Health inspection·October 7, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a licensed nurse transcribed and carried out a physician's telephone order to use resident's own eye drops and apply as ordered; and, for the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) to assess resident's ability to safely keep medication at the bedside and/or administer if able, for one of 12 sampled residents (Resident 128). These failures deprived Resident 128 to have a choice or preference to either keep and/or administer her medications at bedside. Findings: A review of Resident 128's medical record indicated she was admitted on [DATE] with type 2 diabetis mellitus (DM II, a long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), alert and oriented x 4 (person, place, time and current situation), able to make needs known. During an observation on 10/3/22 at 8:57 a.m., Resident 128 layed awake in her bed with dried and crusty discharge on her left eye. The resident stated she bought over the counter (OTC) eye drops from a pharmacy, and I had been using and putting it myself for my eyes for years to clean my eyes. Resident 128 stated, the nurse was very upset, when she found out that she (Resident 128) had the eye drops with her at the bedside; and, the nurse took the bottle away from her last night without any explanation. The resident also claimed the nurse told her she will not get to keep her eye drops. Resident 128 stated, I guess, I'm not suppose to have that. During an interview with the assistant director of nursing (ADON) on 10/3/22 at 9:22 a.m., the ADON heard and validated Resident 128's claim that a nurse was upset and took away her eye drops. The resident told the ADON, she used the eye drops every morning and bedtime, I need it to clean my eyes. The ADON stated, the facility don't allow eye drops at bedside but the nurse could have take an order from MD for it. During a record review on 10/06/22 8:56 a.m., the ADON reviewed Resident 128's nurses notes dated 10/2/22 that indicated, Resident c/o (complained of) redness both eyes and she said, I have my own eye drops that I am using, notified MD (doctor of medicine ) and T.O. (telephone order) obtained and use her own eye drops . During the concurrent interview, the ADON confirmed there was no documented evidence that the telephone order was carried out when received on 10/2/22, and Self- Medication Administration assessment was not done to determine the ability of Resident to keep the medications at bedside and administer it safely as ordered. The ADON stated, the nurse forgot to put a telephone order. Review of the facility's December 2016 revised policy and procedure, Self-Administration of Medications, indicated residents have the right to administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The staff will ask residents who are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 2 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 identified as being able to self-administer medications whether they wish to do so. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 3 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete the required annual comprehensive assessments for one of 12 sampled Residents (Resident 15). Assessments are the bases for resident's plan of care and interventions that would address their individualized and resident-centered needs. Findings: A review of Resident 15's clinical record indicated she was admitted on [DATE] with diagnoses of Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Chronic kidney disease (CKD, moderate kidney damage), and hypertension (abnormally high blood pressure). During a record review and concurrent interview with the minimum data set nurse (MDSN) on 10/4/22 at 3:17 p.m., the MDSN reviewed Resident 15's annual minimum data set (MDS, an assessment tool) done on 5/9/22 and could not find any documented evidence that the following due assessments were completed when MDS was done: Fall Risk Evaluation (assessment to determine risk for falling), Braden Scale (assessment to indicate risk for pressure ulcer development), Pain Evaluation, Wandering Evaluation, and Bowel and Bladder Screener. The MDSN stated, I missed it. The assessments should be completed on admission, quarterly, annually and when there was a significant change of condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 4 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 - Few 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** Based on interview and record review the facility failed to develop a comprehensive care plan for three of 12 sampled residents (Resident 3, 14, 128). 1. Resident 14. had no care plan for risk for wandering/elopement. 2. Resident 128, had no person centered and individualized care plan developed for bowel and balder program. 2. Resident 3, had no care plan for depression. This failure may delay the implementation of the interventions, and identification of specific care areas and services necessary to meet the residents' needs. Findings: 1. A review of Resident 14's clinical record indicated admission on [DATE] with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance and history of falling. Her Wandering Risk Assessment done on 8/16/22 indicated she was Moderate Risk for Wandering. During an interview with certified nursing assistant E (CNA E) on 10/4/22 at 8:37 a.m., CNA E stated Resident 14 is able to walk get out of her recliner chair, risk of falling and can walk on her own around the unit. During a record review and concurrent interview with the assistant director of nursing (ADON) on 10/5/22 at 2:54 p.m., the ADON verified that Resident 14 was at risk for wandering and no care plan for wandering/elopement. The ADON stated a care plan should have been developed. 2. A review of Resident 128's Braden scale (assessment to predict the development of pressure ulcer) done on 9/30/22 indicated a score of 18 or at risk for PU. The Bowel and Bladder (B/B) Program Screener done on 9/30/22 indicated she was a candidate for B/B program Schedule toileting (timed voiding- to be toileted by staff every two hours). The progress notes dated 10/3/22 indicated she was incontinent/continent with bladder, she wears brief. During an interview and concurrent review on 10/04/22 at 2:27 p.m., the ADON reviewed Resident 128's care plan and could not find any documented evidence that a person-centered, individualized care plan for bowel and bladder training for this resident was developed. A review of the facility's March 2022 revised policy and procedure, Baseline Care plans, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Baseline care plan is used until the staff can conduct the comprehensive assessment A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of resident's admission . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 5 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 - Few 3. A Review of Resident 3's medical record indicated she was admitted to the facility with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 3's medical record indicated a physician's order, dated 9/19/2, for escitalopram (an anti-depressant) for depression. It also indicated the facility staff had been monitoring for episodes of crying. There was no documented evidence the facility developed a comprehensive care plan for depression. During a concurrent interview and record review with the assistant director of nursing (ADON) on 10/6/22, at 11:59 a.m., the ADON reviewed Resident 3's medical record and verified there was no care plan developed for depression. The ADON stated, There should be a care plan for depression for this resident. Review of facility's policy titled, Care plans, Comprehensive Person-Centered, revised March 2022, indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 6 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.a A review of Resident 14 clinical record indicated she was admitted [DATE] with diagnosis of history of falling and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Her Fall Risk Evaluation done on 8/19/22. indicated she was high risk for fall. Residents Affected - Some 4.b A review of Resident 15 clinical record indicated admission on [DATE] with diagnoses of dementia and Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks). Her Fall Risk Evaluation done on 2/5/22 and 8/9/22 indicated she was high risk for fall. 4.c A review of Resident 26 clinical record indicated admission on [DATE] with diagnosis of hemiplegia (paralysis of one side of the body). Her Fall Risk Evaluation done on 3/2/22, 5/31/22 and 8/30/22 indicated she was high risk for fall. 4.d A review of Resident 128's clinical record indicated admission on [DATE] with diagnosis of history of falling and humerus fracture (break in the continuity of the upper arm). Her Fall Risk assessment done on 9/29/22 indicated she was high risk for fall. During an interview with the licensed vocational nurse G(LVN G) on 10/5/2022 at 3:34 p.m., LVN G stated licensed nurse completed the Fall Risk Evalualion upon admission and should document the vital signs specific to sitting and lying positions in the resident's vital signs record. During an interview with registered nurse F (RN F) on 10/5/22 at 3:49 p.m. RN F stated she also completed Fall Risk Evaluation upon resident's admission and had taken the resident's blood pressure once unless the resident had problems with elevated blood pressure and documented the vital signs in the resident's record. During an interview and concurrent record review with the assistant director of nursing (ADON) on 10/5/2022 at 4:51 p.m., confirmed the Fall Risk Evaluation, Section F requiring to take the systolic blood pressure in lying and standing/or sitting positions were not done. The ADON validated upon review of Residents 14,15, 26 and 128's vital signs records there were no documented evidences that the SBP were taken in different positions). The ADON admitted this concern was systemic (involved the whole facility) and she would conduct in-services to her staff during their next staff meeting 4. e. Review of Residents 12, 22, 25 and 230's fall risk evaluation records indicated that they should be monitored for any drops in their systolic blood pressures between lying and standing positions. Resident 12 had an admission fall risk evaluation on 8/3/22, Resident 25 had his admission fall risk evaluation on 8/28/22, Resident 230 had her admission fall risk evaluation on 9/19/22 and Resident 22 had his quarterly fall risk evaluation on 9/7/22. Review of Residents 12, 22, 25 and 230's vitals summary records indicated that they were not monitored for any drops of their systolic blood pressures during their fall risk evaluations on 8/3/22, 9/7/22, 8/28/22 and 9/19/22, respectively. Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for 10 of 12 sampled residents when: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 7 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 1. For Resident 9 and 21 pacemakers were not monitored; Level of Harm - Minimal harm or potential for actual harm 2. For Resident 230, her oxygen inhalation order was not followed; 3. For Resident 14, the nursing staff did not carry out the physician's order for labs; Residents Affected - Some 4. For Residents 14, 15, 26, 128, 12, 22, 25 and also 230, staff did not document the systolic blood pressure (amount of pressure in the arteries during the contraction of the heart muscle) between lying and/or standing/siting positions when completing the Fall Risk Evaluation. Accuracy of assessments is important in identifying the resident-centered needs and appropriate interventions of each resident. Resident Assessments are the bases of resident's plan of care. These failures had the potential to compromise the residents' health and well-being. Findings: 1a. Review of Resident 9's clinical record indicated he was admitted on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body), hypertension (increase in blood pressure), hyperlipidemia (an abnormally high concentration of fats in the blood), shortness of breath, and cerebral infarction (disruption of blood flow to the brain). Review of physician order dated 6/24/21 indicated to monitor Medtronic transmitter at bedside every shift related to loop recorder, *transmit information per cardiologist office request. During an interview with licensed vocational nurse A (LVN A) on 10/6/22 at 8:35 a.m., he stated Resident 9 had a pacemaker (device implanted into the chest to control abnormal heart rhythms) and nursing was monitoring the Medtronic transmitter (remote heart monitoring device) at bedside every shift. LVN A stated his role was to check that the device was plugged in and the green light was on. During a concurrent record review with LVN A he stated there was no monitoring for signs and symptoms of pacemaker failure for Resident 9. Review of Resident 9's face sheet (summary of important information about a patient including identification, insurance coverage, contacts, and diagnoses) did not include the presence of a cardiac pacemaker. Review of Resident 9's clinical record did not contain any information regarding the pacemaker's manufacturer, model number, the paced rate, type of leads, date of implant, or the cardiologists address and telephone number. There were no physician orders to monitor the pacemaker or observe for signs and symptoms of pacemaker failure. There was no documentation to indicate nursing was following the facility's policy for monitoring residents with pacemakers. 1b. Review of Resident 21's clinical record indicated he was admitted on [DATE] with diagnoses including sick sinus syndrome (heart rhythm disorder), atherosclerotic heart disease (build-up of cholesterol plaque in the walls of arteries), atrial fibrillation (irregular heart rate), hypertension (increase in blood pressure), hyperlipidemia (abnormally high concentration of fats in the blood), and presence of cardiac pacemaker. During an observation in Resident 21's room on 10/6/22 at 10:00 a.m., with LVN A, there was a Medtronic transmitter on Resident 21's dresser. During a concurrent interview with LVN A, he acknowledged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 8 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 that Resident 21 had a transmitter used by residents who have pacemakers. LVN A stated he was unaware that Resident 21 had a pacemaker. During a concurrent record review of Resident 21's medical record and interview with LVN A, there was no documentation indicating nursing staff monitor Resident 21's pacemaker. LVN A confirmed there was no monitoring of the transmitter by facility staff and there was no monitoring for signs and symptoms of pacemaker malfunction. Residents Affected - Some Review of Resident 21's clinical record did not contain any information regarding the pacemaker's manufacturer, model number, the paced rate, type of leads, date of implant, or the cardiologists address and telephone number. There were no physician orders to monitor the pacemaker or observe for signs and symptoms of pacemaker failure. There was no documentation to indicate nursing was following the facility's policy for monitoring residents with pacemakers. During an interview with the director of nursing (DON) on 10/6/22 at 10:40 a.m., she confirmed that Resident 9 and Resident 21 have implanted cardiac pacemakers. She reviewed Resident 9 and 21's clinical records and confirmed there was no documentation of the pacemaker information for Resident 9 and 21. The DON stated the medical record should contain the pacemaker information including the model number and manufacturer, the type of leads, date of insertion, the set rate, and the cardiologist's information. The DON further stated nursing staff should monitor residents every shift for signs and symptoms of pacemaker malfunction. She confirmed there was no monitoring for signs and symptoms of pacemaker failure in Resident 9 and Resident 21's medical record. A review of the facility's policy Care of a Resident with Pacemaker, revised December 2015, indicated to monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmias (slow heart rate) which include syncope (fainting), shortness of breath, dizziness, fatigue and confusion. The policy further indicated for each resident with a pacemaker, to document the following in the medical record: the name, address and telephone number of the cardiologist; type of pacemaker; type of leads; manufacturer and model; serial number; date of implant; and paced rate. A review of the U.S. Department of Health & Human Services' National Heart, Lung, and Blood Institute website, www.nhlbi.nih.gov, indicated a pacemaker can stop working properly over time because the wires get dislodged or broken, the battery gets weak or fails, the heart disease progresses, and other devices have disrupted its electrical signaling. 2. During a concurrent observation and interview on 10/4/22 at 10:40 a.m. with Resident 230, her oxygen inhalation was at 4 liters per minute via nasal cannula continuous and Resident 230 verified that she's currently receiving 4 liters per minute of oxygen inhalation. Review of Resident 230's resident information admission record indicated, Resident 230 was a [AGE] year old female with diagnoses of unspecified acute (sudden onset) and chronic (persists over time or recurring frequently) respiratory failure (condition in which the body could not get enough oxygen from the blood), unspecified chronic obstructive pulmonary disease (COPD, progressive inflammatory lung disease that causes obstructed airflow from the lungs), anxiety disorder (persistent and excessive fears) and hypertension (elevation of blood pressure). Review of Resident 230's order summary report on 10/4/22 at 11:25 a.m., indicated, she's on oxygen inhalation at 3 liters per minute via nasal cannula continuous. During an interview on 10/4/22 at 12:00 p.m., with the assistant director of nursing (ADON), she verified that they had not followed Resident 230's oxygen inhalation order. ADON further verified that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 9 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 230 was currently receiving oxygen inhalation at 4 liters per minute via nasal cannula continuous and since her order was oxygen inhalation at 3 liters per minute via nasal cannula continuous, they should have called the physician first to change the current oxygen inhalation order which is 3 liters per minute, into 4 liters per minute via nasal cannula continuous, before administering it to Resident 230. Review of the facility's, Nursing Services Policy and Procedure Manual for Long-Term Care: Medication and Treatment Orders, revised February 2014, indicated, Orders for treatments will be consistent with principles of safe and effective order writing and shall be administered only upon the written order of a person duly licensed and authorized to prescribe in this state. Treatment will be administered by nursing service personnel as soon as the order had been received. All orders must be charted and made a part of the resident's medical record and care plan. 3. Resident 14 was admitted to the facility with diagnoses including dementia with behavior Disturbance (Loss of cognitive functioning, thinking, remembering, and reasoning), aortic valve stenosis (type of heart valve disease, reduces or blocks blood flow from the heart to the body's main artery and to the rest of the body), and anemia (Condition in which lack of enough healthy red blood cells to carry adequate oxygen to body's tissues). Review of Resident 14's physician order, dated 6/29/2021, indicated an order for CBC (complete blood count, a blood test used to evaluate overall health and detect a wide range of disorders, including anemia, infection, and leukemia), CMP (comprehensive metabolic panel, a blood test provides information on blood sugar levels, balance of electrolytes and fluid, health of kidneys, and liver), HbgA1c (blood test that measures average blood sugar levels over the past 3 months), and lipid panel (blood test that can measure the amount of cholesterol and triglycerides in blood) annually in June. A review of Resident 14's medical record indicated there were no laboratory results for the above in June 2022. During a concurrent interview and record review with License Vocational Nurse A (LVN A) on 10/5/22, at 11:58 a.m., LVN A verified Resident 14's clinical record did not contain above laboratory results for June 2022 During concurrent interview and record review with the assistant director of nursing (ADON) on 10/6/22, at 10:48 a.m., the ADON stated, Lab work was not done in June 2022, but lab work should have done. She verified the physician's order was not carried out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 10 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 128's clinical record indicated admission on [DATE] with diagnoses of fracture (a partial or complete break in the continuity of the bone) of the left humerus (upper arm). The progress notes dated 9/30/22 indicated resident had an open reduction and internal fixation (ORIF, type of surgery used to stabilize and heal a broken bone) done prior to admission due to left arm fracture. Her physician's order dated 9/29/22 included monitor left arm wrapped with ace bandage and slign every shift for any increase in swelling. The progress notes dated 9/30/22 indicated resident had ORIF(open reduction and internal fixation) due to left arm fracture. Residents Affected - Few During the initial tour on 10/3/22 at 9:11 a.m. Resident 128 had a sling on her left arm which was not properly applied. Her left hand was hanging down her left side and swollen. During an interview with the assistant director of nursing on 10/3/22 at 9:15 a.m, when the ADON came at the bedside, she confirmed Resident 128's sling was not properly applied. The ADON adjusted snugly the sling and elevated the left hand/arm with pillows. Resident 128 expressed relief from discomfort after the sling was adjusted and stated, thank you, I feel much better. The ADON stated the sling should be properly applied for resident's comfort and elevate the hand to decrease swelling. Based on observation, interview and record review, the facility failed to ensure, necessary and proper care and services were provided to 3 (Residents 22, 235 and 128) out of 12 sampled residents when: 1. Staff did not monitor Residents 22 and 235 after their altercation incident; and 2. Staff did not apply Resident 128's left arm sling correctly. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 22 and Resident 235's progress notes indicated, Resident 22 had an altercation with Resident 235 on 5/18/22. Further review of Resident 22 and Resident 235's progress notes showed, they did not have 72-hour continued psychosocial monitoring and follow-up after their altercation. Resident 22 did not have progress notes on 5/20/22, while Resident 235 did not have progress notes on 5/21/22 and was discharged to his home on 8/30/22. Review of Resident 22's resident information admission record indicated, Resident 22 was a [AGE] year old male with diagnoses of dementia (loss of memory or decision-making) without behavioral disturbance, hypertension (elevation of blood pressure) and glaucoma (progressive eye disease caused by damage to the optic nerve). Review of Resident 235's resident information admission record indicated, Resident 235 was an [AGE] year old male with type 2 diabetes mellitus (DM2, condition that causes the level of blood sugar to become too high) with foot ulcer (open wound on the foot that will not heal or keeps returning), cellulitis (common skin infection caused by bacteria), osteomyelitis (inflammation of bone or bone marrow) and unspecified mood disorder (mental condition that occur when a person's emotional state does not reflect their circumstances). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 11 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 10/5/22 with Resident 22, he was seen outside in his wheelchair and appears calm and alert. Resident 22 verified that he remembered that altercation incident with Resident 235 but he did not incur any injuries and the staffs separated them right away. During concurrent interviews on 10/5/22 at 3:50 p.m. with the director of nursing (DON) and assistant director of nursing (ADON), they both verified that Resident 22 and Resident 235 did not have complete 72-hour psychosocial monitoring and follow-up after they had altercation. DON further stated that they did not have social worker that time but the other disciplines should have done the psychosocial monitoring and follow-up and she also said that they will do better next time. ADON agreed with the DON. During an interview on 10/7/22 with the social service director (SSD), she said that she was still not working at the facility that time, when the altercation incident between Residents 22 and 235 happened, but SSD verified that 72-hour psychosocial monitoring and follow-up should have been done for Residents 22 and 235 after their altercation last 5/18/22. Review of the facility's intervention report to the altercation incident, faxed to the California Department of Public Health (CDPH), indicated, that Residents 22 and 235 would be placed on 72-hour monitoring. Review of the facility's Nursing Services Policy and Procedure Manual for Long-Term Care: Charting and Documentation, revised, February 2021, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record including events, incidents or accidents involving the resident and progress toward or changes in the care plan goals and objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 12 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to carry out physician's orders to help prevent the worsening of existing pressure ulcer (PU, the breakdown of skin integrity due to pressure. which can occur when a bony prominence is under persistent contact with an external surface) for one of 12 sampled residents (Resident 14); and, the facility failed to implement interventions to help prevent the development of pressure ulcers for two of 12 sampled residents (Resident 128 and 232). These failures could potentially result in the development or delayed healing of resident's pressure ulcers. Residents Affected - Few Findings: 1. A review of Resident 14's wound Weekly Observation Tool, dated 5/24/22 indicated she developed a Stage 2 PU (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough) on her right and left buttocks with preventative measures that included Roho cushion. The Weekly Observation Tool dated 9/7/22 indicated skin on both buttocks are starting to break, continue with current treatment plan. A review of Resident 14's physician's order dated 5/25/22 included Roho cushion while up in a recliner chair. During an observation on 10/3/22 at 10:11 a.m., Resident was sitting on her recliner chair and when certified nursing assistant D (CNA D) assisted her to attend the morning activity there was no cushion found in her recliner chair. During an observation and concurrent interview on 10/4/22 at 10:43 a.m., while Resident 14 was seated in her recliner chair, certified nursing assistant E (CNA E) confirmed there was no cushion placed in her recliner chair. CNA E stated resident slept and stayed most of the time in the recliner chair. CNA E also stated she had not seen the cushion in the recliner chair but available on resident's wheelchair. During an interview with licensed vocational nurse A (LVN A) on 10/4/22 at 11:08 a.m. he stated nurses should follow doctor's orders. During an interview and concurrent record review with the assistant director of nursing on 10/5/22 at 2:58 p.m., she confirmed the Roho cushion was to help prevent the worsening of Resident 14's PU and staff did not follow the doctor's order. 2a. A review of Resident 128's Braden scale (assessment to predict the development of pressure ulcer) done on 9/30/22 indicated a score of 18 or at risk for PU. The Bowel and Bladder (B/B) Program Screener done on 9/30/22 indicated she was a candidate for B/B program Schedule toileting (timed voiding- to be toileted by staff every two hours). The progress notes dated 10/3/22 indicated she was incontinent/continent with bladder, she wears brief. During an interview and concurrent review on 10/04/22 at 2:27 p.m., the ADON could not find any documented evidence that a B/B program or timed voiding was started on 9/30/22. 2b. A review of Resident 232's Braden Scale dated 9/28/22 indicated a score of 17 or at risk for PU and the B/B Program Screener done on 9/28/22 indicated she was a candidate for toileting program or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 13 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0686 timed voiding, Level of Harm - Minimal harm or potential for actual harm During a record review and concurrent interview on 10/5/22 at 3:03 p.m., the ADON confirmed Resident 232 should have been started on toileting program on 9/28/22. The ADON also stated the B/B training should be completed for 14 days. Residents Affected - Few A review of the facility's October 2010 revised policy and procedure, Behavioral Programs and Toileting Plans for Urinary Incontinence, indicated staff to monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence, including voiding patterns, type and level of incontinence, and response to specific interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 14 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review, the facility failed to consistently provide a restorative nurse assistant (RNA) program (nursing intervention to assist or promote resident's ability to attain their maximum functional potential) for one of 12 sampled residents (Resident 26). This failure had the potential to compromise the residents' ability to attain her maximum functional potential and may result in a decline of resident's health. Findings: Review of Resident 26's clinical record indicated she was admitted with diagnoses including hemiplegia (paralysis of one side of the body), muscle weakness, difficulty in walking, Alzheimer's disease (is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks). A review of Resident 26's occupational therapy (OT) and physical therapy (PT) discharge summary indicated she was discharged from therapy as of 9/30/21 and included recommendations: RNA to promote upper body ROM (range of motion) and strength. A review of Resident 26's care plan, Limited mobility for left sided weakness, dated 9/30/21 included RNA for passive/active ROM of UEs (upper extremities) and LEs (lower extremities). A review of Resident 26's physician's order dated 8/30/22 included RNA program 3x/week for three months for routine exercises for RLE(right lower extremity and LLE (left lower extremity) AAROM (active assisted range of motion). During an observation and concurrent interview on 10/4/22 at 10:22 a.m., Resident 26 was in bed and stated the left side of her body was weak. She was unable to lift her left leg and had difficulty lifting her left arm. During an interview and concurrent record review with the restorative nursing assistant (RNA) on 10/5/22 at 10:55 a.m., the RNA claimed Resident 26 had been on RNA program for months after she was discharged from OT/PT since 9/30/21. The RNA orders are renewed every three months until she could be discharged from the program. During the concurrent record review, the RNA confirmed Resident 26's RNA Weekly Progress Notes indicated RNA staff did not follow the doctor's order to provide RNA 3x/week on the weeks of: 3/12/22, 3/19/22, 3/26/22, 4/9/22, 5/14/22, 5/21/22, 7/2/22, 7/16/22, 9/10/22, 9/17/22 and 9/24/22. She confirmed there was no documented refusal during those identified weeks. The RNA claimed she was the only RNA staff and could be off on days when RNA was not provided 3x/week. During an interview with the director of nursing (DON) on 10/7/22 at 10:58 a.m., the DON claimed she was aware of the RNA not provided as ordered. She stated work in progress to train/educate RNA aides to be able to follow doctor's orders. A review of the the July 2017 revised policy and procedure, Restorative Nursing Services, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 15 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0688 of stay or when discharged from rehab care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 16 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate supervision to prevent one of twelve sampled residents (Resident 15) from leaving the facility without staff's knowledge and permission when: 1. Staff did not provide the required assistance and supervision when Resident 15 walked off the unit. 2. Staff did not complete the annual and post wandering incident Wandering Risk Assesment required . The annual assessment was due on May 9, 2022, and the post wandering or elopement episode was due May 22, 2022. The Wandering assessment done on 8/9/22 was inaccurate. 3. Staff did not update/revise/personalized Resident 15's Wanderguard care plan (wanderguard, a device applied to resident's body designed to support caregivers, with simple keypad commands, the option for door bypass using keypads that helps prevent elopement) for elopement/wandering. 4. Staff did not notify the responsible party (RP ) and the attending physician (PCP) when Resident 14 wandered outside the facility. 5. Staff did not complete a post incident 72-hour alert charting (follow up progress notes after any incidnet or change of condition), conduct an interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) meeting, and complete the every 15-minute monitoring as indicated. These failures could potentially compromise Resident 15's health and safety. Findings: A review of Resident 15's facesheet indicated admission on [DATE] with diagnoses of dementia (condition with problems with reasoning, planning, judgment, memory and other thought processes) without behavioral disturbance, Alzheimer's disease, hypertension (abnormally elevated blood pressure) , disorders of bone density and structure. Her minimum data set (MDS, an assessment tool) dated 8/9/22 indicated a brief interview for mental status (BIMS, an assessment tool for cognition) score of 3 or impaired cognition. 1. A review of Resident 15's MDS dated [DATE] indicated she required limited assitance with one person physical assistance with walking in room, corridor and locomotion on unit (how resident moves between locations in her room and adjacent corridor on same floor) and locomotion off unit (how resident moves to and returns from off unit locations (moves to and from distant areas on the floor. A review of the facility's report to the California Department of Public Health (CDPH) dated 5/24/22 indicated, Reporting an unusual occurence here at our facility. On 5/22/22 at around 7:30 p.m. staff reported to me that they found our patient in the front parking lot unattended not with a staff member at the time . We also did increase monitoring q (every) 15 minutes for her . During an interview with the assistant director of nursing on 10/4/22 at 4:01 p.m., the ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 17 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm confirmed Resident 15's MDS indicated she needed one person physical assistance when walking in and off the unit but she was found by herself by the front parking lot without any staff. 2. A review of Resident 15's clinical record indicated there was no quarterly Wandering Risk Assessment done when the MDS was due on 5/9/22 and when Resident 15 had the wandering episode on 5/22/22. Residents Affected - Few 3. During a record review of Resident 16's care plan dated 5/22/22 and revised on 6/6/22 indicated, Resident has wanderguard on place r/t (related to ) impaired cognitive function . The care plan did not include the monitoring of wanderguard's placement and functionality, and the resident's history of wandering. 4. During an interview on 10/3/22 at 1:37 p.m., with Resident 15's family member, the responsible party (RP) who visited resident, the RP denied having been notified of Resident 15's wandering episode last May 2022. The RP stated she remembered confirming to facility staff that she was not informed about her mother's wandering episode when someone asked her before. The RP also stated, she had asked staff why her mother was wearing a wanderguard. 5. During an interview with the director of nursing (DON) on 10/4/22 at 11:55 a.m., the DON stated any incident of wandering or elopement outside the facility, needs alert charting, During an interview and concurrent record review with the assistant director of nursing (ADON) on 10/4/22 at 2:31 p.m., the ADON confirmed the Resident 15' Wandering Assessment required for May 9 and May 22,2022 were not done, and the Wandering Assesment on 8/9/22 was not accurate because it did not indicate the presence of Alzheimer's diagnosis and history of wandering that happened on 5/22/22. The ADON also reviewed Resident 15's care plan and verified this was not personalized/updated, and confirmed there was no documented evidence that a 72-hour alert charting, IDT meeting, 15-mniute monitoring and MD/RP notification were done. During an interview and record review with licensed vocational nurse A (LVN A) on 10/5/22 at 10:48 a.m., LVN A stated for any elopement or wandering incident, the nurse should initiate a Risk Management notes and complete a 72-hour alert charting. A review of the facility's March 2019 revised policy and procedure,Wandering and Elopements, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as a risk for wandering the resident's care plan will include strategies and interventions to maintain resident's safety. If a resident returns to the facility . notify the resident's legal representative, contact the attending physicican, document relevant information in the resident's medical record. A review of the March 2007 revised policy and procedure, Comprehensive Person-Centered Care Plans, indicated the IDT . develops and implements a comprehensive, person-centered care plan for each resident that includes interventions based on on-going assessments and care plans are revised with each resident's condition change. A review of the undated facility's policy and procedure, Wanderguard, indicated the wanderguard may be used on a resident who is deemed unsafe through the nursing assessment Nursing assessment of each resident must be done on admission, quarterly, and change of condition to evaluate if he/she is at risk for elopement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 18 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (G-tube, a tube surgically inserted into the stomach through the abdomen wall incision for administration of food, fluids, and medications) placement was checked prior to administering medications and water for one of one sampled resident (Resident 5). This failure had the potential to compromise Resident 5's care and could cause health complications. Findings: Resident 5 was admitted to the facility with diagnoses including gastrostomy status. During the medication administration observation for Resident 5 on 10/3/22 at 9:15 a.m., Licensed Vocational Nurse H (LVN H) turned the feeding pump off, disconnected the G-tube connection tubing, and flushed the G-tube with water. Then LVN H started the medication administration without verifying G-tube placement first. During an interview with LVN H on 10/3/22 at 10:15 a.m., the LVN H said, I should check the G-tube placement before I started flushing water and medications via the G-tube. I did not verify G-tube placement before I flushed water and medications. During an interview with the director of nursing (DON) on 10/4/22 at 3:19 p.m., the DON stated, The nurse should verify G-tube placement each time before giving medications or flushing water via G-tube by gravity. Review of facility's policy titled, Administering Medications through an Enteral Tube, revised November 2018, indicated, Verify placement of feeding tube before flushing water and administering medications by gravity flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 19 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 14) was free from unnecessary psychotropic medication (drug that affects brain activities associated with mental processes and behaviors). Resident 14 had been receiving olanzapine (Zyprexa, an antipsychotic medication) since 11/5/20: 1. Without adequate side effect monitoring; 2. Without every 6-month monitoring for AIMS (a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications); and 3. Without attempted gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); These failures resulted in inadequate monitoring and the potential for unnecessary medication for Resident 14, which potentially placed the resident at risk for experiencing harmful adverse effects from the antipsychotic medication. Findings: Resident 14 was an elderly resident admitted to the facility with diagnoses including depression (a common but serious mood disorder), dementia (a disorder which manifests loss of cognitive functioning, thinking, remembering, and reasoning), and aortic valve stenosis (type of heart valve disease, reduces or blocks blood flow from the heart to the body's main artery and to the rest of the body). 1. A review of Resident 14's medical record indicated the following physician's orders: a. Olanzapine 5 milligrams (mg, unit of measurement) for dementia with behavior disturbances dated 11/5/20. It indicated the facility nursing staff had been monitoring for behavior of physical aggression as evidenced by grabbing things and throwing them while unable to be redirected and behavior of verbal aggression while unable to be redirected associated with the use of olanzepine; b. Mirtazapine (an anti-depressant) 7.5 mg, by mouth at bedtime for depression, dated 9/3/2020. c. Monitor adverse effects of Zyprexa: Sedation, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity, excessive weight gain, dated 11/2/20; and d. Monitor adverse effects of mirtazapine: Sedation, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity, excessive weight gain, dated 9/3/20. A review of the side effect monitoring on Resident 14's medication administration record indicated the nursing staff had been monitoring for the same list of side effects (as mentioned above) although one medication was an antipsychotic, and the other was an anti-depressant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 20 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review with the assistant director of nursing (ADON) on 10/6/22 at 10:48 a.m., the ADON acknowledged the side effect monitoring for both olanzapine and mirtazapine were the same, but they should not be. 2. A review of Lexi-comp, a nationally recognized drug information resource, indicated the side effects for olanzapine included abnormal involuntary muscle movements such as continuous muscle spasm and contractions, tremors, and tardive dyskinesia (or TD: irregular, jerky movements). It indicated to monitor abnormal involuntary movements and TD at baseline and every 6 months for high-risk patients. A review of Resident 14's medical record indicated the latest AIMS assessment was completed on 10/5/21, a year ago. During a concurrent interview and record review with the ADON on 10/6/22 at 10:48 a.m., the ADON verified the latest AIMS was conducted on 10/5/21 and stated it should be done every 6 months. 3. A review of Resident 14's Psychotropic Behavior Summary for olanzapine indicated zero (0) episodes of behaviors of physical and verbal aggression in the last 11 months. Her medical record showed there was no documented evidence the facility attempted GDRs for olanzapine since 11/5/20. During the survey, Resident 14 was observed on multiple occasions, on 10/4/22 at 4:11 p.m., 10/5/22 at 8:29 a.m., 10/5/22 at 11:32 a.m., 10/5/22 at 1:30 p.m., 10/05/22 03:18 p.m., and 10/06/22 at 8:34 a.m. without having any behaviors. During an interview with Certified Nursing Assistant D (CNA D) on 10/5/22 at 10:31 a.m., CNA D stated Resident 14 does not have combative or aggressive behaviors. During an interview with Registered Nurse I (RN I) on 10/5/22 at 4:06 p.m., RN J stated, Resident rarely has behavior concerns. No physical or verbal aggression behaviors I noted during my shift lately. During an interview with the activity assistant (AA) on 10/6/22 at 9:19 a.m., the AA stated Resident 14 did not have any physical or verbal aggression behaviors that she was aware. During an interview with the social service director (SSD) on 10/6/22 at 9:32 a.m., the SSD stated, I have not observed resident exhibiting any kind of combativeness, physical or verbal aggression. During a concurrent interview and record review with the ADON on 10/6/22 at 10:48 a.m., the ADON reviewed Resident 14's medical record and confirmed there had been no attempted GDRs for olanzapine since 11/5/2020 despite the resident has had minimal or zero behaviors for the last two years. She stated the interdisciplinary team (IDT) recommended for olanzapine GDR on 6/20/21, but the family refused any changes. She also stated the pharmacy consultant recommended for GDR on 3/26/22, and on 8/26/22, but the physician refused. She further reviewed the medical record and stated there was no documentation the facility or the physician explaining to family the risks and benefits of a GDR. Furthermore, the ADON confirmed there was no documented evidence of why a GDR was contraindicated such as an attempt of reduction was tried and failed. A review of facility's policy titled Antipsychotic Medication Use revised December 2016, indicated, the nursing staff shall monitor for and report any of the following side effects and adverse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 21 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0758 consequences of antipsychotic medications to the Attending Physician: Level of Harm - Minimal harm or potential for actual harm a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension [low blood pressure], arrhythmias [irregular heart rhythms]; Residents Affected - Few c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA [transient ischemic attack or mini stroke] . The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 22 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions when: Residents Affected - Some 1. six aluminum baking pans were rusty; and 2. food trays were stored underneath the dishwashing sink beside chemicals. These failures had the potential for foodborne illness (caused by food or water contaminated with bacteria, viruses, parasites or toxins) for the 33 residents receiving food from the kitchen. Findings: 1. Observation and interview during the initial kitchen tour with the dietary supervisor (DS), on 10/3/22 at 9:14 a.m., yielded the following: a.) six rusty aluminum baking pans were on the storage rack. DS verified that these six aluminum baking pans were rusty and should not be used or placed in the storage rack. According to the Food and Drug Administration (FDA, responsible for protecting public health) Food Code 2017, Section 4-601.11, indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Review of the facility's Food Service Procedures Manual: Safety, Equipment Care and Cleaning, dated 2019, indicated, Staff will be oriented and trained on the care and cleaning of equipment. Equipment will be cleaned according to the frequency outlined on the facility's cleaning schedule list. 2. During the dishwashing observation on 10/6/22 at 9:18 a.m., clean and air-dried food trays were placed underneath the dishwashing sink beside the detergent, bleach and drying agent additive. During an interview with DS on 10/6/22 at 9:20 a.m., she verified that these clean and air-dried food trays should not be placed underneath the dishwashing sink beside the chemicals. DS further stated that they will transfer them right away to another storage area. During an interview on 10/6/22 at 2:45 p.m., with the registered dietician (RD), she verified that baking pans should be clean, sanitary and without rust. RD also verified that clean food trays should not be placed underneath the sink beside the dishwashing detergent, bleach and drying agent additive. Review of the facility's Food Service Policies and Procedures Manual: Safety, dated 2019, indicated, Chemicals will be stored separately. All soaps, detergents, cleaning compounds or similar substances will be stored in an area separate from food supplies and/or eating utensils. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 23 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 2. During medication administration observation for Resident 5 on 10/3/22 at 9:15 a.m., LVN H was observed donning on a pair of gloves, then turning off the G-tube feeding by touching the feeding pump. LVN H touched the bed remote control to raise the bed and disconnected the G-tube. Then LVN H flushed the G-tube with water and proceeded with the medication administration without changing gloves and washing hands after touched potentially contaminated surfaces. Residents Affected - Some During an interview with LVN H on 1/3/22 at 10:15 a.m., the LVN H stated, I should remove gloves, wash my hands, and apply new pair of gloves after I touched the bed remote control, G-Tube, and pump. I should do hand hygiene before I started flushing water and medications via GT. During an interview with ADON on 10/3/22 at 11:00 a.m., the ADON said, Nurses should wash hands after touching possible contaminated surfaces before start giving medications via G-tube. A review of the Center for Disease Control and Prevention (CDC) website titled, Guidelines for Hand Hygiene in Healthcare Settings dated October 2002, indicated, Failure to remove gloves between 'dirty' and 'clean' body site care on the same patient must be regarded as non-adherence to hand-hygiene recommendations, and, Change gloves and perform hand hygiene during patient care, if . moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Based on observation, interview, and record review, the facility failed to implement infection control practices to help prevent the spread of infection and COVID-19 (Coronavirus disease is an infectious disease, spread from person to person via respiratory droplets) when: 1. Two facility staff (OFS 1 and OFS 2) did not wear their face masks while in the open safe in the front desk. 2. One staff did not perform hand hygiene after touching possibly contaminated surfaces during medication administration. These failures could spread the infection to residents, staff and visitors. Findings: 1. During an observation on 10/4/22 at 2:51 p.m., the office staff 1 (OFS 1) and OFS 2 who worked in the front office accessible to staff, visitors and residents were not wearing any masks while working in their cubicle. Both staff were not eating or drinking and validated the observation. During the concurrent interview, the OFS 1 ans OFS 2 both stated, they should wear their facemasks at all times except when eating or drinking. During an interview on 10/4/22 at 3:50 p.m., the assistant director of nursing (ADON) and infection preventionist (IP) both stated staff should wear surgical (procedure) masks outside resident care area and use of appropriate mask as source control measures for COVID-19. The California Department of Public Health (CDPH) Guidance for the Use of Face Masks dated 9/20/22 indicated, Long-term care indoor settings, masks are required for all individuals regardless of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 24 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 FORM CMS-2567 (02/99) Previous Versions Obsolete vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended. The AFL 22-07.1 dated 10.6.22 indicate SNF residents and health care personnel (HCP) must continue to follow current CDPH Masking Guidance to protect themselves and others, including wearing a mask, avoiding crowds and poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following guidance for personal protective equipment use and SARS-CoV-2 testing. Event ID: Facility ID: 555538 If continuation sheet Page 25 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to ensure education on the risks and benefits of vaccine for COVID-19 (corona virus-illness caused by a virus that can be transmitted from person to person) was provided to the residents/ or responsible party (RP) for three of 12 sampled residents (Resident 9,10,23). This failure resulted in the residents' responsible parties not to have the opportunity to accept or refuse a COVID-19 vaccine for the three residents or for themselves. Findings: During an interview and concurrent record review with the infection preventionist (IP ) on 10/6/22 at 9:41 a.m., the IP stated there were three residents (Resident 9,10, 23) who refused COVID-19 vaccination because they do not believe in vaccines. During the concurrent record review, the IP could not find any documented evidence in Resident 9,10 and 23's medical records that the residents or resident representatives were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, unless due to medical contraindications. The All Facilities Letter (AFL) 22-09 dated 2/24/22 reminds facilities of the importance of offering and encouraging COVID-19 vaccinations, including booster doses, to clinically eligible individuals, especially those at highest risk of morbidity and mortality, at all interactions across the healthcare continuum. The LTC facility must develop and implement policies and procedures to ensure all the following: (i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized; (ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine; (iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine; (iv) In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 26 of 27 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 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 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 0887 Level of Harm - Minimal harm or potential for actual harm (v) The resident or resident representative, has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision; Note: States that are not subject to the Interim Final Rule - 6 [CMS-3415-IFC], must comply with requirements of 483.80(d)(3)(v) that apply to staff under IFC-5 [CMS-3414-IFC] Residents Affected - Few and (vi) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and (B) Each dose of COVID-19 vaccine administered to the resident; or (C) If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 27 of 27