Inspection·January 16, 2024

F 0678 Resuscitation/CPR and a box checked for Full Treatment. It contains dated signatures of both Physician 1 on [DATE], and Resident 1 on [DATE]. Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's Order Summary Report printed on [DATE] indicated, Active orders as of [DATE] . FULL CODE, Order Status: Active, Order Date [DATE]. Review of Resident 1's Record of Death received on [DATE] indicated, date of death [DATE] Hour 0500 (5:00 AM), Nurse present at time of death: name of [LVN A] (Licensed Vocational Nurse), Name of person notified: [name of Physician 1], Relationship to Patient/Resident: Physician, Attending physician notified by: [LVN A], Date and Hour: [DATE] 0545 (5:45 AM). Remarks: Resident expired peacefully in his sleep at 0500 on [DATE]. Notified [Name of Funeral Home] [Phone number of Funeral Home] . Called by [Signature of LVN A] . Mortician's Report; Received from [name of LVN D] The remains of: [Name of Resident 1] . Body released by: [Name of LVN D] at [DATE] at 0920 . Signed by [Funeral Home Staff]/Mortician, [Name of Mortuary], [Address of Mortuary]. Review of Resident 1's Nurse Notes with effective date: [DATE], at 07:31, indicated, Late Note: Nursing staff attempted to administer routine medication to resident. Resident was not responding to voice. This nurse tapped on his shoulder with no response. Nurse applied sternum stimulation (rubbing the bone in central part of the chest to test an unconscious person's responsiveness) and no response. Lungs auscultated (listened for airflow in the lungs) with no sounds heard. No heartbeat presented. Capillary refill (pressure applied to a finger to detect blood flow after releasing pressure) was not present. Complexation to the skin was pale and cold to touch. Request 2nd nurse in facility to verify and same results obtained from body. Resident expired at 0500 this morning on 3rd shift. Dr. [Name of Physician 1] primary physician, informed of resident status and aware. Administrator and DON (Director of Nursing) notified as well. Resident is his own responsible family. Friend [name of friend] number dialed but is not able to get a hold of. Orders to release body to mortuary obtained and carried out. [Name of Funeral Home] notified. Spoke to [name of staff]. Informed that mortuary will be at facility to pick up body after 0900 today. Report over to oncoming nurse . During an interview on [DATE], at 12:04 p.m., with Licensed Vocational Nurse B (LVN B), she stated she knew Resident 1 to be, alert, oriented, made his own decisions, was his own responsible party . Full Code. He died on [DATE] . On day shift on [DATE] . he was fine. Review of a document received [DATE] from Interim DON (INT-DON) regarding Resident 1 titled, Statement of [LVN A] on [DATE] at 1600 indicated, What happened? I (LVN A) was passing my meds (medications); when I arrived at the resident's room, I announced it was time for his medication. He usually responds to me; so, I went to the side of his bed and started talking to him; I called out his name and he did not respond to me. I then went to the other side of the bed and turned on the light. I touched him and he was cold to the touch. He did not wake up or respond. Then I did the sternum rub. He still did not wake up. I went to listen to his lungs and there were no sounds. I could not find his heartbeat nor his pulse rate. I noticed his capillary refill was not present. Why did you not perform CPR? I did not perform CPR because he was not breathing anymore. No life was in him. Were there any signs of declining during your shift? No, he was fine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2024 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 0678 Level of Harm - Actual harm Residents Affected - Few When was the last time you interacted with the resident while he was alive? The last time I looked into his room, it was around 0400. I could see the glare from the television on his face; his eyes were open, and he had his remote in his hands - he was putting it on his table. Are you aware where the crash cart (a wheeled container carrying medicines and equipment for emergency resuscitations) is and how to call a Code Blue (used to indicate a patient requiring resuscitation or immediate medical attention)? Yes, I know where those things are, I have never had to do that here. But I know how to do it. Did you know the resident was Full Code? I did not know until after I called the doctor; I assumed he was DNR (do not resuscitate) because of his condition. Is your CPR current? Yes, it is good for 2 years; It expires [expiry date]. Is there anything you would do different next time? I will check the code status . Signed by [LVN A]; DSD and INT-DON. During an interview with the Interim Director of Nursing (INT-DON) on [DATE], at 12:12 p.m., when asked why Resident 1 was not given CPR she stated, Yes Ma'am, it was not done. When asked what should have been done, the INT-DON stated, Life saving measures should have been implemented right away . That's a patient's choice, he had the right to be Full Code . he designated that in his POLST. When asked if CPR was not done as per LVN A's statement and if there was a failure, the INT-DON stated, correct, to both questions. During an interview with LVN C on [DATE], at 1:15 p.m., when asked what she would do if a resident were Full code, LVN C stated, If I found someone unresponsive, I assess vital signs (V/S, essential body functions like heartbeat, pulse rate, temperature and blood pressure) and call a code on the Intercom so all nurses can come and help me regardless of day and time of incident. So, I will be in-charge since I was the one who found the patient unresponsive. I'll have a CNA (Certified Nursing Assistant) or myself start CPR; when code team (emergency medical response personnel) arrives, we could start oxygen (air we breathe to live), AED (automated external defibrillator, medical device to analyze a heart's rhythm, if necessary, deliver an electric shock to help the heart re-establish an effective rhythm). I would also assign a nurse to call 911 and assign a CNA or Nurse to wait by the door for EMS (emergency medical services staff) so they could come to the patient's room. We continue CPR (chest compressions, AED) until EMS tells us that we are relieved, and they will take over. When asked how to check if the patient is DNR or Full Code, LVN C stated there is a binder in every unit that has the Code Status, it has their POLST there as well . we also have our laptop on [the] Med Cart, in the EMR [name of electronic medical record] the code status is there . We notify the Provider (Physician), DON, Administrator, and family . this is taught to us usually monthly . we have nurse meetings every 2nd Tuesday of the month where they tell us what the expectations are and if the code status was updated . Station One is Post-Acute unit . every time a new patient comes, the Code Binder is updated. Station Two is Long Term Unit. Review of Facility policy titled In-Service Training, All Staff revised [DATE] indicated . 1) All staff are required to participate in regular in-service education. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. 5. Training methods and teaching materials are appropriate to the level of education and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2024 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 0678 expected roles of those attending. Level of Harm - Actual harm During an interview with Physician 1 on [DATE], at 1:30 p.m., he stated, . if patient was doing okay at 4:00 a.m. and at around 5:00 a.m. was found unresponsive, the nurse should have initiated a Code Blue (code blue or code, used to indicate a patient requiring CPR or to indicate a patient requiring resuscitation or immediate medical attention) . The reality of the situation, even say patient died say 4 hours ago, she should have initiated a code and called 911. She is not a licensed person that can pronounce death. It's not her place to declare death . I did not pronounce the patient dead at 5:00 a.m. when she called. I wasn't aware it was an issue until . later I found out no code was done, and the patient was a full code. Residents Affected - Few During an interview with the Director of Staff Development (DSD) on [DATE], at 2:07 p.m., she stated all the facility's LVN staff should know how to do CPR and should know whether their assigned residents are full code, or not. Review of Facility's Job Description for Position Title: Licensed Vocational Nurse (LVN), with Date written: [DATE] indicated, . Purpose: LVNs provide medical support to physicians, registered nurses and patients. They provide routine care, take vital information from patients, provide information about treatments and prescriptions and observe patient health.Responsibilities: . Observe patients under treatment to identify progress, side effects of medications etc. Monitor patients' condition .Requirements: Familiarity with skilled Nursing, safety and sanitation standards and procedures, .Current BLS (Basic Life Support - medical care used for patients with life-threatening illnesses or injuries, covers CPR but includes additional life-saving techniques that can help those experiencing cardiac arrest, respiratory distress, or an obstructed airway) Certification Required. According to the California Code of Regulations: Title 16 CCR § 2518.5. Scope of Vocational Nursing Practice. The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan and treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. Title 16 CCR § 2518.6. Performance Standards. (b) A licensed vocational nurse shall adhere to standards of the profession and shall incorporate ethical and behavioral standards of professional practice which include but are not limited to the following: (1) Maintaining current knowledge and skills for safe and competent practice . During an interview on [DATE], at 2:23 p.m. with LVN A, she stated, I was in the hallway passing meds, usually when I go in there, he (meant Resident 1) is alert and he responds. I went in there the TV was on. I called out his name, Mr. [Resident 1 name] here's your meds, usually he would respond, but he did not. I bumped the bed with my hip, my hands were full with meds and drink, no response . I went around the other side of the bed to pull the light, I noticed he was very pale, eyes wide open. So, I touched him, and he was cold. I was feeling the pulse, no pulse. I listened to his lungs with the stethoscope (medical instrument used to listen to sounds produced within the body), there was nothing then I did the sternum rub. LVN A was asked if she knew the code status and she stated, No, not at that time and that was my mistake, I should have checked that because he was going downhill, he was already weak, he had bedsores. There were times he wouldn't want his drink or care and would say 'leave, me alone, no I don't want that,' I didn't want him to be riled. LVN A was asked if she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2024 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 0678 Level of Harm - Actual harm Residents Affected - Few thought about doing CPR, LVN A stated, no because he had no more life, he was cold. LVN A was asked if she knew that, as an LVN, she could not pronounce death, LVN A stated, Now I am aware, I was a home health nurse . I guess it's different than what I thought. When LVN A was asked if she knew there is a Code Binder in the unit, LVN A stated, Yeah, no I did not look at that time . after the sternum rub, I called the CNA 'hey he passed away,' I let the Doctor (Physician 1) know . I texted him; he got the message, he said okay . I let the Administrator (ADMIN) know, I texted them all and the DON . The ADMIN said/texted, 'Was it expected?' I texted everything was fine during the shift until he was found unresponsive. When asked if the ADMIN asked her if they did CPR, LVN A stated, No. LVN A further stated, I called the Mortuary on his chart, informed the mortuary that he died . they did not pick up right away. LVN A was asked who pronounced Resident 1 dead, LVN A stated It was me I guess, the doctor (Physician 1) said okay on text . At this time the CNAs cleaned him up and prepared him for the mortuary . The body was in the room ready for pick-up for mortuary. I endorsed to the next shift nurse . I left the facility at 8:00 a.m. came back at 2:00 p.m. they (Facility) were telling me I need to redo my statement to make it clearer on my notes to reword it to make it understandable, I reworded it, but it is the same thing, why I didn't do CPR. When LVN A was asked if Physician 1 gave an order to release the body, LVN A stated, No, he said okay, so I wrote it as an order to send him out to mortuary. When he asked if she assumed it was an order, LVN A stated, Yes. LVN A confirmed there was no mention of CPR done and 911 was not called in her note. She stated, I feel bad that I didn't. I didn't focus that night . it takes a toll . I take the blame, I'm sorry. Record review of the Emergency Medical Record Progress Notes, dated [DATE], at 1500, indicated, Note/Text: Discharge/Death Summary, Dx (Diagnoses): CVA (cerebrovascular accident, STROKE, interruption of blood flow to the brain), BPH (Benign Prostatic Hyperplasia, enlarged prostate glands in men), HTN (Hypertension, high blood pressure), RA (Rheumatoid Arthritis, swollen painful joints), Hx CAUTI (history of catheter - associated urinary tract infection) and pneumonia (inflammation of the lungs) . Hospital Course . The patient was treated again with abx (antibiotics) and then sent back to [the skilled nursing facility's name] and admitted on 8/17. The patient was last seen on 11/22 at which time RN reported dysuria (painful or difficult urination) symptoms. UA (urinalysis, laboratory examination of a person's urine) ordered. On the morning of 11/29, I was informed by RN that the patient had passed away peacefully at 5 AM. Author: [Physician 1]. Review of Facility policy Emergency Procedure - Cardiopulmonary Resuscitation, Revised February 2018, indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS, type of care that first responders, healthcare providers and public safety professionals provide to anyone experiencing cardiac arrest, respiratory distress, or obstructed airway), including defibrillation, for victims of sudden cardiac arrest . If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a do not resuscitate (DNR) that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g. rigor mortis, stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days) . If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR (do not resuscitate) or a physician's order not to administer CPR . if the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instruction until a CPR-certified staff member arrives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555538 If continuation sheet Page 5 of 5