Health inspection·July 12, 2023

F 0692 weight was 156 lbs, her usual weight was 150's, and the desired/goal body weight was stable weight. Level of Harm - Actual harm Review of Resident 1's Weight Change Note, dated 12/2/22 indicated, IDT met for monthly weight meeting .IDT recommends to cont. [continue] weekly weight, monitoring PO [by mouth] intake and follow up as needed. Residents Affected - Few Review of Resident 1's short term: IDT monthly meeting care plan, dated 12/3/22 indicated current weight of 146.4 lbs. and weight loss of 7.6 lbs/4.9% in 30 days. A care plan intervention indicated, Weekly weights, date initiated 12/3/22. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weights were taken weekly after 12/3/22. Review of Resident 1's Food and Nutrition Services Quarterly Assessment (Registered Dietitian [RD] Assessment), dated 2/27/23, indicated Resident 1's current weight was 137.8 lbs and the rate of unplanned weight loss was greater than 5 percent (%) in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. The assessment indicated, Unintended Weight Loss related to Psychological causes 2/2 [secondary to] depression as evidenced by weight loss of -16.2# [lbs] over last 90 days and -18.2# [lbs] over the last 180 days (significant weight loss). It also indicated, Please re-weigh, weigh weekly for 4 weeks. Will monitor nutrition intake and tolerance, and weight. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weight was re-weighed. There was no documented evidence Resident 1's weights were taken weekly after 2/27/23. Review of Resident 1's potential nutritional problem care plan, dated 8/30/21, indicated, 2/27/23: 30 days: no data, 90 days: -16.2# [lbs] (-11.8%), 180 days: -18.2# (-13.2%). Significant weight changes . The nutritional problem care plan was revised on 2/27/23. The care plan's goal, also indicated, The resident will maintain adequate nutritional status as evidenced by maintaining weight within, no s/sx [signs and symptoms] of malnutrition, and consuming at least 50% of meals daily through review date. The care plan's Goal did not specify the range Resident 1's weight should be maintained within. There was no update or revision to the care plan's goal. The latest revision to the goal was 9/20/22. There was no update or revision to the care plan's Interventions. The latest care plan intervention was initiated on 12/3/22. Review of Resident 1's clinical record indicated there was no documentation that indicated the IDT discussed the RD's recommendation and Resident 1's significant weight loss identified in the 2/27/23 RD assessment. There was no documentation that indicated the IDT followed up on Resident 1's continued weight loss, addressed Resident 1's depression, identified the possible cause of Resident 1's weight loss, or discussed interventions or plan regarding Resident 1's weight. Review of Resident 1's Weights and Vitals Summary, dated 5/11/23, indicated the resident's most recent weights were 146.8 lbs on 12/8/22, 143.6 lbs on 12/29/22, and 137.8 lbs on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 12/27/22 indicated, Wt [weight] 146.8 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 1/30/23 indicated, Wt 143.6 lbs- stable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 2 of 6 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 07/12/2023 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 0692 Review of Resident 1's Physician's Progress Note, dated 2/13/23 indicated, Wt 137.8 lbs- stable. Level of Harm - Actual harm Review of Resident 1's Physician's Progress Note, dated 3/20/23 indicated, Wt 137.8 lbs- stable., which was the resident's weight on 2/2/23. Residents Affected - Few Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Wt 137.8 lbs- stable., which was the resident's weight on 2/2/23. During an interview on 4/11/23 at 2:04 p.m., the registered dietitian eligible (RDE) stated if he had a recommendation to add a resident to be weighed weekly, he would inform the administrator, charge nurse, and director of nursing. The RDE stated nursing staff is responsible for weekly weights and documenting the weekly weights. During an interview on 5/11/23 at 1:08 p.m., the MDS coordinator (MDSC) confirmed there was no weight input in Resident 1's electronic medical record after 2/2/23. The MDSC stated weights are documented on paper and then the previous director of nursing would enter the weights into the electronic medical record. During concurrent interview and record review, on 5/11/23 at 1:30 p.m., the MDSC stated Resident 1's weights were taken monthly and provided paper documentation of Resident 1's weights. The documentation indicated Resident 1's weight was decreasing at 137.6 lbs in March 2023, 133.8 lbs in April 2023, and 133.2 in May 2023. The MDSC confirmed there was no documentation Resident 1's weights were taken weekly after the RD's 2/27/23 assessment. During an interview on 5/23/23 at 11:45 a.m., the MDSC confirmed there were no new interventions added to Resident 1's potential nutritional problem care plan after 12/3/22. The MDSC stated any intervention could have been added at any time to address Resident 1's weight loss. During an interview on 5/23/23 at 11 a.m., the director of nursing (DON) stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 11:43 a.m., the DON stated in the past, IDT weight meetings were held by the dietary supervisor and involved all department heads, including the dietitian, DON, assistant DON, MDSC, and restorative nursing assistant. The DON stated she did not know how often IDT weight meetings were held. During an interview on 5/23/23 at 11:45 a.m., the MDSC stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 1:08 p.m., the dietary supervisor (DS) stated there was no IDT meeting that addressed resident weights since March 2023. During a telephone interview on 5/23/23 at 12:42 p.m., Resident 1's physician (MD) stated she was aware Resident 1 had gradual weight loss in February 2023 but was not sure Resident 1 was continuing to lose weight. During an interview with the registered dietitian (RD) on 5/25/23 at 12:50 p.m., the RD stated he would expect Resident 1 weekly weights to be done if it was a care plan intervention or an RD recommendation. The RD stated adding a resident on a list to be weighed weekly does not require an MD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 3 of 6 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 07/12/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few order. He stated it is within an RD's scope to add a resident to weekly weights. The RD stated that it falls under nursing to make sure the weights are being taken. He stated an RD not having the most updated weight would affect an RD's assessment. The RD also stated that it was important to work with the IDT. He stated there should have been documentation of an IDT discussion regarding Resident 1's weight. The RD confirmed Resident 1's care plan did not specify what Resident 1's weight should be maintained within. He stated the care plan should have a specific goal that is measurable, typically a target body mass index (BMI, a measure of body fat based on height and weight) range or a target weight range. The RD stated in the 2/27/23 RD assessment, after Resident 1's weight loss, there was no specific calculations for calorie, protein, or fluid needs and there was no target weight range indicated. During an interview on 6/6/23 at 1:18 p.m., the administrator (ADM) confirmed Resident 1 did not have weekly weights taken because there was no physician's order for weekly weights. During an interview and concurrent record review on 6/6/23 at 4 p.m., the ADM confirmed there was no documentation that the IDT discussed Resident 1's weight loss after 12/2/22. The ADM confirmed the last IDT note was on 12/2/22 and the note indicated the IDT would follow up as needed. The ADM stated if the RD were to review information and identify issues, then the IDT should follow up at that time. The ADM stated there were no nursing notes or IDT documentation regarding Resident 1's weight loss identified in the 2/27/23 RD assessment. The ADM also stated there was no documentation by the IDT regarding Resident 1's depression. The ADM confirmed there should have been some type of discussion and documentation by the IDT regarding Resident 1's weight loss after the 2/27/23 RD assessment identified significant weight loss. 2. Review of Resident 2's face sheet indicated he was admitted to the facility with diagnoses including severe sepsis with septic shock (serious infection that can cause organ failure and low blood pressure). Review of Resident 2's Weights and Vitals Summary indicated his weights were 189 lbs on 12/29/23, 184.8 lbs on 1/5/23, 178.4 lbs on 1/12/23, 175 lbs on 1/19/23, and 172 lbs on 2/2/23. Review of Resident 2's Weight Change Note, dated 1/13/23, indicated the resident had a 6.4 lbs weight loss in one week and the IDT will continue to monitor and follow up as needed. Review of Resident 2's Weight Change Note, dated 1/23/23, indicated the resident had a 3.4 lbs weight loss in one week and the IDT would continue to monitor and follow up as needed. Review of Resident 2's Food and Nutrition Services Quarterly Assessment, dated 3/21/23, indicated the resident's most recent weight was 172 lbs, documented on 2/2/23. The assessment indicated the weight history was No updated weight, unable to calculate weight changes. The assessment indicated, Documented by [RDE] and was signed by the MDSC, who is a licensed vocational nurse (LVN). Review of Resident 2's Food and Nutrition Services Assessment, dated 4/4/23, indicated the resident's most recent weight was 172 lbs, documented on 2/2/23. The assessment indicated, Documented by [RDE] and was signed by the MDSC, an LVN. Review of Resident 2's physician orders indicated an order, dated 4/8/23, for weekly weight one time a day every Monday. There was no documented evidence Resident 2's weights were taken weekly after 4/8/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 4 of 6 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 07/12/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few Review of Resident 2's Medication Administration Record for April 2023 and May 2023, indicated the order weekly weight one time a day every Monday was not signed as administered on 4/17/23, 4/24/23, 5/1/23, and 5/8/23. During concurrent interview and record review on 5/11/23 at 1:30 p.m., the MDSC confirmed there was no documentation Resident 2's weights were monitored weekly in April and May. Review of the facility weights for May 2023 indicated Resident 2's weight was 162. There was no documentation that the IDT discussed Resident 2's weight from February 2023 to May 2023. During concurrent interview and record review, on 7/7/23 at 10:30 a.m., the RD confirmed the 3/21/23 and 4/4/23 Food and Nutrition Services assessments utilized Resident 2's weight on 2/2/23. The RD stated the assessments would not be accurate and Resident 2's weight should have been taken. The RD also confirmed the assessments were documented by the RDE and signed by an LVN (MDSC). The RD stated if an assessment was documented by an RDE, the assessment should be monitored and signed by an official registered dietitian. During an interview, on 7/10/23 at 10:25 a.m., the RD confirmed there was no IDT discussion regarding Resident 2's weight between February 2023 and May 2023. 3. Review of Resident 3's face sheet indicated she was admitted to the facility with diagnoses including Type 2 diabetes and hypertension (high blood pressure). Review of Resident 3's Weights and Vitals Summary, dated 4/11/23 indicated her last recorded weight was 121 lbs on 2/2/23. Review of Resident 3's Food and Nutrition Services Assessment, dated 2/13/23, indicated Resident 3 had a change in condition and had a slight decrease in intake by mouth. The assessments indicated the nutritional monitoring and evaluation was Will monitor weekly weight, dietary intake and tolerance. Review of Resident 3's clinical record indicated there was no documented evidence Resident 3's weights were taken weekly after 2/13/23. During concurrent interview and record review on 5/11/23 at 1:30 p.m., the MDSC stated Resident 3's weights were taken monthly. The MDSC confirmed there was no documentation Resident 3's weights were taken weekly. Review of the facility's policy, Weight Assessment and Intervention, revised 3/2022 indicated the following: - Residents are weighed upon admission and at intervals established by the interdisciplinary team . - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 5 of 6 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 07/12/2023 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 0692 b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe Level of Harm - Actual harm c. 6 month - 10% weight loss is significant; greater than 10% is severe Residents Affected - Few - Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight chance has been met. The evaluation includes the resident's calorie, protein, and other nutrient needs compared with the resident's current intake. - The physician and the multidisciplinary team identify conditions and medications that may be causing weight loss. - Individualized care plans shall address the identified causes of weight loss, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the comprehensive, person-centered care plan includes measurable objectives and timeframes and the interdisciplinary team reviews and updates the care plan when the desired outcome is not met. Review of the facility's policy, Care Planning - Interdisciplinary Team, revised 3/2022, indicated the interdisciplinary team is responsible for the development of resident care plans and the IDT includes but is not limited to the resident ' s attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services staff, the resident and/or the resident's representative and other staff as appropriate or necessary to meet the needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 6 of 6