A review of WD note, dated 05/20/2024 indicated excoriation chest, arms, and leg, general examination skin: resolved back lesion, lower leg excoriation, wrist, hand fingers dry skin treatment resolved. A review of weekly skin assessments for Resident 2, dated 04/08/2024, 05/13/2024, 05/20/2024, 05/27/2024, 06/10/2024, 06/17/2024, 06/24/2024, 07/01/2024, 07/08/2024, 07/15/2024, 07/22/2024, 08/05/2024, and 08/12/2024 indicated there were no new skin issues noted. Only the weekly skin assessment from 07/29/2024 indicated any kind of rash on the body. A review of skin and wound note, dated 06/07/2024 at 2:54 pm, indicated CNA (Certified Nursing Assistant) reported Resident 2 had a rash on entire body. Pink/red raised skin rash on back, arms, shoulders, chest abdomen, and buttocks. Resident 2 complained of itching. A verbal order for [NAME] lotion (anti-itch lotion) twice a day until resolved. A review of nurse note, dated 06/07/2024 at 11:34 pm, stated prednisone (corticosteroid used to decrease inflammation) 40 mg to be given at bedtime for rash for 7 days, urgent dermatology consults for ongoing rash. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 2 of 13 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 04/17/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm A review of alert charting dated 06/08/2024 at 4:05 pm, 06/09/2024 at 2:55 pm, 06/10/2024 at 2:51 pm, and 06/11/2024 at 3:35 pm, indicated Resident 2 had rash on upper body, no signs and symptoms of infection. A review of nurse note, dated 07/24/2024 at 12:33 pm, indicated new order for A&D ointment (moisturizer to treat dry, rough, scaly, itchy skin and minor skin irritations) topically for skin rash. Residents Affected - Some A review of skin and wound note, dated 07/25/2024 at 1:11 pm, indicated a call was made for a dermatology consult for Resident 2's ongoing rash. Dermatology appointment was scheduled for 7/26/24 at 2 pm, over three months since RP gave permission and WD requested to arrange if rash unresolved. A review of nurse note, dated 07/26/2024 at 4:54 pm, indicated Resident 2 went to dermatology appointment and saw physician who gave orders for permethrin external cream 5 % to be applied from neck to toe one time only for scabies, apply cream again in seven days on 08/03/2024. Give ivermectin 9 mg by mouth one time only for scabies until 07/27/2024. Repeat tabs again in one month on 08/27/2024. A review of an infection note dated 07/31/2024 at 6:46 am, a dermatology report indicated Resident 2 was positive for scabies and to continue treatment/isolation. A review of electronic Medication Administration Record note, dated 07/31/24 at 11:18 pm, indicated resident on contact precaution for unknown rash for possible scabies for 10 days. A review of Facility job description titled Job Description: Infection Control Nurse dated 02/2024 indicated the IP should assist in the scheduling of care plans to be presented and discussed at each committee meeting in relation to prevention and control of infection diseases. The IP should plan, develop, organize, implement, evaluate, coordinate, and direct our Infection Control Program. The IP should ensure that residents with known communicable or infection disease are placed in isolation or on infection control precautions. During an interview on 02/28/2025, at 3 pm, IP 2 stated there has been no training for licensed nurses on how to scrape the skin when testing for scabies. IP stated that if they had a resident with possible scabies, they would put the resident on isolation precautions, and call physician to do the scabies scraping. IP confirmed the licensed nurses at the facility should not have performed the scraping for Resident 2. During an interview on 03/06/2025 at 12:15 pm, DON confirmed that there was no physician order for the skin scraping to test for scabies for Resident 2 that was performed on 05/09/2024. DON confirmed licensed nurses were not trained on this procedure and it was not within their scope of practice to determine whether residents had scabies. During an interview on 03/19/2025 at 12:40 pm, MD stated they do not know who does the scrapings for scabies at the facility and that an experienced nurse who has been trained in scrapping for scabies should be the one performing a scraping. MD stated that they would not even do the scrapping themselves and would have another medical professional do the scrapping who was trained, as well as send it out to a laboratory to be tested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 3 of 13 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 04/17/2025 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 0841 Level of Harm - Minimal harm or potential for actual harm Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Based on interview and record review, the facility failed to ensure that the Medical Director (MD) supervised the development and implementation of mitigating a scabies outbreak that effected 31 residents. Residents Affected - Many This failure resulted in a six-month scabies outbreak in the facility. Findings: A review of Medical Directorship Agreement, dated 01/01/2019 indicates the MD is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The MD services as the clinician who oversees and guides the care that is provided'. The MD is responsible for coordinating of medical care in the facility to ensure that adequate and appropriate medical services are provided to the patients in the facility, reviewing incidents and accidents in the facility to identify hazards to human health and safety, serving as a member of the infection control committee at the facility. A review of alert charting, dated 04/05/2024 at 11:05 pm indicated a new order for permethrin 5% topical cream (a cream to treat scabies) for possible scabies treatment needs to be done tomorrow, continue isolation per doctor order. The order for permethrin 5% to start on 04/05/2024 end on 04/07/2024. During an interview on 03/19/2025 at 12:40 pm, MD stated best practice is two treatments of permethrin is always beneficial in treating scabies, especially if you are seeing signs that the issue is not resolved. MD explained after two treatments it is considered resolved unless skin issues continue. A review of WD progress note, dated 04/15/2024 and 04/29/2024 indicated excoriation on knee, forearm, thigh, lesion on back, wrist, hand, fingers dry skin. Clobetasol 0.05% (ointment to be applied to the skin for eczema and psoriasis) to excoriated areas twice a day for 14 days. WD documented plan for biopsy if not improved. A review of infection note documentation, dated 05/09/2024 at 2:05 pm, indicated Resident 2 had a rash across chest, abdominal wall, bilateral hip, and thigh. Mild bumpy redness some scabs noted. Scraping (remove skin for testing) performed in house negative for scabies confirmed by unidentified second nurse. Continue ivermectin (an anti-parasitic medication used to treat scabies) as ordered. Previous treatment of permethrin ineffective, tac cream (a topical corticosteroid used to reduce inflammation, itching, and redness) ineffective, hydrocortisone (a steroid medication can treat skin conditions) ineffective, environmental sciences instructed to deep clean room. A review of skin and wound note, dated 07/25/2024 at 1:11 pm, indicated a call was made for a dermatology consult for Resident 2's ongoing rash. Dermatology appointment was scheduled for 07/26/2024 at 2 pm, over three months since RP gave permission and WD requested to arrange if rash unresolved. A review of the Monthly Infection Control meeting minutes indicated: -MD was in attendance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 4 of 13 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 04/17/2025 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many -On 04/30/2024, it was documented under discussion skin infections. Under the departmental reports from Nursing and Housekeeping indicated Skin issues. The actions taken for both Nursing and Housekeeping departments indicated in-services for staff with a date of completion 04/30/2024. -On 5/31/24, it was documented under departmental reports for housekeeping deep cleans (cleaning and disinfecting hard-to-reach areas and surfaces that are not typically cleaned as part of routine daily or weekly cleaning) not being performed. There were no actions taken documented for this issue. -On 07/01/2024, it was documented under discussion ongoing skin issues, action taken was treatment/investigation and date of completion ongoing. Under departmental reports, nursing indicated hand hygiene and infection prevention education, no date of completion. Housekeeping indicated issues with glove changes and deep cleaning during infection, no action taken and ongoing no completion date. -July 2024, there was no documentation about any outbreak of scabies or skin issues. -August 2024, it was documented under discussion follow up on skin issues. During an interview on 03/19/2025 at 12:40 pm, MD stated that they did remember a few patients that were identified with scabies and was unaware of that the line listings included 31 residents. MD indicated that they did not know what to expect when it comes to tracking and trending for scabies. MD stated that on infection control meeting minutes it would be expected that the issue would be discussed in detail and state that it is resolved in a timely manner. MD stated they do not know who does the scrapings for scabies at the facility and that an experienced nurse who has been trained in scrapping for scabies should be the one performing a scraping. MD stated that they would not even do the scrapping themselves and would have another medical professional do the scrapping who was trained, as well as send it out to a laboratory to be tested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 5 of 13 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 04/17/2025 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI - a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) when the committee did not develop, implement, and identify performance improvement activities related to a scabies outbreak. Refer to F 880 and F 658. Residents Affected - Many This resulted in 31 residents and all staff, vendors, and visitors being at risk for exposure to scabies. Findings: A review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised February 2020, indicated this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation The objectives of the QAPI Program are to provide a means to measure current and potential indicators for outcomes of care and quality of life. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators Reinforce and build upon effective systems and processes related to the delivery of quality care and services. Establish systems through which to monitor and evaluate corrective actions. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI Program. The governing board/owner evaluates the effectiveness of its QAPI Program at least annually and presents findings to the QAPI Committee. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. The QAPI Committee reports directly to the Administrator. During review of resident outbreak line listings (tracking tool of infectious outbreaks) were documented as follows: -Line listing dated 04/15/2024, indicated an outbreak of scabies was documented on Nursing Station 1 (secure dementia unit) a total of 18 residents identified. The area for the date of specimen collected and laboratory (lab) results returned indicated not applicable (no entries) for all 18 residents. The area for prescribed medication for treatment was blank for all 18 residents. The area for date of recovery and present status and condition was blank for all 18 residents. The area for date Medical Director (MD) notified indicated Yes, no specific date. -Line listing dated 08/02/2024, indicated a second outbreak of scabies for a total of 13 residents on Nursing Station 2 (right outside doors to secure dementia unit) were identified. The area for the date of specimen collected and lab results returned indicated not applicable (no entries) for all 12 residents, Resident 2 had a specimen collected for lab testing on 07/29/2024, with no date documented for lab results. The area for prescribed medication for treatment was blank for all 13 residents. The area for date of recovery and present status and condition was blank for all 13 residents. The area for MD notified indicated 08/02/2024, when Resident 2 had a date of onset of 07/01/2024 on the line listing. A review of the Monthly Infection Control meeting minutes indicated: -On 04/30/2024, it was documented under discussion skin infections. Under the departmental reports (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 6 of 13 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 04/17/2025 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many from Nursing and Housekeeping indicated Skin issues. The actions taken for both Nursing and Housekeeping departments indicated in-services for staff with a date of completion 04/30/2024. -On 05/31/2024, it was documented under departmental reports for housekeeping deep cleans (cleaning and disinfecting hard-to-reach areas and surfaces that are not typically cleaned as part of routine daily or weekly cleaning) not being performed. There were no actions taken documented for this issue. -On 07/01/2024, it was documented under discussion ongoing skin issues, action taken was treatment/investigation and date of completion ongoing. Under departmental reports, nursing indicated hand hygiene and infection prevention education, no date of completion. Housekeeping indicated issues with glove changes and deep cleaning during infection, no action taken and ongoing no completion date. -July 2024, there was no documentation about any outbreak of scabies or skin issues. -August 2024, it was documented under discussion follow up on skin issues. A review of QAPI minutes dated 08/28/2024 for the previous quarter, indicated attendees included Administrator (Admin), Director of Nursing (DON), Infection Preventionist (IP), and MD. Under section Identify , Clarify, and Prioritize indicates skin issues on station 2, under Understand, Cause and Analysis stated residents noted to have dryness and redness to skin (no mention of scabies), under Solution, Plan, and Mobilize indicated to keep on in-servicing housekeeping on proper infection control and continue the use of A &D, for residents experiencing these issues monitor effects and results .residents treated with ivermectin effectively - treatment effective, under Implement, Monitor, and Evaluate stated monitor skin issues and make changes in treatment accordingly. A review of an infection note dated 07/31/2024 at 6:46 am, a dermatology report indicated Resident 2 was positive for scabies and to continue treatment/isolation. During a concurrent interview and record review, on 02/28/2025 at 1:55 pm, the DON confirmed that the infection control meeting minutes related to the scabies outbreak was lacking tracking and trending information. During a concurrent interview and record review, on 02/28/2025 at 3 pm, IP 2 confirmed that there should be more information on the scabies outbreak on the infection control meeting minutes. During a concurrent interview and record review on 03/13/2025 at 10:25 am, the Admin confirmed the July meeting minutes do not include documentation demonstrating the development, implementation and evaluation, of corrective actions or performance improvement actions related to the possible scabies outbreak. During an interview on 04/09/2025 at 2:04 pm, the Admin confirmed that there are no QAPI minutes for the time period of April - June of 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 7 of 13 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 04/17/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify a scabies (a highly contagious skin infestation caused by human itch mites that causes intense itching of the skin) outbreak, implement appropriate precautions, monitor the effectiveness of the corrective actions and prevent further transmission when: Residents Affected - Some 1. The facility's surveillance system (line listing that tracks infectious outbreaks) was incomplete. 2. Infection control committee did not monitor the scabies outbreak and evaluate the effectiveness of the corrective actions taken. 3. The nursing and housekeeping department did not implement appropriate precautions to prevent spread of scabies outbreak. 4. The staff were not trained in infection prevention and control practices to prevent further spread of scabies outbreak. 5. The facility did not take appropriate steps to diagnose and manage the resident scabies cases for two of the 31 residents. This resulted in a scabies outbreak from April to August 2024 which affected 31 residents and one direct care staff member and put all residents in the facility at risk for disease. Findings: 1. A review of a facility policy titled, Infection Prevention and Control, dated June 2022, indicated an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program consist of coordination/oversight, surveillance, data analysis, and prevention of infection. -Surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the Infection Prevention Control Program effectiveness. Surveillance tools are used for recognizing the occurrence of infections, recording the number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. -Data Analysis is gathered during surveillance and is used to oversee infections and identify trends. Monthly rates can be plotted graphically or otherwise compared side-by-side to allow for trend comparison. -Outbreak Management is a process that consists of: (1) determining the presence of an outbreak. (2) managing the affected residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 8 of 13 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 04/17/2025 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 0880 (3) preventing the spread to other residents. Level of Harm - Minimal harm or potential for actual harm (4) documenting information about the outbreak. (6) educating the staff and the public. Residents Affected - Some (7) monitoring for recurrences. (8) reviewing the care after the outbreak has subsided; and (9) recommending new or revised policies to handle similar events in the future. -Prevention of Infection include: (1) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). During review of resident outbreak line listings (tracking tool of infectious outbreaks) were documented as follows: -Line listing dated 04/15/2024, indicated an outbreak of scabies was documented on Nursing Station 1 (secure dementia unit) a total of 18 residents identified. The area for the date of specimen collected and laboratory (lab) results returned indicated not applicable (no entries) for all 18 residents. The area for prescribed medication for treatment was blank for all 18 residents. The area for date of recovery and present status and condition was blank for all 18 residents. The area for date Medical Director (MD) notified indicated Yes, no specific date. -Line listing dated 08/02/2024, indicated a second outbreak of scabies for a total 13 residents on Nursing Station 2 (right outside doors to secure dementia unit) were identified. The area for the date of specimen collected and laboratory results returned indicated not applicable (no entries) for all 12 residents, Resident 2 had a specimen collected for lab testing on 07/29/2024, with no date documented for lab results. The area for prescribed medication for treatment was blank for all 13 residents. The area for date of recovery and present status and condition was blank for all 13 residents. The area for MD notified indicated 08/02/2024, when Resident 2 had a date of onset of 07/01/2024 on the line listing. During a concurrent interview and record review on 02/11/2024, at 11:31 am, with the Infection Preventionist (IP), she confirmed for both outbreak line listings dated 04/15/2024 and 07/01/2024 there is missing information which included: -The date the specimen was collected -The date the lab results were returned -What medication was prescribed by physician -Date of recovery -Present status and condition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 9 of 13 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 04/17/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IP stated all missing data on the line listing forms were essential for tracking and trending the scabies outbreak and should have been documented on the forms. 2. A review of a facility policy titled, Infection Prevention and Control, dated June 2022, indicated the coordination and oversight of the infection prevention and control program is overseen by an infection prevention specialist (infection preventionist). The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: (1) documented incidents and corrective actions taken; (2) whether physician management of infections is optimal; (3) whether there is appropriate follow-up of acute infections. (4). The committee meets regularly and consists of team members from across disciplines. During record review from Monthly Infection Control Meeting minutes from April - September 2024, indicated the facility staff attendance included the MD, Director of Staff Development, Director of Nursing (DON), IP, Administrator (Admin), Activities Director, Housekeeping/Laundry Director, Maintenance Director and Dietary department. A review of the Monthly Infection Control meeting minutes indicated: -On 04/30/2024, it was documented under discussion skin infections. Under the departmental reports from Nursing and Housekeeping indicated Skin issues. The actions taken for both Nursing and Housekeeping departments indicated in-services for staff with a date of completion of 04/30/2024. -On 05/31/2024, it was documented under departmental reports for housekeeping deep cleans (cleaning and disinfecting hard-to-reach areas and surfaces that are not typically cleaned as part of routine daily or weekly cleaning) not being performed. There were no actions taken documented for this issue. -On 07/01/2024, it was documented under discussion ongoing skin issues, action taken was treatment/investigation and date of completion ongoing. Under departmental reports, nursing indicated hand hygiene and infection prevention education, no date of completion. Housekeeping indicated issues with glove changes and deep cleaning during infection, no action taken and ongoing no completion date. -July 2024, there was no documentation about any outbreak of scabies or skin issues. -August 2024, it was documented under discussion follow up on skin issues. During a concurrent interview and record review of the infection control meeting minutes on 02/28/2024, at 1:55 pm, the DON confirmed the meeting minutes were incomplete when there was no tracking and trending information documented or discussed amongst the team members. DON confirmed there were no consistent plans to mitigate the scabies outbreak. During a concurrent interview and record review, on 2/28/2025 at 3 pm, the IP confirmed that there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 10 of 13 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 04/17/2025 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 0880 should be more information on the infection control meeting minutes related to the scabies outbreak. Level of Harm - Minimal harm or potential for actual harm 3. A review of alert charting for Resident 2, dated 04/05/2024 at 11:05 pm indicated a new order for permethrin 5% topical cream (a cream to treat scabies) for possible scabies treatment needs to be done tomorrow, continue isolation per doctor order. Residents Affected - Some A review of the housekeeping records for Resident 2's room [ROOM NUMBER]A (scabies outbreak from 4/1/24-8/1/24) had weekly deep cleaning completed on 04/27/2024, (22 days after start of isolation for scabies). A review of alert charting dated 07/30/2024 at 5:21 am, 07/30/2024 at 2:35 pm, and 07/30/2024 11:46 pm, indicated tolerating isolation due to scabies. During an interview on 3/12/25 at 11:15 am, the Director of Housekeeping (HKD) stated that she did remember the scabies outbreak last year and she thinks that it happened in the middle on the facility around rooms 201 or 203. HKD explained the DON was the one who informs her of rooms that needed to be deep cleaned for an infection reason and when she can stop. HKD explained with rooms identified with scabies would do an initial deep clean and then you would clean it every day. HSK stated when there was a deep cleaning done on a room a form was filled out and signed. HSK was asked to provide documentation of any type of cleaning RM [ROOM NUMBER] received from April-September 2024 and documentation of DON notification which room had scabies and when it started and stopped. HKD was unable to provided documented evidence that deep cleaning occurred for RM [ROOM NUMBER] during the outbreak, and when to start and stop deep cleaning for rooms effected by scabies. 4. A review of an Inservice Sign In sheet for scabies outbreak dated 08/04/2024, indicated facility staff were educated about scabies. The scabies in-service was four months after Resident 2 was identified as possible scabies on 04/01/2024 and Resident 4 was identified on 04/05/2024, and an additional18 residents in the secure unit on 04/15/2024. 5. A review of Resident 2's medical record indicated she was admitted to the facility on [DATE], with diagnoses that included dementia, adult failure to thrive, prediabetes, and major depressive disorder. A review of the Minimum Data Set (MDS, a resident assessment) dated 04/12/2024, indicated Resident 2 has severe cognitive impairment. Resident 2 has a responsible party (RP) who makes health care decision for them. A review of skin/wound charting, dated 04/01/2024 at 1:03 pm, indicated Wound Doctor (WD) was in the facility to assess skin excoriation (a wound or scratch caused by picking at the skin) to back, chest and legs for Resident 2. WD ordered clobetasol 0.05% (ointment to be applied to the skin for eczema and psoriasis) twice daily for 14 days. WD documented a plan for a biopsy (a medical procedure that involves removing tissue or cells from the body for examination) if the skin wounds did not improve, consent was given from RP for biopsy. A review of skin/wound note, dated 05/08/2024 at 1:55 pm, indicated Resident 2 has a rash on bilateral chest, abdominal wall, bilateral hip and bilateral thigh red raised bumps, no fluid, resident was itching. MD was in house and assessed Resident 2. DON and IP were notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 11 of 13 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 04/17/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of infection note documentation, dated 05/09/2024 at 2:05 pm, indicated Resident 2 had a rash across chest, abdominal wall, bilateral hip, and thigh. Mild bumpy redness some scabs noted. Scraping (remove skin for testing) performed in house negative for scabies confirmed by unidentified second nurse. Continue ivermectin (an anti-parasitic medication used to treat scabies) as ordered. Previous treatment of permethrin ineffective, tac cream (a topical corticosteroid used to reduce inflammation, itching, and redness) ineffective, hydrocortisone (a steroid medication can treat skin conditions) ineffective, environmental sciences instructed to deep clean room. A review of skin and wound note, dated 06/07/2024 at 2:54 pm, indicated Certified Nursing Assistant (CNA) reported Resident 2 had a rash on entire body. Pink/red raised skin rash on back, arms, shoulders, chest abdomen, and buttocks. Resident 2 complained of itching. A verbal order for [NAME] lotion (anti-itch lotion) twice a day until resolved. A review of skin and wound note, dated 07/25/2024 at 1:11 pm, indicated a call was made for a dermatology consult for Resident 2's ongoing rash. Dermatology appointment was scheduled for 07/26/2024 at 2 pm, over three months since RP gave permission and WD requested to arrange if rash unresolved. A review of an infection note dated 07/31/2024 at 6:46 am, a dermatology report indicated Resident 2 was positive for scabies and to continue treatment/isolation. Residents 2 and 4 were roommates in RM [ROOM NUMBER] during the scabies outbreak. Review of Resident 4 medical record revealed the resident was admitted [DATE] with diagnoses that included Alzheimer's, dementia, and muscle weakness. Resident 4 has a RP who makes health care decisions for them. A review of the MDS dated [DATE] reveled that Resident 4 has sever cognitive impairment. A review of alert charting dated 04/05/2024 11:03 pm, 04/06/2024 10:53 pm, 04/0720/24 12:17 am, 04/08/2024 11:29 pm, 04/09/2024 11:02 pm, indicated permethrin 5% topical cream for possible scabies applied all over body and soul of feet not applied to face. A review of weekly skin observation dated 04/08/2024, 04/15/2024, 05/06/2024, 05/20/2024, 05/27/2024, 07/08/2024 indicated redness on the buttocks. A review of infection note dated 07/29/2024 at 1:37 pm, indicated that the resident was put on isolation for skin rash with unknown cause. A review of alert charting dated 07/31/2024 3:29 pm, 08/01/2024 3:10 pm, indicated resident is on isolation precautions for exposure to scabies, no itching noted. A review of infection note dated 08/05/2024 at 6:51 pm, indicated Resident 4 was on treatment for possible exposure to scabies. Buttocks and back of thighs have mild red bumps with evidence of scratching present. A review of IDT (interdisciplinary team) Skin Management note, dated 08/09/2024 3:58 pm, indicated rash to buttock, roommate positive for scabies treatment of ivermectin in place. During an interview on 02/28/2025, at 3 pm, IP stated that if they had a resident with possible scabies, they would put the resident on isolation precautions and notify the MD. IP confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 12 of 13 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 04/17/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm licensed nurses at the facility should not have performed the scraping for Resident 2. IP confirmed the only in-services they could find for direct care staff for scabies was dated 08/04/2024. During an interview on 03/19/2025 at 12:40 pm, MD stated that they did remember a few patients that were identified with scabies and was unaware that the line listings included 31 residents. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555535 If continuation sheet Page 13 of 13