Health inspection·September 5, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 6's list of MDS assessments indicated the resident's last annual assessment was on 2/15/22 and the resident's last quarterly assessment was on 11/17/22. There was no annual assessment completed on 2/2023. During a concurrent interview and record review of Residents 2, 3, 4, 5, 6's MDS assessments on 7/5/23 at 12:55 p.m., the MDSC stated MDS assessments should be signed as completed within 14 days of the assessment reference date (ARD). The MDSC stated the MDS ARD is date of the MDS. The MDSC confirmed the Residents 2, 3, and 4's MDS assessments were completed more than 14 days after the ARD. The MDSC stated they were late. The MDSC also confirmed Residents 5 and 6 should have had annual MDS assessments done on 2/2023. The MDSC stated, It does not look like they were done. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). For an admission assessment, the MDS completion date should be no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days). For a Quarterly assessment, the MDS completion date should be no later than the ARD + 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 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 0642 Ensure a qualified health professional conducts resident assessments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a registered nurse (RN) signed and certified that Minimum Data Set (MDS, an assessment tool) assessments were completed when: Residents Affected - Few 1. The MDS Coordinator (MDSC), a licensed vocational nurse, falsified the dates and signatures for three MDS assessments for Residents 2, 3, and 4. 2. The Medical Director signed Resident 1's MDS assessment when there was no RN available. These failures had a potential to result in inaccurate assessments that could affect the plan of care and delivery of necessary care and services for residents. Findings: Review of Resident 2's admission MDS assessment, dated 2/27/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI, damage to the brain caused by an external force) and seizure disorder or epilepsy (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity); For Section Z0400 (Signature of Persons Completing the Assessment), the MDSC completed Sections A, F, G, GG, H, I, J, K , L , M, N, O, P, and S on 3/23/23; For Section Z0500A (Signature of RN Assessment Coordinator Verifying Assessment Completion), the interim Director of Nursing (IDON) signed the assessment; and For Section Z0500B (Date RN Assessment Coordinator signed assessment as complete), the IDON signed the assessment as complete on 3/1/23. Review of Resident 3's Annual MDS assessment, dated 2/15/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and atrial fibrillation (extremely fast, irregular, abnormal heartbeat); For Section Z0400, the MDSC completed Sections A to P on 3/24/23; For Section Z0500A, the IDON signed the assessment; and For Section Z0500B, the IDON signed the assessment as complete on 3/1/23. Review of Resident 4's Quarterly MDS assessment, dated 2/20/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including renal insufficiency, renal failure, or end stage renal disease (the loss of the kidney's ability to remove waste and balance fluid) and seizure disorder or epilepsy; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 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 0642 For Section Z0400, the MDSC completed Sections A, G, GG, H, I, J, K, L, M, N, O, P, and S on 3/24/22; Level of Harm - Minimal harm or potential for actual harm For Section Z0500A, the IDON signed the assessment; and For Section Z0500B, the IDON signed the assessment as complete on 3/5/23. Residents Affected - Few Review of Resident 1's MDS assessment, dated 2/5/23 indicated for Section Z0500A, the Medical Director signed under Signature of RN Assessment Coordinator Verifying Assessment Completion. During a concurrent interview and record review of Residents 2, 3, and 4's MDS assessments on 7/5/23 at 12:55 p.m., the MDSC stated MDS assessments should be signed as completed within 14 days of the assessment reference date (ARD). The MDSC stated the MDS ARD is date of the MDS. When asked how the assessments were signed as completed prior to the MDSC's completion date, the MDSC stated, I don't have an answer. During concurrent interview and record review of Residents 2, 3, and 4's MDS assessments on 7/5/23 at 1:09 p.m., IDON confirmed she was hired on 3/10/23. When asked how she could have signed the MDS assessments prior to the date she was hired, the IDON stated, I don't know how it makes sense. I wasn't here on 3/1/23 and 3/5/23. During a telephone interview on 7/10/23 at 3:55 p.m., the administrator (ADM) stated she looked into Resident 2, 3, and 4's MDS assessments and audit reports of the facility's electronic health record. The ADM stated the IDON did not sign Resident 2, 3, and 4's MDS assessments on 3/1/23 and 3/5/23. She stated the MDSC falsified dates and created a different username to make it appear as if the IDON signed the MDS assessments. Review of the ADM's letter to CDPH, Re: Falsification of Records (MDS), dated 7/11/23 indicated, The Facility concluded that [the MDSC] altered the dates on the MDS once signed in . It was discovered the [the MDSC] had Admin access at the time which would allow him the ability to manage other usernames and passwords. During an interview on 7/12/23 at 11:27 a.m., the ADM stated there was no RN to sign Resident 1's MDS assessment, so the MD signed. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated the following: Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete. Registered Nurse Assessment Coordinator (RNAC) is defined as an individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility, and is responsible for coordinating and certifying completion of the resident assessment instrument. For Z0500B, use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator. This date must be equal to the latest date at Z0400 or later than the date(s) at Z0400, which documents when portions of the assessment information were completed by assessment team members. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 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 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** Based on interview and record review, the facility failed to provide necessary treatment when there was no registered nurse available on 2/4/23, 2/5/23, and 2/9/23 to administer intravenous (IV, to deliver a medication into a vein) antibiotic (medication used to treat bacterial infections) medication for Resident 1. This failure resulted in three missed IV antibiotic doses for Resident 1. This failure had the potential to compromise the resident's health and result in ineffective antibiotic therapy. Residents Affected - Few Findings: Review of Resident 1's face sheet, indicated he was admitted on [DATE] with a primary diagnosis of sepsis (complication of an infection that can lead to tissue damage, organ failure, and death). Review of Resident 1's medication administration record (MAR), dated 2/1/23 – 2/28/23, indicated the following: Resident 1 had a physician order for Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM IV (IV antibiotic) one time a day for sepsis, start date 1/31/23, until 2/7/23; Resident 1 had a physician order for Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM IV one time a day for sepsis, start date 2/7/23, until 3/3/23; Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM was On Hold by Physician on 2/4/23 and 2/5/23 and was not signed as administered on 2/9/23. Review of Resident 1's nursing note, dated 2/4/23 indicated, MD notified of unavailable RN coverage. Hold IV ATB [antibiotic] for 2 days. During a telephone interview on 7/10/23 at 10:41 a.m., the director of staff development (DSD) confirmed that Resident 1's IV antibiotic was not given on 2/4/23 and 2/5/23 because there was no RN to administer the medication. The DSD confirmed that Resident 1's IV antibiotic was not signed on 2/9/23. The DSD stated if it was not signed, then it was not given. During a telephone interview on 7/11/23 at 11:34 a.m., the human resources administrator (HRA) stated there was no RN that worked on 2/9/23. Review of the facility's policy, Administering Medications, dated 4/2019 indicated, Medications are administered in accordance with prescriber orders, including any required time frame . Medication administration times are determined by resident need and benefit, not staff convenience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 5 of 5