Inspection·September 26, 2023

F 0622 Level of Harm - Actual harm Residents Affected - Few dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with dressing and required physical help in part of bathing activity. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 3/15/23, indicated the resident required one-person limited assistance/supervision with ADL's. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn ' s disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated Resident 1 required supervision and set up help for ADLs including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program notes, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt . Review of Resident 1's social services progress notes, dated 4/10/23, one day before the resident was discharged , indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 2 of 31 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 09/26/2023 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 0622 Level of Harm - Actual harm Residents Affected - Few There was no documentation that indicated Resident 1's psych referral or appointment was set up. There was no documentation the interdisciplinary team (IDT) discussed regarding Resident 1's discharge, to determine whether the resident was sufficiently independent to discharge or the resident agreed to be discharged to a shelter. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Patient has been doing well. She continues with knee and hip pain .A/P [assessment/plan]: 1. Debility - cont rehab 2. Knee, hip pain S/P fall- degenerative disease on imaging. Continue pain control .dispo [disposition]: cont rehab. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/23, indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with bed mobility, transfer, walking in the room, walking in the corridor, locomotion, dressing, and eating. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 3 of 31 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 09/26/2023 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 0622 Resident 1 because she was not able to walk or look for job placement. Level of Harm - Actual harm During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. Residents Affected - Few During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she was not familiar with the facility's discharge policies. She stated Resident 1's stay at the facility was not paid by her insurance. She stated Resident 1 was not appropriate for this facility. The SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 4 of 31 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 09/26/2023 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 0622 Level of Harm - Actual harm During a telephone interview, on 7/24/23 at 8:50 a.m., the BOM stated she was actively searching for a payor source for Resident 1. She stated she had a conversation with Resident 1, who informed her that someone was working on her Medi-Cal eligibility, so Resident 1 was updated to Medi-Cal pending. The BOM stated Resident 1 became eligible for Medi-Cal as of 4/24/23. Residents Affected - Few During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A ' facility-initiated transfer or discharge ' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. Based on interview and record review, the facility failed to safely discharge on e of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her, and Resident 1 returned to the facility. The resident is currently residing in the facility with coverage provided by Medi-Cal. These failures resulted in an inappropriate discharge for Resident 1 and caused harm to the resident's mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 5 of 31 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 09/26/2023 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 0622 social environment) well-being. Level of Harm - Actual harm Findings: Residents Affected - Few Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with dressing and required physical help in part of bathing activity. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 3/15/23, indicated the resident required one-person limited assistance/supervision with ADL's. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility – cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated Resident 1 required supervision and set up help for ADLs including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 6 of 31 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 09/26/2023 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 0622 Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's restorative program notes, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt . Review of Resident 1's social services progress notes, dated 4/10/23, one day before the resident was discharged , indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing Care Needs , Activity Limitations , Treatment/Special Instructions , Nutrition/Diet Order , Physical/Occupational Therapy , and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. There was no documentation the interdisciplinary team (IDT) discussed regarding Resident 1's discharge, to determine whether the resident was sufficiently independent to discharge or the resident agreed to be discharged to a shelter. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Patient has been doing well. She continues with knee and hip pain . A/P [assessment/plan]: 1. Debility – cont rehab 2. Knee, hip pain S/P fall- degenerative disease on imaging. Continue pain control . dispo [disposition]: cont rehab. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/23, indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with bed mobility, transfer, walking in the room, walking in the corridor, locomotion, dressing, and eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 7 of 31 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 09/26/2023 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 0622 During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . Level of Harm - Actual harm Residents Affected - Few During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she was not familiar with the facility's discharge policies. She stated Resident 1's stay at the facility was not paid by her insurance. She stated Resident 1 was not appropriate for this facility. The SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 8 of 31 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 09/26/2023 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 0622 Level of Harm - Actual harm stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. Residents Affected - Few During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. During a telephone interview, on 7/24/23 at 8:50 a.m., the BOM stated she was actively searching for a payor source for Resident 1. She stated she had a conversation with Resident 1, who informed her that someone was working on her Medi-Cal eligibility, so Resident 1 was updated to Medi-Cal pending. The BOM stated Resident 1 became eligible for Medi-Cal as of 4/24/23. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A ' facility-initiated transfer or discharge' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or <[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 9 of 31 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 09/26/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to provide a discharge notice 30 days prior to discharge for one of three residents (Resident 1) when: Residents Affected - Few 1. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a shelter. 2. The Office of the State Long-Term Care Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) did not receive a discharge notice 30 days prior to the resident ' s discharge. This failure resulted in Resident 1 not receiving sufficient notice prior to her discharge to prepare her post discharge care. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): .The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she did not send the notice of Resident 1's discharge to the office of the State Long-Term Care Ombudsman. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated, The resident and his or her representative are given a 30-day advance written notice of an impending transfer or discharge from this facility. It also indicated, A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Based on interview and record review, the facility failed to provide a discharge notice 30 days prior to discharge for one of three residents (Resident 1) when: 1. Resident 1 received a discharge notice one day prior to her discharge and became upset when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 10 of 31 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 09/26/2023 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 0623 informed she would be discharged to a shelter. Level of Harm - Minimal harm or potential for actual harm 2. The Office of the State Long-Term Care Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) did not receive a discharge notice 30 days prior to the resident's discharge. Residents Affected - Few This failure resulted in Resident 1 not receiving sufficient notice prior to her discharge to prepare her post discharge care. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): . The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she did not send the notice of Resident 1's discharge to the office of the State Long-Term Care Ombudsman. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated, The resident and his or her representative are given a 30-day advance written notice of an impending transfer or discharge from this facility. It also indicated, A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 11 of 31 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 09/26/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASRR, a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care; Level I Screening is a tool to identify individuals who are diagnosed or suspected to have MI, DD, or ID; based on the Level II Evaluation, as performed by the State-Designated Authority [SDA] when Level I screening showed the individual is positive for MI, the Department of Health Services would issue a determination of the treatment and placement recommended for the individual) assessments for one of three residents (Resident 1) when: 1. Resident 1's PASSR was not completed prior to admission or within 30 days of admission; and, 2. Resident 1's Level II evaluation was not completed when the resident's PASSR Level I screening was positive. These failures had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance), dated 7/12/23 indicated, she was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's PASSR Level I Screening, dated 5/30/23 indicated, Result of Level I Screening: Level I - Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the response was, Yes and anxiety disorder, adhd. During a telephone interview on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1 ' s 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR . All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 12 of 31 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 09/26/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation. Based on interview and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASRR, a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care; Level I Screening is a tool to identify individuals who are diagnosed or suspected to have MI, DD, or ID; based on the Level II Evaluation, as performed by the State-Designated Authority [SDA] when Level I screening showed the individual is positive for MI, the Department of Health Services would issue a determination of the treatment and placement recommended for the individual) assessments for one of three residents (Resident 1) when: 1. Resident 1's PASSR was not completed prior to admission or within 30 days of admission; and, 2. Resident 1's Level II evaluation was not completed when the resident's PASSR Level I screening was positive. These failures had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance), dated 7/12/23 indicated, she was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's PASSR Level I Screening, dated 5/30/23 indicated, Result of Level I Screening: Level I &ndash; Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the response was, Yes and anxiety disorder, adhd. During a telephone interview on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1's 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR . All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 13 of 31 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 09/26/2023 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 0644 II PASRR evaluation. 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 14 of 31 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 09/26/2023 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 and services for one of three residents (Resident 1) prior to discharge when: Residents Affected - Few 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm were not evaluated prior to her discharge. 4. Resident 1's ordered referrals (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) for gastrointestinal (GI) services related to Crohn's disease (a type of inflammatory bowel disease) and psychological (psych) services for her diagnoses of post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder were not initiated or followed up. These failures had the potential to result in missed opportunities for the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) to evaluate the resident's continuing care needs. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn ' s disease, ADHD, and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 15 of 31 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 09/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self-harm. States she does not have a plan but has self harmed in the past .Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's social services notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] .dispo [disposition]: cont rehab. Review of Resident 1's physician orders, dated 3/21/23, indicated, Per MD [medicine doctor] start GI [gastrointestinal] Referral r/t [related to] Crohn's disease. Review of Resident 1's physician orders, dated 3/29/23, indicated, Per MD start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t Anxiety Disorder, ADHD, and PTSD. Review of Resident 1's progress notes, indicated there was no documentation Resident 1's GI and psych referrals were initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 16 of 31 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 09/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs .Res states she knows she reacted horrible to the leaving but it is related to her PTSD. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI appointment and a psych appointment. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places)as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 17 of 31 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 09/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on [DATE]. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the nurse should document a change of condition assessment and it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm, there was no documentation that indicated staff attempted to request for psych services for Resident 1, and there was no documentation that indicated the IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report - which will trigger 72 hour charting; Notify the physician ' s office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 18 of 31 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 09/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on interview and record review, the facility failed to provide necessary treatment and services for one of three residents (Resident 1) prior to discharge when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm were not evaluated prior to her discharge. 4. Resident 1's ordered referrals (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) for gastrointestinal (GI) services related to Crohn's disease (a type of inflammatory bowel disease) and psychological (psych) services for her diagnoses of post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder were not initiated or followed up. These failures had the potential to result in missed opportunities for the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) to evaluate the resident's continuing care needs. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease, ADHD, and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self-harm. States she does not have a plan but has self harmed in the past . Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's social services notes, indicated there was no documentation that the SSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 19 of 31 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 09/26/2023 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 followed up regarding Resident 1's thoughts of self-harm. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Residents Affected - Few Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility &ndash; cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's physician orders, dated 3/21/23, indicated, Per MD [medicine doctor] start GI [gastrointestinal] Referral r/t [related to] Crohn's disease. Review of Resident 1's physician orders, dated 3/29/23, indicated, Per MD start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t Anxiety Disorder, ADHD, and PTSD. Review of Resident 1's progress notes, indicated there was no documentation Resident 1's GI and psych referrals were initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing Care Needs , Activity Limitations , Treatment/Special Instructions , Nutrition/Diet Order , Physical/Occupational Therapy , and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 20 of 31 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 09/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI appointment and a psych appointment. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places)as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 21 of 31 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 09/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on [DATE]. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the nurse should document a change of condition assessment and it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm, there was no documentation that indicated staff attempted to request for psych services for Resident 1, and there was no documentation that indicated the IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care . Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report &ndash; which will trigger 72 hour charting; Notify the physician's office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 22 of 31 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 09/26/2023 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 0742 Level of Harm - Actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be discharged . Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 23 of 31 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 09/26/2023 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 0742 Level of Harm - Actual harm Residents Affected - Few disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self harm. States she does not have a plan but has self harmed in the past .Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's physician order, dated 3/29/23, indicated, Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD. There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 24 of 31 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 09/26/2023 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 0742 Level of Harm - Actual harm Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely) . Residents Affected - Few Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): .The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Resident 1's social services progress note, dated 4/12/23 after she returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal [California's health care program which covers most medically necessary care], she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs .Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's PASSR Level I Screening, dated 5/30/23, indicated, Result of Level I Screening: Level I - Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the responses were, Yes and anxiety disorder, adhd. There was no documentation that indicated Resident 1 had a PASRR Level I assessment prior to admission or within 30 days of admission. There was no documentation that indicated Resident 1 had a PASRR Level II evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 25 of 31 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 09/26/2023 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 0742 During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . Level of Harm - Actual harm Residents Affected - Few During an interview on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI (gastrointestinal) appointment and a psych appointment. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD (a mental health condition with similar symptoms as PTSD, but may include problems controlling emotions and feelings of worthlessness, shame and guilt) due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but stated she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 1:50 p.m., Resident 1 stated she has not had a psych referral yet and expressed the need for it. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 26 of 31 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 09/26/2023 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 0742 Level of Harm - Actual harm Residents Affected - Few During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m. with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on [DATE]. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1's 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the staff should stay with the resident and ask if they have an active plan. The staff should let the SSD, DON, and MD know, and monitor the resident for emotional distress. The ADON stated the nurse should document a change of condition assessment and monitor the resident for 72 hours or past 72 hours. She stated it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm. The ADON confirmed there was no documentation that indicated staff attempted to request for psych services for Resident 1. The ADON also confirmed there was no documentation that indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 27 of 31 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 09/26/2023 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 0742 Level of Harm - Actual harm Residents Affected - Few IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility, she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later on. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. The ADON stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report - which will trigger 72 hour charting; Notify the physician's office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A 'facility-initiated transfer or discharge' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. The resident and his or her representative are given a 30-day advance written notice of an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 28 of 31 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 09/26/2023 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 0742 impending transfer or discharge from this facility. Level of Harm - Actual harm Review of the facility's undated position description for Director of Social Services indicated the essential functions included to develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident and Participate in discharge planning, development and implementation of social care plans. Residents Affected - Few According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States, dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR .All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation. Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) and treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 29 of 31 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 09/26/2023 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 0742 Level of Harm - Actual harm Residents Affected - Few discharged . Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self harm. States she does not have a plan but has self harmed in the past . Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 30 of 31 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 09/26/2023 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 0742 monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's physician order, dated 3/29/23, indicated, Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD. There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely) . Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): . The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 31 of 31