Health inspection·November 16, 2023

F 0554 present that indicated the IDT team had assessed Resident 53 for safety of self-administration of medication and there should have been. 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: 555682 If continuation sheet Page 2 of 19 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 11/16/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to maintain the facility in a safe and operable manner and provide a homelike environment when: Residents Affected - Few 1. A handrail at the end of Hall 3 was not attached securely to the wall, sections of the ceiling had missing and peeling popcorn texture (a sprayed on bumpy texture that was applied to the ceiling) on Hall 3 and near the nurse station. 2. Five of 13 sampled residents (Residents 18, 75, 46, 55, and 27) expressed that their belongings were missing. This failure had the potential to cause resident harm and resulted in residents' inability to access their own belongings and had the potential to foster an environment that was not home-like. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 10/1/09, indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated maintenance personnel were responsible for Maintaining the building in good repair. During a review of the facility's P&P titled, Homelike Environment, revised 5/1/22, indicated, Residents are provided with a safe, comfortable, and homelike environment During a concurrent observation and interview on 11/15/23 at 10:23 am with Maintenance Supervisor (MS) the handrail at the end of Hall 3 to the left was observed. MS stated maintenance staff performed daily rounding of the facility and would shake the handrails to assure they were attached securely to the wall. MS observed the handrail and confirmed it was no longer attached to the metal wall fastener and was not safe for resident use. MS observed an area of the ceiling, located on Hall 3, in-between the fire sprinkler and a light fixture, and confirmed a section of the popcorn texture on the ceiling was peeling and missing. MS observed a large section of the ceiling near the nurse's station and stated the popcorn texture was missing and the edges had a visible gap of space between the popcorn texture and the ceiling. MS stated over a year ago there had been a water leak from the facility's air conditioning unit that was located on the roof. MS stated the water leak had caused damage to the ceiling where the popcorn texture was missing near the nurse's station. MS stated the popcorn texture had been peeling in different sections throughout the facility, the plan was to replace the all the popcorn texture, and a company had been contacted to obtain a quote for the cost of the repair. A request was made to review a copy of the quote, MS stated there was no documentation and the quote was provided over the phone. 2. A review of the facility's policy titled, Resident Rights, revised October 2022, indicated that residents have the right to retain and use personal possessions A review of the facility's record titled discharge notes for resident 75, dated 11/14/23, indicated that resident 75's cell phone was missing upon discharge. In an interview on 11/13/23 at 9:15 AM, Resident 18 stated that he had brought in three shirts and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 3 of 19 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 11/16/2023 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 0584 two pair of pants that were laundered and misplaced by the facility. Level of Harm - Minimal harm or potential for actual harm In a group resident interview on 11/15/23 at 1:45 PM, three of 11 sampled residents (Residents 46, 55, and 27) stated they were missing belongings. Residents Affected - Few Resident 55 stated that she was missing two pairs of pants because there was another resident in the facility with the same name, so they get mixed up. Resident 46 stated that the facility lost her pair of purple sweatpants a week ago and she then saw a male resident wearing them. A family member of Resident 27 stated in the group interview that Resident 27 was given two beautiful blankets, and we've never been able to find them. I walk down the hallway and find other people wearing the things I brought for my mother. In an interview on 11/15/23 at 3:52 PM, Social Services Director (SSD) acknowledged that there had been quite a few residents who had missing items because families don't label them. The facility has been working on finding a way to ensure everything families bring in gets labeled and that they are working on ways to improve the situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 4 of 19 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 11/16/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient staffing that met the needs of the residents when: 1. Two out of 11 residents (Resident 45 and 50) stated they did not receive a shower due to the facility not having enough staff. 2. Eight out of 11 residents stated they experienced long call light wait time due to the facility not having enough staff. This failure had the potential to result in resident inability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Staffing, revised 4/1/21, indicated, Our facility provides adequate staffing to meet needed care and services for our resident population. The P&P indicated, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. 1. During a review if the facility's P&P titled Shower, revised 5/1/18, indicated, The purposes of this procedure are to promote self-determination and facilitate resident choice regarding shower and bathing to ensure cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The P&P indicated Staff will honor shower and/or bathing preferences such as frequency of shower schedule. During an interview on 11/14/23 at 12:18 pm, CNA L stated on 11/12/23, there was only three CNAs working in the facility. CNA L stated, when the facility was short staffed, the residents did not get their assigned showers, there were long call light wait times, and stated feelings of sadness and concern due to the residents not getting the care they should. CNA L stated, documenting NA (not applicable) in the resident's medical records, when a shower was not provided to a resident due to the facility being short staffed. A review of Resident 45's record titled Bathing, dated 10/19/23 and 10/30/23, indicated, the shower response of NA was selected. During a review of Resident #50's clinical record it indicated admission was on 6/19/23, with diagnoses Unspecified Heart Failure, Diabetes Mellitus (DM), Benign Prostatic Hyperplasia (BPH, enlarged prostate blocking the flow of urine), and bipolar disorder (mental health condition causing extreme mood swings of extreme highs (mania) and lows (depression)). The facility's MDS dated [DATE], rated Resident #50's cognition 12/15, moderately impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 5 of 19 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 11/16/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 11/13/23 at 11:40 am with Resident #50 and family member (FM), Resident #50 was observed to have a full moustache and beard and was lying in bed with clothing that had food remnants noted on the front of the shirt. Resident #50 stated, they are short staffed. I may get one shower a week. I have never been shaven since I have been here, and I like to be clean shaven. FM stated the only things we have problems with are related to getting the resident's clothes changed regularly and sometimes the clothes have had evidence of being soiled with food or even feces. The same clothes have been worn for several days. The resident does wear a brief and has a foley catheter, the brief can leak onto the clothes. We think they are short on staff, across the board short staffed for days and nights. First thing I did today was go to the nurse station and told them I wanted Resident #50 to be changed into the clean clothes I have brought in, and we are still waiting. I just want Resident #50 clean. They must have shaven at some point, but they have not shaven Resident #50 very often, and the preference is clean shaven. I am here every other day, and this is a continuous issue. During a review of Resident #45's clinical record, indicated that Resident 45 was admitted to the facility on [DATE] with diagnoses which included stroke, affecting left non-dominant side, type 2 diabetes (high blood sugar) and muscle weakness. He was his own healthcare decision maker. During a review of Resident #45's MDS, dated [DATE], the MDS indicated that Resident #45 had a BIMS score of 15, at section C Cognitive Patterns indicating that his cognition was intact. During an interview on 11/13/2023 at 12:15 pm in Resident #45's room, with Resident #45, Resident # 45 stated Today is my shower day. They told me that I cannot have my shower because there were only two CNAs on the floor today . During an interview on 11/13/2023 at 12:32 pm with LN A, LN A acknowledged that she was aware that Resident #45 was told that he could not have his shower. LN A said Ya, that was earlier, we had short staff. We have registry now; we can give him shower. I'll go and tell him. During a concurrent observation and interview with HA F on 11/14/23 at 10:00 am regarding the whiteboard of roommates, Resident #34's whiteboard indicated the resident is to be shaven with hygiene and is clean shaven, Resident #50's whiteboard does not have a shaving designation and has a full beard and moustache. HA F stated, there is a shortness of CNAs that is why I am sitting for Resident #34. Typically, this would not be my job. I understand the CNA that was supposed to be here called in or something. We have a lot of call ins. I feel like we are short staffed often. I do feel like our residents suffer. I think the staffer quit last weekend. It didn't matter because staffing is bad at this building anyway. We are assigned [NAME]-nilly kind of. Some days there is a lot of CNAs and some days there's hardly any. Like the other day we only had two CNAs to cover the day. This place is very understaffed. We used to use Registry, but they stopped because we had some bad registry people that did not care for our residents adequately. But we are running so short, people are getting tired and overwhelmed. They have been offering incentives like money to pick up shifts, especially since state is here. We only had two aids on yesterday until you guys showed up then they start calling to recruit. We cannot do a really good job with the lack of staff. As a Hospitality Aid, we are directed to turn lights off and ask what the person wants and help if we can. We cannot often-times and we need to get a nurse or aid and sometimes they aren't available. The lights are timed, so when we turn them off it breaks the time. People for the most part get showered. I mean, sometimes they refuse, or we can't get to them. Shaving should be done as part of a shower, but it does not always happen unless there is a specific reminder written on the resident's white board. There are some residents that don't want a shave, but others that probably do but don't get them because they haven't been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 6 of 19 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 11/16/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few put on the list and have the shaving designation written on the white board. We just can't provide what is best for our residents. 2. During a review of the facility's P&P titled, Answering the Call Light, revised 10/2/22, indicated, The purpose of this procedure is to respond to the residents' requests and needs. The P&P indicated staff would Answer the resident's call light as soon as possible and that when staff answered a call light with the intent to come back with an item of information, do so promptly. A review of the undated Admissions Record, indicated Resident 22 was admitted to the facility on [DATE] with the diagnosis of hypertension (high blood pressure) and unsteadiness on feet. Resident 22's cognition (ability to remember, recall information, and think) was intact. During an interview on 11/13/23 at 9:24 am, Resident 22 stated Resident 22's roommate, Resident 14 vomited. Resident 22 stated pressing the call light, along with Resident 14 at approximately 4:30 am and it took one and a half hour for staff to respond to the call light. Resident 22 stated after 15 minutes with no staff response to the call light, Resident 22 turned on a timer, located on Resident 22's personal cell phone. The timer indicated, a time of one hour and 15 minutes, was dated 11/23/23 and the time indicted the personal cell phone timer started 4:45 am. A review of the undated Admissions Record indicated, Resident 55 was admitted to the facility on [DATE] with the diagnosis of repeated falls, muscle weakness, and difficulty in walking. Resident 55 had good cognition and was her own responsible party (RP, made own decisions). During an interview on 11/13/23 at 10:33 am, Resident 55 stated sometimes the facility was short staffed. Resident stated on the night of 11/12/23 at 9:45 pm, pressing the call light. Resident 55 stated, Resident 55 had urinated in the brief (adult diaper) and needed to be cleaned up. Resident 55 stated an hour and a half had passed before facility staff responded to the call light. During an interview in 11/14/23 at 5:22 am, Certified Nurse Assistant H (CNA) stated staffing in the facility had been a challenge due to staff being sick. CNA H stated last week, there were three CNAs for the NOC (nighttime) shift. CNA H stated resident outcomes that could occur when the facility was short staffed included longer call light wait times. During an interview on 11/14/23 at 5:28 am, Licensed Nurse I (LN) stated staffing the facility could be a challenge when you had unforeseen call offs and staff members who just don't show up for their shift. LN I stated normally the NOC shift had two LN and four CNAs. LN I stated one night, recently, only two CNAs had arrived to work the NOC shift. During an interview on 11/14/23 at 5:34 am, with CNA J and CNA K, CNA J stated, on 11/11/23, there were two CNAs on the NOC shift and on 11/12/23 there was three CNAs. CNA J and CNA K both stated when the facility was short staffed on the NOC shift, it was not possible to perform good resident care, there was an inability to perform every two-hour rounding (checking residents to see if they were incontinent of urine or stool and repositioning a resident to prevent wounds), and call light wait times were longer. During an interview on 11/14/23 at 5:41 am, LN M confirmed working a NOC shift with only two CNAs recently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 7 of 19 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 11/16/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the undated Admissions Record indicated Resident 14 was admitted to the facility 3/12/18 with the diagnosis of chronic obstructive pulmonary disease (a lung disease that caused difficulty in breathing). A review of the record titled, Cognitive Patterns, dated 10/28/23, indicated, Resident 14 had good cognition. A review if the record titled, Functional Abilities and Goals, dated 10/28/23, indicated, Resident 14 was dependent (helper does all the work) with bathing, rolling from side to side in the bed, and was not able to sit up in bed without assistance from facility staff. During an interview on 11/14/23 at 8:15 am, Resident 14 stated around 4:30 am on 11/13/23, Resident 14 vomited all over self. Resident 14 stated pressing the call light for staff assistance and it took over an hour and half for staff to respond to the call light. Resident 14 stated, one time Resident 14 wanted out of bed and needed assistance getting into the chair. Resident 14 stated it took a long time before staff responded to the call light and I never got to sit in my chair. Resident 14 stated when staff did not respond to the call light it made me feel like I wasn't worth much and they don't care about me. Resident 14's roommate, Resident 22, stated feeling the same way when staff did not respond to the call lights in a timely manner. Resident 133 was admitted to the facility on [DATE] with a diagnosis including arthritis and muscle weakness. Resident 133 (R133) was at the facility for strengthening and rehabilitation for returning to her home. On 11/13/23 at 8:50 AM Resident 133 was observed having physical therapy. Resident 133 was interviewed regarding care and staffing in the facility. Resident 133 stated, There are slow responses to call lights. It takes up to 30 minutes before they come to answer them. I can hear them helping others and I don't need anything urgent. So, I just wait. Resident 133 denies having incontinence due to waiting for staff to answer her call light. Resident 136 was admitted to the facility on [DATE] with a diagnosis including Vertigo (Dizziness) and falling. Resident 136 needed assistance to get out of bed due to her history of falling and dizziness. On 11/13/23 at 9:04 AM Resident 136 was observed lying in bed at 9:04 AM with distinct odor of urine present in her room. Resident 136 was questioned of needing staff to assist with toileting. Resident 136 said, I have a wet bed and need changed. Resident 136 answered questions regarding incontinence and lying in a wet bed by stating, it happens all the time. Resident 136 turned on her call light and waited for staff to answer her call for help. It took 2 minutes 40 seconds for the call light to be answered by a hospitality aid (HA). The HA asked what Resident 136 needed. Resident 136 answered, My bed is wet, and I need to go to the restroom. The HA replied that she would send someone to help and left the room. An additional 39 minutes and 11 seconds passed before a CNA returned to provide incontinent care and change bedding. Resident 136 stated, This happens all the time. My bottom is getting sore. During a review of Resident #6's clinical record, indicated that Resident #6 was admitted to the facility on [DATE] with diagnoses which included stroke, affecting left non-dominant side, chronic pain, right below-knee amputation (a surgery to remove the right leg below the knee), and muscle weakness. She was her own healthcare decision maker. During a review of Resident #6's Minimum Data Set (MDS - an assessment and care screening tool),, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 8 of 19 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 11/16/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 8/29/2023, the MDS indicated that Resident #6 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During an interview on 11/13/2023 at 9:27 am in Resident #6's room, Resident #6 stated they took forever to come her, they didn't have enough help .I pushed the bottom, waited for a long time to be changed. It's horrible. During a review of Resident #70's clinical record it indicated admission was on 9/22/23, with diagnoses of Systolic and Diastolic Congestive Heart Failure (CHF, heart works less efficiently pumping blood, oxygen, and nutrients), and Chronic Pulmonary Edema (long term and progressive fluid collecting in the air sacs of the lungs making it difficult to breathe). The facility's MDS (minimum data set, a standardized assessment tool) dated 9/26/23 rated Resident #70's cognition 13/15, cognitively intact. During an interview on 11/13/23 at 11:00 am with Resident #70, who stated, occasionally, it looks like they don't have enough staff, it takes a while for them to answer the call light. During a review of Resident # 8's clinical record it indicated admission was on 2/13/23, with diagnoses Acute and Chronic Respiratory Failure (condition that makes it difficult to breathe by oneself, which develops when the lungs cannot get enough oxygen in the blood and retain carbon dioxide), Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease with respiratory difficulty and airflow limitations), and DM. The facility's MDS dated [DATE] rated Resident #8's cognition 13/15, cognitively intact. During an interview on 11/13/23 at 12:15 pm with Resident #8, who stated, On the day shift it is better for answering the call light. I always look at the clock when I push the button. I have waited up to an hour for the call light, mostly nights. There are Hospitality Aids during the day to help buffer the staff. I will press my light and the helpers will come in and ask what I need. I will say I need my CNA and they will turn my light off and say they will go get them, but never return. I just turn my light back on. During a review of Resident # 11's clinical record it indicated admission was on 5/20/23, with diagnoses COPD, Rectal Prolapse (part of the large intestine bulges outside the anus), right lower leg Cellulitis (RLL Cellulitis, bacterial infection involving inner layers of the skin causing redness, warmth, pain, and swelling). The facility's MDS dated [DATE], rated Resident #11's cognition 14/15, cognitively intact. During an interview on 11/14/23 at 09:00 am with Resident #11, who stated, two weekends in a row we were so short staffed, one CNA to 40 residents, today there were only two CNAs on. It happens on the weekend and mostly at nighttime. I stay awake at night worried when we are so short staffed. I have watched the clock and there was a time it took two hours. There was a time that I was sitting in liquid shit for an hour, I had the call light on for a hour. I had to call a FM to call the Nurse's station to have someone come help me. I do not feel safe with the lack of staff available to take care of me. When it takes a lot of time to answer the light, they usually will say that they are short staffed. I was told they have a special machine that keeps track of how long the lights were on. They hired a few Hospitality Aids that I have been told cannot touch me, but they come in and turn out the call light and ask me what I need. This stops the light timing. They will not do anything for me, they say they will tell the CNA or the nurse. They always turn the call light off, but don't always get back to me with the CNA or nurse timely. I will wake up covered in poop and then call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 9 of 19 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 11/16/2023 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 0725 nurse, but it takes a long time for them to get to the call light to help me. Level of Harm - Minimal harm or potential for actual harm During a review of Resident # 18's clinical record it indicated admission was on 11/28/15, with diagnoses Metabolic Encephalopathy (Chemical imbalance in the blood that causes problems in the brain), COPD, and Parkinson's Disease (Progressive central nervous system disorder affecting parts of the body controlled by nerves such as movement, often including tremors). The facility's MDS dated [DATE], rated Resident #18's cognition 15/15, cognitively intact. Residents Affected - Few During an interview on 11/13/23 at 1:00 pm with Resident #18's family member, who stated, my only concerns is that they have such a turnover of workers and they do not know Resident 18's diagnoses or how to respond to symptoms, they do not know what is going on because they do not know the residents. Oftentimes, they seem very short staffed. During a review of the facility's P&P titled, Resident Council, revised 12/1/06, indicated, A Resident Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible to address the item(s) of concern. During a confidential interview on 11/15/23 at 1:50 pm, one out of 11 residents stated not receiving a scheduled shower and three out of 11 residents stated they experienced long call light wait times due to the facility not having enough staff. Residents expressed feelings of frustration, inability to sleep, and a burning sensation on the inner thighs due to sitting in a brief full of urine that was not changed in a timely manner. A review of the record titled, Resident Council Minutes, dated 9/14/23, indicated, old business (review of last month's meeting minutes) of call lights not answered timely (all shifts) had not been resolved. A review of the record titled Resident Council Minutes, dated 10/19/23, indicated, old business (review of last month's meeting minutes) of call light concerns had not been resolved. A review of the record titled Resident Council Minutes, dated 11/9/23, indicated, old business (review of last month's meeting minutes) of call light concerns had not been resolved. During a concurrent observation and interview on 11/15/23 at 3:23 pm, with Director of Nursing (DON), DON stated call light wait time expectancy was for staff to answer the call light within three to five minutes. DON stated all staff employed in the facility were expected to answer call lights. DON stated there was a display screen at the nurse station that showed which room had a call light on and for how long the call light had been ringing. DON walked over to the nurse station, where four staff members were sitting in chairs and one staff member was standing, using a cell phone. DON stated the call light display monitor indicated the resident in room 110B had pressed the call light 10 minutes ago. DON requested staff to respond to the call light. DON stated barriers for timely call light answering could be due to lack of staff urgency, staff were caught up with other resident care, and when the facility was short staffed. DON stated it was a challenge to staff PM (evening) and NOC shifts. DON stated facility staffing ratios (the number of residents assigned to one LN or CNA) was dependent on resident census (number of residents that lived in the facility) as follows: AM (morning) shift required three LN and five to eight CNAs, PM shift was three LN, five to seven CNAs, NOC shift was two LN and three to five CNAs. DON clarified the number of CNAs required per shift did not include the Restorative Nursing Assistants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 10 of 19 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 11/16/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/15/23 at 3:48 pm, located in hall 2, the call light for room [ROOM NUMBER] was on upon arrival. A housekeeper, the Social Services Director, and the DON were observed to walk past the call light without answering it. During a concurrent record review and interview on 11/16/23 at 9:20 am, with Human Resources (HR), an untitled record with the date 11/11/23 was reviewed. HR stated the untitled record was time punches for the staff members who worked on 11/11/23. HR stated the untitled record indicated, on 11/11/23, the PM shift had two LN, and two CNAs. The untitled record indicated there were no LN working the NOC shift and there were three CNAs. HR stated the facility would have utilized registry (travel nurse, employed by a third party) LN for NOC shift on 11/11/23. A request for registry time sheets had been made. HR reviewed the untitled record with the date of 11/12/23, and stated the untitled document indicated, the AM shift had three LN, the PM shift had two LN and three CNAs, the NOC shift had 1 LN. A review of the facility record titled Daily Census, dated Saturday, 11/11/23, indicated, the facility had 81 residents. A review of the facility record titled Daily Census, dated Sunday, 11/12/23, indicated the facility had 80 residents. On 11/16/23 at 1:15 pm, a second request was made for registry time sheets. During an interview on 11/16/23 at 1:26 PM, the facility's Administrator (ADMIN) stated when the facility had a census of 80, the staffing expectancy was as follows: the AM shift would have four LN and seven CNAs, the PM shift would have four LN and seven CNAs, the NOC shift would have two LN and four CNAs. ADMIN stated when facility staff called in, the expectation was to utilize the facility's own staff to cover the needed shifts and staff currently working would be asked to work a double (two, eight hour shifts in a row). ADMIN stated if the facility's staff was not able to work the extra hours, a registry service would be utilized. ADMIN stated if the facility was not able to obtain registry staff, a last resort would be for the facility would utilize department heads (DON, Social Services Director, Director of Staff Development, and Admissions Coordinator) to float (answer call lights, pick up meal trays, wiping down a bedside table, and provide water if needed). ADMIN stated the department heads being utilized as floaters were not required to change diapers and performed tasks as requested by the CNA who was responsible for direct resident care. ADMIN stated there had been low staffing on some weekends; when three to five CNAs do not show up for work, weekends were tough to staff, and confirmed low staffing could contribute to long call light wait times and showers not being provided to the residents. Registry time sheets were requested a third time and not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 11 of 19 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 11/16/2023 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility did not post daily staffing for public viewing as required by regulation. This failure created the potential for staffing issues including, short staffing, staffing and workload misinformation leading to decreased quality of care and adverse clinical outcomes. Residents Affected - Few Findings: During a concurrent Interview and record review on 11/14/23 at 3:42 PM, the Director of Nursing (DON) attempted to locate the daily staffing posting. When the document for 11/14/23 was not available and determined not to exist the DON stated, It is not here. I will check and see if I can find it and left the DON's office. The DON approached the Assistant Director of Nursing (ADON), asked if the ADON was familiar with the form and had a current copy. The ADON did not have knowledge of the form and did not have a copy. Neither the ADON nor DON had the regulation required documents for the last 18 months. At 3:50 PM on 11/14/23 during a concurrent interview and document review the Facility Administrator (Admin) was not familiar with the requirement for posting daily staffing in a public location and the 18-month retention requirement. The Admin stated, My staffing probably has that but she walked off the job last Sunday. No daily staffing posting document was provided on request. No posting was observed during the survey. The regulatory requirement was provided to the Admin via email. The Admin affirmatively responded, Obviously we haven't been posting it . and affirmed the facility would publicly post the required information for future compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 12 of 19 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure the five rights of medication administration had been followed for one resident (Resident 53) when Licensed Nurse (LN) F did not know the name or dosage of a medication that LN F provided to Resident 53 and LN F did not document the medication had been given. This failure had the potential for incorrect medication administration, duplication for medication administration, and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's policy and procedure (P&P) titled, Administrating Medications, revised 12/1/22, indicated, The individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. The P&P indicated the Individual administering the medication will record in the resident's medical record: the date, time, dose, and sign record. A review of the undated record titled admission Record indicated Resident 53 was admitted to the facility with the diagnosis of morbid (severe) obesity (more than 80 to 100 pounds over the ideal body weight) and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breath). The admission Record indicated Resident 53 had good cognition (ability to think and recall information) and was her own responsible party (had the ability to make own medical decisions). During a concurrent observation and interview in 11/13/23 at 9:57 am, LN F was observed walking into Resident 53's room with a suppository. Resident 53 stated LNs did not administer the suppository and that Resident 53 would self-administer the suppository. LN F handed a suppository to Resident 53 and left the room. Resident 53 placed the suppository in a box on top of the bedside table and stated Resident 53 would administer the suppository later. During an interview on 11/14/23 at 2:47 pm, LN F stated Resident 53 requested a suppository, an unknown staff member handed LN F a suppository, and was told that Resident 53 administered her own suppositories. LN F stated not looking at the suppository prior to handing it to Resident 53. LN F stated not being aware if the suppository LN F provided to Resident 53 was the suppository that the physician ordered, if it was the right medication, or the right dose. LN F confirmed not signing the Medication Administration Record and stated LN F thought the nurse who gave LN F the suppository signed it out on the Medication Administration Record (MAR). LN F stated LN F did not review Resident 53's order to ensure a different medication was to be used prior to administering the suppository. During a concurrent interview and record review on 11/14/23 at 4:10 pm, with Director if Nurses (DON), Resident 53's MAR, dated 11/1/23 through 11/30/23 was reviewed. DON stated the MAR indicated a suppository had not been signed out by a LN on 11/13/23. DON stated the MAR indicated the physician had ordered a Dulcolax suppository 10 milligrams insert 1 suppository rectally every 24 hours as needed for constipation if milk of magnesia was ineffective. Record if taken. DON stated medication administration expectancy was for LN know the five rights of medication administration which included: LN were to not administer a medication that the LN did not prepare, LN should follow the physician order's, LN are required to know what medication and dose was being given to a resident, and LN needed to sign the MAR to indicate the medication was given to the resident. DON confirmed LN F did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 13 of 19 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 11/16/2023 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 0755 follow facility expectancy or policies for medication administration. Level of Harm - Minimal harm or potential for actual harm A copy of the MAR was requested. The MAR provided had been updated after the record request to include May self-administer this medication by keeping at bedside. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 14 of 19 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 11/16/2023 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to have or follow policies and procedures for Quality Assurance and Performance Improvement (QA/PI) nor any formalized QAPI projects as required. This failure demonstrated a lack of quality and performance improvement that could lead to a decrease in Resident quality of life, enjoyment and happiness, causing adverse clinical outcomes. Residents Affected - Some Findings: On 11/16/23 at 10:30 AM during a concurrent interview and record review the Facility Administrator (Admin) was interviewed regarding facility administration functions. The Admin was not able to provide regulation required policies and procedures on Quality Assurance and Performance Improvement (QA/PI). The QA/PI processes assist a facility in recognizing issues potentially affecting residents adversely, guiding the facility in monitoring and improving issues to reduce or prevent adverse outcomes. The Admin stated he did not have a policy for QA/PI processes available. The Admin did not have any documented formalized regulatory required QA/PI projects with planning, review, data analysis and outcome progress. The Admin verbalized understanding of the process and need for ongoing QA/PI initiatives stating he would be sure these will be done in the future. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 15 of 19 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 11/16/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview and record review the facility failed to have records of Quality Assurance and Performance Improvement (QA/PI) meetings to obtain feedback, use data, and take action in conducting structured, systematic investigations and analysis of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility failing to have a structured, functional QA/PI process addressing potentially harmful and preventable issues creates the potential for resident harm and adverse clinical outcomes. Findings: During a concurrent record review and interview on 11/16/23 at 9:56 AM, with the Facility Administrator (Admin) when questioned about monthly and quarterly Quality Assurance and Performance Improvement (QA/PI) meetings the Admin stated the facility has, Daily quality meetings with department by department issues the managers select. The Admin was not able to print a report. Observed the form and it appears to be a day by day (not a formal monthly or quarterly) account of departmental quality assessments and improvement but not in the format of a QA/PI meeting. The Admin provided Quality Assurance (QA) sign in sheets for the months of June, July, August, September, October and November 2023. The Admin reviewed and acknowledged the Medical Director did not attend nor sign the attendance sheets on a quarterly basis (as required). The Admin provided a document set titled, Welcome November 13, 2023 Quality assurance monthly meeting consisting of six double sided pages containing a list format of usual Quality Assurance/Performance Improvement (QA/PI) functions. From the documents there are no discussions seen as would be expected resulting from a QA/PI meeting. The Admin acknowledged the list format provided does not include discussions of the items present; meeting minutes do not include meaningful information upon which an improvement plan or process can be monitored and assessed. The Admin stated, We do work on issues like falls and they are improving. The document provided does not have any feedback for results as would be an expected result from a QA/PI meeting such as improving the current status of items present. There is no discussion of adverse events, whether or not they occurred. In addition, there were no prioritization, development or action plans of any QA/PI activities discussed. When asked the Admin was not able to produce a copy of a policy/procedure on QA/PI program activities. At 11/16/23 12:41 PM, the Admissions Coordinator (AC) member was interviewed. When asked if the AC attended monthly QA/PI meetings the AC replied, Yes, daily in stand-up (a daily status meeting) I go. The AC identified her names and signatures on the QA/PI meeting attendance sign in sheets. The AC was not able to elaborate on any discussion of quality or performance issues discussed in the QA/PI meetings. At 11/16/23 12:52 PM, The Assistant Director of Nursing (ADON) was interviewed regarding attendance at QA/PI meetings. The ADON was not familiar with the meeting frequency and stated, We talk about it in the daily stand-up. When asked specifically regarding when the QA/PI meeting is held the ADON replied, I think Quarterly. It has been some time. I'm thinking October? The ADON did not state any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 16 of 19 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 11/16/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some QA/PI projects when asked though he offered, We go over things in stand-up. The ADON signature appears on the October QA/PI attendance sheet. At 11/16/23 12:56 PM, the Director of Nursing (DON) was interviewed regarding the QA/PI meeting. The DON replied, Quarterly when asked how often the QA/PI meeting was held. The DON's signature appears on monthly sign in sheets for June, July, August, October and November 2023. The DON has signed he attends the QA/PI meetings consistently on a monthly basis (with exception of September 2023) but states the meetings are only held quarterly. The DON offered that a QA/PI project is fall reduction and that the falls have decreased. The ADON and AO were not aware of falls being a QA/PI project. At 11/16/23 01:49 PM, The Medical Records Director (MRD) member was interviewed as the MR's name appears on the sign in sheets. We have meetings monthly. We work on falls, yes we go over the numbers. Every manager attends. Yes, the Medical Director attends monthly. The Medical Director signature does not appear on the monthly sign in sheets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 17 of 19 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 11/16/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control program was properly maintained or implemented to reduce the spread of infection when: Residents Affected - Some 1. Personal protective equipment (PPE, gloves, gowns, eye protection, and masks) was not consistently and correctly used by staff when providing care for Coronavirus disease (COVID-19: an infectious disease caused by the SARS-CoV-2 virus) positive residents; and 2. Tuberculosis (TB-a bacterial infection that mainly attacks the lung. A tuberculosis screening test checks to see if a person has the bacteria (germs) that cause TB in the body) screen was not done per the facility's policy for one out of six sampled employees. 3. Hospitality Aide (HA) did not perform hand hygiene (wash hands or use hand sanitizer) before or after direct resident contact with five out of five residents (Resident 41, 66, 52, 62, and 15) including contact with self. These failures had the potential to result in the development and transmission of infectious diseases that could lead to significant adverse consequences to residents, staff, and visitors. Findings: A review of Centers for Disease Control and Prevention (CDC)'s guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/2023, the guideline indicated, Healthcare Personnel (HCP) who enter the room of a patient with suspected or confirmed COVID infection should adhere to Standard Precautions and use a The National Institute for Occupational Safety (NIOSH)-approved particulate respirator (a type of air-purifying respirators protects by filtering particles out of the air the user is breathing) with N95 filters (N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). During a concurrent observation and interviewed on 11//13/2023, at 8:30 am, at Hall 100, observed an unidentified staff (Staff C) coming out of room [ROOM NUMBER] without wearing a face shield. Staff 1 stated we don't need to wear an eye shield . During a concurrent observation and interviewed on 11/13/23 at 12:08 pm outside room [ROOM NUMBER], a sign of airborne precautions (for patients known or suspected to be infected with pathogens transmitted by the airborne route) was posted at the door of room [ROOM NUMBER], a 3-drawer plastic storage for PPE was placed outside the room. Observed a Certified Nursing Assistant (CNA) B providing care to Resident 29 without wearing gloves and a face shield. Observed CNA B coming out of room [ROOM NUMBER], opening the top drawer of the PPE storage without sanitizing her hands. CNA B stated, You don't need gloves if you don't contact the resident . CNA B stated that she just attended an infection control in-service couple weeks ago and she was taught that she didn't need gloves. During a concurrent observation and interviewed on 11/14/2023 at 8:31 am, outside room [ROOM NUMBER], CNA D was observed coming out of room [ROOM NUMBER] without wearing N 95 mask and a face shield. CNA stated Yeah, we do need to wear N 95, I just did not do it . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 18 of 19 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 11/16/2023 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 Residents Affected - Some During an interview on 11/14/2023 at 9:02 am at the Infection Preventionist (IP)'s office, the IP consultant stated that the facility followed CDC guideline which indicated that the staff should wear gown, gloves, eye protection, and mask while taking care of COVID-19 positive residents. The IP consultant said, The staff were expected to wear gloves and face shield. 2. A review of the facility policy, titled Employee Health Records, revised 11/2019, the policy indicated that A health record for each employee will contain associate TB screening Record. During a concurrent interview and record review on 11/15/2023 at 4:31 pm at the Director of Staff Development's (DSD) office. The DSD stated that the facility followed CDC guidelines for employee TB screen which was two-step skin test for new hire. Staff E's Health record was reviewed, indicated that Staff E was hired on 6/17/2023, and Staff E's TB screening record was missing. The DSD stated that she could not find Staff E's TB screening record and that's why she asked Staff E to do TB skin test on 11/8/2023. 3. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/1/19, indicated This facility considers hand hygiene the primary means to prevent the spread of infection. The P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures . and hand hygiene would be performed, Before and after direct contact with residents. During an observation on 11/13/23 at 12:12 pm, in the social dining room, located on hall 4, Hospitality Aide (HA) was observed touching Resident 41's head with bare hands. HA touched HA's face, eyeglasses, hair, and while readjusting the N95 mask (a mask that filtered 95 percent of airborne particles) HA placed uncleansed fingers into the N95. HA was observed placing a kiss on top of Resident 66's head while touching Resident 66's shoulders. HA walked over to Resident 52 and touched the arm rest and handles of Resident 52's wheelchair. HA placed hands on Resident 62's shoulders and was rubbing HA hands back and forth. HA walked across the social dining room and hugged Resident 15. HA was observed readjusting N95 mask, placing fingers on the inside of the N95. HA had not performed hand hygiene before or after coming into direct contact of each resident with bare hands or touching self. During an interview on 11/14/23 at 12:01 pm, HA confirmed not performing hand hygiene during 11/13/23's observations in the dining hall, confirmed touching five residents and self without performing hand hygiene, and stated importance of hand hygiene in between direct resident contact was to protect self and residents from getting sick. HA stated being an employee of the facility since May 2023 and received training about hand hygiene upon hire and had not attended any in-services provided by the facility. HA stated the in-services were for the Certified Nursing Assistants and not the HA. During a concurrent interview and record review on 11/14/23 at 4:15 pm, with Director of Staff Development (DSD), Inservice-Sign in Sheet and Education Program Lesson Plan, dated 11/6/23 was reviewed. DSD stated the Education Program Lesson Plan indicated, hand hygiene was required Before and after direct contact with residents. DSD stated the In-Service Sign in Sheet indicated, HA wad been present for the in-service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555682 If continuation sheet Page 19 of 19