Health inspection·November 7, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/16/2023, Resident 8 refused [shower] due to water pressure. The form did not indicate a shower or bath had been provided for Resident 21. On 10/18/2023, Resident 9 refused a bath or shower. During an interview on 10/19/2023 at 9:05 am with Administrator (ADM 1), ADM 1 stated the facility had purchased a bunch of wipes for bed baths because the facility had no hot water since last night. ADM 1 stated the facility planned to bring in an extra Certified Nurse Assistant (CNA) when hot water was back to catch up on showers. ADM 1 stated one of two water heaters was shut off yesterday (10/18/2023) for repair, but since that time a new water leak had been discovered. During a concurrent interview on 10/19/2023 at 9:05 am with Maintenance Supervisor (MS), MS stated a water leak had been discovered in the dining room at 6:00 am, and water to the facility had been shut off shortly thereafter so the leak could be fixed. During an interview on 10/19/2023 at 9:20 am, CNA 3 stated water in the facility runs warm but cools quickly, which has caused residents to decline showers. CNA 3 stated the hot water had been an issue since last Friday. During an interview on 10/19/2023 at 9:35 am, CNA 5 stated the DON was not admitting to residents there was no hot water. During an interview on 10/19/2023 at 9:37 am, Resident 14 stated she hadn ' t had a shower and the water was cold. During an interview on 10/19/2023 at 9:38 am, Resident 25 stated it had been about a week with no shower or bed bath. During an interview on 10/19/2023 at 9:40 am, Resident 8 stated she had asked DON on 10/13/2023 about no hot water for showers. Resident 8 stated the hot water had been out about a week at that time, but now it's been two weeks. Resident 8 stated showers had been offered by staff, but the resident refused because showers were cold. Resident 8 stated wipes had been offered for bed baths, but that's not going to get me clean, either. Resident 8 stated she had refused wipes. During an interview on 10/19/2023 at 9:45 am, Resident 26 stated, It ' s about time you got here. I want a hot shower. It ' s been 15 days. Resident 26 stated he was very frustrated and had a fit about it. During an interview on 10/19/2023 at 9:50 am, Resident 9 stated there had not been hot water in the facility for 15 days. Resident 9 stated, That's close to elder abuse. Resident 9 stated her home was near the facility and that she was able to go home to shower, but she feels awful and is pissed she can't wash her hair at the facility. Resident 9 stated it has been a long time with no accommodation. Resident 9 stated, I feel left behind. I ' m pretty independent, so they don ' t check on me very much. During an interview on 10/19/2023 at 9:50 am, Housekeeper (HK) stated residents had been complaining about no hot water and not getting showers, particularly Resident 16. During an interview on 10/19/2023 at 11:10 am, CNA 1 stated the facility had no hot water for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 2 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 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 0677 Level of Harm - Minimal harm or potential for actual harm almost three weeks. CNA 1 stated a family complained about lack of bathing their bedbound family member and reported she heated water in a microwave to do a bed bath. CNA 1 reported another resident wanted a shower prior to dialysis. CNA 1 stated she reported the issue to Staffing Coordinator (SC) and was told to use a shower cap with soap in it to wash the resident's hair. CNA 1 stated, Residents are complaining about showers. I was told just do what you can. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 3 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the supervision required to keep all residents free from potential accidents and hazards when: 1. One of seven residents (Resident 1) eloped unsupervised (left without notice) from the facility without staff being aware he was gone. 2. Wanderguard alarms (prevent wander-prone residents from leaving unattended) were not working at two of four facility exit doors. These failures had the potential to compromise the safety and well-being of all residents from unsupervised wandering/elopement with the potential for accident or harm. Findings: Review of facility policy titled, Safety and Supervision of Residents, revised 10/2022, indicated the facility would strive to make the environment as free from accident hazards as possible based on individual resident need. The policy indicated the facility would monitor the effectiveness of interventions by (a) ensuring that interventions are implemented correctly and consistently, (b) evaluate the effectiveness of interventions, and (c) modify interventions as needed. Review of facility policy titled, Wandering and Elopements, revised 3/2019, indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1.Review of Resident 1's admission record indicated he was admitted to the facility on [DATE], with diagnoses which included heart disease and muscle weakness. Review of Minimum Data Set (MDS) record, dated 2/25/2023, indicated Resident 1 had a Brief Interview for Mental Status (tool used to identify the mental capacity of residents) score of 12 out of 15. The record indicated Resident 1 required limited staff guidance (guided maneuvering of limbs or other non-weightbearing assistance) for moving about on and off the unit. The record indicated Resident 1 was not steady, but able to stabilize without staff assistance when walking and turning around. The record indicated Resident 1 used a walker and/or wheelchair for mobility following a stroke, and a wander/elopement alarm was not used. The record indicated care areas triggered for care planning included cognitive (mental capacity) loss/dementia, activities of daily living functional/rehabilitation potential, and falls. Review of an Interdisciplinary Team (IDT - a group of professionals from different disciplines who meets to discuss resident care) Note for Resident 1, dated 3/16/2023 at 9:05 am, indicated that staff was alerted by a civilian that Resident 1 was seen outside of the facility. The note indicated staff searched surrounding areas to locate Resident 1, who was known to have exit-seeking behaviors with a risk for fall. The note indicated Resident 1 had moderately impaired cognition (the ability to acquire and process information). Resident 1's description of the event was that he went out for a walk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 4 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/13/2023 at 12:10 pm with Administrator (ADM 1) and Director of Nursing (DON), ADM 1 and DON could not confirm Resident 1 ' s 3/16/2023 elopement had been reported to SA. ADM 1 stated he did not work for the facility until 4/2023 and was not present in the facility at the time of elopement. During an interview with DON on 10/13/2023 at 1:25, DON stated he had just called ADM 2 (administrator in 3/2023) who reported he can ' t remember if they called SA or not. DON stated ADM 2 reported to him that if there was proof of a report to SA, it would have been on the computer. ADM 1 and DON were unable to produce an unusual occurrence report. During an interview on 10/19/2023 at 12:15 pm with Director of Social Services (DSS), DSS stated Resident 1 was his own Responsible Party and wanted to go out at the time of elopement on 3/16/2023. DSS stated Resident 1 didn't sign out and got to the park before it was noticed he was not in the facility. DSS stated, Someone brought him back, she thought possibly the DON. DSS stated Resident 1 was not wearing a Wanderguard bracelet at the time of elopement, but Wanderguard bracelet was placed on Resident 1 after the elopement to prevent further incidents. 2. Review of documents titled RF Technologies Down Payment Requisition, dated 09/28/2023, indicated a request for purchase of Code Alert 9450 Wander Management (WM) System components. During an observational tour of the facility 16 days later on 10/13/2023 at 8:45 am with Director of Nursing (DON), two of four alarms did not sound at Wanderguard-monitored exit doors located (a) between rooms [ROOM NUMBERS] and (b) between the storage shed and outside storage. During an interview on 10/13/2023 at 9:00 am with DON, DON stated a log of Wanderguard alarm system checks did not exist but that he had checked the alarm system a couple days ago and it was working at that time. DON stated he checked the alarm system about once or twice a week for my peace of mind. During a concurrent observation and interview with DON on 10/13/2023 at 12:35 pm, the Wanderguard at exit door between rooms [ROOM NUMBERS] was again tested. A very loud alarm sounded. DON verified that the Wanderguard was still not working but that a universal door alarm had been turned on. DON stated a new Wanderguard unit had been ordered. Record review was performed for a sample of seven residents (Residents 1-7), each of whom was identified as being at risk for elopement:.Residents 2-7 had orders for Wanderguard, signed consents, and elopement care plans in place and updated. Each resident had orders for battery function of Wanderguard documented checked nightly and placement checked each shift. Review of Minimum Data Set (MDS) record, dated 9/20/2023, indicated Resident 2 exhibited wandering behaviors 1 to 3 times on admission. The record indicated Resident 2 required limited staff guidance (guided maneuvering of limbs or other non-weightbearing assistance) for moving about in his room and on and off the unit. The record indicated Resident 2 was not steady, but able to stabilize without staff assistance when walking and turning around. The record indicated Resident 1 used a wheelchair for mobility due to impairment in his lower extremity (legs) function related to diagnoses of Parkinson's disease and history of stroke. The record indicated Resident 2 had had a fall since admission and was on an alarm to prevent wander/elopement daily. Review of an IDT Note for Resident 2, dated 10/12/2023 at 1:41 pm, indicated, Resident 2 walked out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 5 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some back door of facility pushing his wheelchair in front of him. The note indicated Resident 2 became combative and resisted assistance when staff attempted to redirect him back into the building. The plan was to monitor for further elopement attempts. Root cause analysis indicated Resident 2 has a history of exit-seeking behavior looking for his wife with a baseline cognition level of severe impairment. The note indicated Resident 2 was at risk for wandering, elopement, fall or accident. Interventions prior to Resident 2's elopement on 10/12/2023 were an elopement prevention care plan and Wanderguard. The note indicated the facility planned to increase safety checks, provide calm reassurance that his wife knows where he is, and encourage family to visit more often. During an interview on 10/19/2023 at 9:35 am, CNA 4 confirmed Resident 5 is a wanderer and seeks to exit the facility enough for staff to monitor him. During an interview on 10/19/2023 at 11:00 am with Maintenance Supervisor (MS), MS stated he did not keep a log of weekly checks of the Wanderguard, so there was no proof, and to his knowledge DON was not doing checks of the Wanderguard system. During a concurrent interview on 10/19/2023 at 11:00 am with ADM 1, ADM 1 stated Both Wanderguard systems on Hall 1 and Hall 2 near laundry and kitchen aren ' t working. During an interview on 10/19/2023 at 12:15 pm with Director of Social Services (DSS), DSS stated Resident 2 had a witnessed elopement on 10/12/2023. DSS stated he made it out the front door. Staff saw him and followed him out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 6 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents' linens were being clean and sanitized using infection control standards. This failure resulted in residents' linens not being cleaned and sanitized properly and had the potential to spread disease and infection throughout the facility. Residents Affected - Some Findings: A review of a facility policy titled, Infection Prevention and Control, revised 10/2021, indicated, An infection prevention and control program (ICPC) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation on 10/13/2023 at 8:50 am, overheard Director of Nursing (DON) inform Resident 8 an issue with no hot water in the facility was fixed Wednesday (10/11/2023). Resident 8 stated the hot water had been out for like a week. DON again replied that maintenance staff had resolved the issue two days prior. During a review of Plumbing Doctor Invoice #24467745, dated 10/17/2023, the invoice indicated it was an estimate to replace a gas control valve, thermostat, temperature and pressure valve, and drain valve on a 100-gallon water heater. During a review of Plumbing Doctor Estimate #24523298, dated 10/17/2023, the estimate indicated This estimate is to remove old leaking 100-gallon water heater and install a new 100-gallon water heater up to state and city code. This will include an expansion tank and seismic straps. During an interview on 10/19/2023 at 9:05 am, Maintenance Supervisor (MS) stated one of two facility water heaters was out. MS stated a plumber had been called to replace parts, but a decision had been made to replace the broken water heater. MS stated he knows hot water temperatures should be between 106- and 120-degrees Fahrenheit, but we don't have that now. During an interview on 10/19/2023 at 10:30 with Housekeeper (HK), HK stated the laundry has been dirtier. HK stated they were having to rewash the laudry often. During an interview on 10/19/2023 at 11:10 am with Administrator (ADM 1), ADM 1 stated he was unaware of the laundry issues. ADM 1 stated he did not know where to find the Ecolab (manufacturer) operating manual for washing machines but would look for it. During a concurrent observation in the laundry room and interview with MS on 10/19/2023 at 11:43 am, MS stated Ecolab maintains facility washing machines. When asked how often machines were maintained, MS stated Ecolab had been in the facility 2 to 3 days ago to check the dishwashers but could not state when washing machines were last maintained. MS stated he was aware residents were complaining about the laundry and things aren't getting clean. MS stated he did not know where to find the manufacturer operating manual for facility washing machines. MS confirmed the two of two washing machines were overfilled with blankets and articles of clothing; this did not allow water to agitate or cleaning chemicals to circulate properly through laundry items. During an interview on 10/19/2023 at 12:40 pm, ADM 1 stated he could not locate the manufacturer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 7 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm operating manual for washing machines. ADM 1 stated he had called Ecolab and confirmed the facility washing machines require low temperature at a minimum of 120-degrees Fahrenheit for proper cleaning and sanitizing with the detergent. Despite two requests on 10/19/2023 and 11/6/2023, Ecolab operating manuals were not provided to SA. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 8 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain essential equipment necessary to ensure resident safety and activities of daily living needs were met when: Residents Affected - Some 1 The Wanderguard Alarm System (prevents wander-prone residents from leaving the facility unattended) did not work for three weeks or more. This failure led to the potential for unsupervised resident elopement (leaving without notice), leading to the potential for harm and preventable accidents/hazards for all residents. 2. One of two facility water heaters did not work for two weeks or more. This failure led to residents not getting baths or showers due to no hot water in the facility with the potential to result in poor self-esteem, depression, denial of resident rights, contribution to skin breakdown, infection, and negative clinical outcomes for all residents. Findings: 1. Review of a facility policy titled, Wandering and Elopements, revised 3/2019, indicated that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of facility policy titled, Safety and Supervision of Residents, revised 10/2022, indicated the facility will strive to make the environment as free from accident hazards as possible based on individual resident need. The policy indicated the facility will monitor the effectiveness of interventions by (a) ensuring interventions are implemented correctly and consistently, (b) evaluate the effectiveness of interventions, and (c) modify interventions as needed. Review of documents titled RF Technologies Down Payment Requisition, dated 09/28/2023, indicated request for purchase of Code Alert 9450 Wander Management (WM) System components. During an observational tour of the facility 16 days later on 10/13/2023 at 8:45 am with Director of Nursing (DON), a test was performed to the Wanderguard alarm system. The Wanderguard alarm did not sound at two of four Wanderguard-monitored exit doors: (a) between rooms [ROOM NUMBERS] and (b) near the laundry room. During an interview on 10/13/2023 at 9:00 am with DON, DON stated he had checked the alarm system a couple days ago and it was working at that time. DON stated he did not keep a log of checks performed to the Wanderguard system but stated he checked the system about once or twice a week for my peace of mind. During a concurrent observation and interview with DON on 10/13/2023 at 12:35 pm, the Wanderguard at exit door between rooms [ROOM NUMBERS] was again tested. A very loud alarm sounded. DON stated that a universal door alarm had been turned on but confirmed Maintenance Supervisor (MS) had been unable to fix the Wanderguard. DON stated a new Wanderguard unit had been ordered. During an interview on 10/19/2023 at 11:00 am with MS, MS stated he did not keep a log of his weekly checks of the Wanderguard so there was no proof, and DON was not doing the checks to his knowledge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 9 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview on 10/19/2023 at 11:00 am with Administrator (ADM 1), ADM 1 stated Both Wanderguard systems on Hall 1 and Hall 2 near laundry and kitchen aren ' t working. 2. During observation on 10/13/2023 at 8:50 am, overheard Resident 8 ask DON when hot water for showers would be available again. DON stated, That was fixed Wednesday (10/11/2023). Resident 8 stated the hot water had been out for like a week. DON again stated maintenance staff had resolved the issue two days prior. During observation on 10/13/2023 at 12:30 pm, a facility staff member handed this surveyor a note indicating, the facility has not been giving residents showers due to no hot water! They do not have any shower caps for alternatives. -Anonymous (sic). During a review of Plumbing Doctor Invoice #24467745, dated 10/17/2023, the invoice indicated it was an estimate to replace a gas control valve, thermostat, temperature and pressure valve, and drain valve on a 100-gallon water heater. During a review of Plumbing Doctor Estimate #24523298, dated 10/17/2023, the estimate indicated This estimate is to remove old leaking 100-gallon water heater and install a new 100-gallon water heater up to state and city code. This will include an expansion tank and seismic straps. During an interview on 10/19/2023 at 9:05 am, Administrator (ADM 1) stated the facility had been without hot water since last night. ADM 1 stated the facility bought a bunch of wipes for bed baths and planned to bring in an extra Certified Nurse Assistant (CNA) when the hot water is back to catch up on showers. During a concurrent interview on 10/19/2023 at 9:05 am, MS stated one of two facility water heaters was out. MS stated the water heater had a known leak and a plumber was called for parts, however getting the parts was a problem. MS stated it had been decided to replace the water heater. MS stated he understood water needs to be between 106- and 120-degrees Fahrenheit for proper cleaning and sanitizing, but we don't have that now. MS stated a water leak had been discovered in the dining room at 6:00 am, and water to the facility had been shut off shortly thereafter so the leak could be fixed. During an interview on 10/19/2023 at 11:10 am, CNA 1 stated the facility had no hot water for almost three weeks. CNA 1 stated a family complained about lack of bathing their bedbound family member and reported she heated water in a microwave to do a bed bath. CNA 1 reported another resident wanted a shower prior to dialysis. CNA 1 stated she reported the issue to Staffing Coordinator (SC) and was told to use a shower cap with soap in it to wash the resident's hair. CNA 1 stated, Residents are complaining about showers. I was told just do what you can. During observation on 10/19/2023 at 12:30 pm, overheard MS tell ADM 1 running water had been restored to the facility that was turned off for 6 1/2 hours. During an concurrent interview and record review with MS on 10/19/2023 at 11:00 am, MS stated he had not checked facility water temperatures after fixes to the water heaters. MS stated he was unaware water was still not hot. MS stated he did not have a regular system for checking water temperatures. MS stated he was also only checking water temperature in random resident rooms, not in common areas nor shower rooms in the facility. MS provided the Daily Maintenance Rounds log that indicated on 9/18/2023, Rooms 109, 209, 302, and 402 had hot water temperatures between 110- and 112-degrees Farhenheit and on 9/19/2023, Rooms 109, 209, 304, and 404 had hot water temperatures between 109- and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 10 of 11 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 555682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901 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 0908 111-degrees Farhenheit. MS confirmed these were the only recorded water temperatures he had for the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 11 of 11