Health inspection·October 27, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA student, who witnessed the alleged event, was interviewed on 7/28/23 at 12:33 p.m. The CNA student stated Unlicensed Staff L walked into Resident 8's room to transfer her for a shower. The CNA students told Unlicensed Staff L they would give Resident 8 a bed bath, and Unlicensed Staff L said, okay. The CNA student stated Licensed Staff N came into Resident 8's room and positioned Resident 8 into a seated position and stated to Resident 8, We are going to take you to the shower. Then Resident 8 hit Licensed Staff N. The CNA student stated Unlicensed Staff M came into Resident 8's room and transferred her into the shower chair. The CNA student stated she saw blood on the floor after Unlicensed Staff M transferred Resident 8 to the shower chair. The CNA student stated Resident 8 was yelling when she was quickly returned from her shower to her room and was transferred back to bed by Unlicensed Staff L and another CNA student. Unlicensed Staff L, with the assistance of a CNA student, did not explain to Resident 8, what she was doing for her, when Unlicensed Staff L was forcefully changing Resident 8's brief. Resident 8 then told Unlicensed Staff L to, Get the F out. Another CNA student was interviewed on 7/28/23 at 1:10 p.m., who stated she had asked Resident 8 about taking a shower, but Resident 8 said, No. Resident 8 agreed to a bed bath. The CNA student stated Unlicensed Staff L came into Resident 8's room and said, Time for shower. When Unlicensed Staff L tried to position Resident 8 in a sitting position, Resident 8 hit her and Unlicensed Staff L told Resident 8, Lets do a bed bath. The CNA student stated Licensed Staff N came into Resident 8's room and Unlicensed Staff L asked Licensed Staff N to help her get Resident 8 up for a shower. When Licensed Staff N tried to help transfer Resident 8, Resident 8 hit Licensed Staff N's breasts and Resident 8 said, I am going to call the police. Unlicensed Staff M came into the room and helped Licensed Staff N transfer Resident 8 to a shower chair. Resident 8 was upset. When Unlicensed Staff L was wheeling Resident 8 to the shower, blood was noticed coming from Resident 8's leg. The CNA student stated Resident 8 tried hitting Unlicensed Staff L in the shower and it was a quick shower. A review of Resident 8's Non-Compliance care plan, initiated 8/24/22 indicated Resident 8 had refused showers. Interventions included resident's wishes will be honored. During an interview on 10/23/23 at 5:06 p.m., the DON stated there was a gap in communication. The DON stated Resident 8 had told Unlicensed Staff L she was okay with taking a shower then told the CNA students she would be okay with a bed bath. Unlicensed Staff M was just there to assist with transferring Resident 8 to the shower chair. The DON stated if a resident said, No to taking a shower then it meant No. The DON stated the nurse and/or CNA could ask the resident again later on in the shift if they would like their scheduled shower. During an interview on 10/25/23 at 8:40 a.m., Unlicensed Staff M stated he was taking care of one of his assigned residents when Unlicensed Staff L called Unlicensed Staff M using their walkie talkie on 7/28/23 to help transfer Resident 8 to a shower chair. Unlicensed Staff M stated Licensed Staff R pushed the CNAs to give residents their showers even when the resident did not want one. Unlicensed Staff M stated healthcare staff should never force a resident to have a shower. Unlicensed Staff M stated the videos the CNAs have to watch emphasize not to force residents to do something they do not want to. During an interview on 10/26/23 at 9:25 a.m. Unlicensed Staff P stated you cannot force a resident to have a shower. Unlicensed Staff P stated he would let the resident's nurse know if the resident refused their scheduled shower. During an interview on 10/26/23 at 12:29 p.m., Licensed Staff Q stated the CNA would offer the resident their scheduled shower. If the resident refused their shower, the CNA would tell Licensed Staff Q. Licensed Staff Q stated she would then talk to the resident. Licensed Staff Q stated she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 2 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ask the resident three times during her shift if they would like their shower and if the resident still refused their scheduled shower, Licensed Staff Q would honor their wishes. The facility Policy/Procedure titled, Dignity, revised 2/2021, indicated: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay . 5. When assisting with care, residents are supported in exercising their rights. For example, residents are . d. allowed to choose when to sleep, eat and conduct activities of daily living . The facility Policy/Procedure titled, Resident Rights, revised 2/2021, indicated: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . e. self-determination . g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights . Resident 20 During an interview on 10/23/23 at 10:58 a.m., Resident 20 stated she would have preferred to administer her own medications. Resident 20 stated she spoke about her preference with the Admissions Coordinator, who told her that it was not allowed in the facility. During an interview on 10/24/23 at 10:33 a.m., Director of Nursing (DON) stated self-administration of medications was allowed in the facility. DON stated the resident who requests to self-administer medications would have to be assessed first by the nurses to ensure safety and competency, and the physician would sign off on the assessments. DON stated she was not aware of Resident 20's request to self-administer her medications and added that Resident 20 should have been assessed if she requested for it. During an interview on 10/24/23 at 12:15 p.m., Admissions Coordinator stated she could not recall any resident requests for self-administration of medications. When queried about her response should a resident request to administer their medications, Admissions Coordinator stated she would notify the residents that self-administration of medications was not allowed in a skilled nursing facility. During a review of the facility's policy and procedure titled, Self-Administration of Medications, dated February 2021, the policy and procedure indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that is is clinically appropriate and safe for the resident to do so . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 3 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide care and services in accordance with standards of practice when: Residents Affected - Few 1. A licensed therapist did not reassess a resident for a Restorative Nursing assistant (RNA) program (focused on nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) and obtain a new physician order for an RNA program after an RNA order had expired for three out of three sampled residents (Residents 5, 13 and 17), 2. Nursing staff were not repositioning and floating bilateral (both sides) heels of Resident 8 per physician's order and per facility policy, and 3. A dispensed medication was left unattended at a resident's bedside (Resident 1). These failures could lead to an ineffective RNA program for Residents 5, 13 and 17, a potential for Resident 8 to develop a skin breakdown, and increased the risk for Resident 1 to consume a potentially-contaminated medication. Findings: 1. A review of Resident 5's face sheet (demographics) indicated she was [AGE] years old, initially admitted to the facility on [DATE]. Her diagnoses included Multiple Sclerosis (MS, a condition that affects your brain and spinal cord - a long, tube-like band of tissue that connects your brain to your lower back.), Quadriplegia (paralysis - a loss of muscle function in part of your body, below the neck that affects all of a person's limbs) and Hyperlipidemia (HLP, an excess of lipids or fats in your blood). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated [DATE], Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 15 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 5's functional status indicated she needed an extensive assistance of 1 to 2 staff when performing her Activities of Daily Living (ADL's, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 13's face sheet indicated he was [AGE] years old, initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia, Major Depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Weakness. His MDS dated [DATE] BIMS score was 9 indicating moderately impaired cognition. Resident 13's functional status indicated he needed an extensive assistance of 1 to 2 staff when performing his ADLs. A review of Resident 17's face sheet indicated she was [AGE] years old, initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia, Weakness and Anemia (a disease where your body does not get enough oxygen-rich blood). Her MDS dated [DATE] BIMS score was 15 indicating intact cognition. Resident 17's functional status indicated she needed an extensive assistance of 1 staff when performing her ADLs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 4 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an RNA program sheet and RNA program flowsheet record review for Resident 5 dated [DATE], it indicated her RNA program would expire in 12 weeks, roughly on [DATE]. Resident 5's RNA flowsheet for 6/2023, 7/2023, 8/2023 and 9/2023 indicated she actively participates in RNA program. Resident 5 had an RNA flowsheet for 10/2023 however there was no form that would indicate a licensed therapist staff had reassessed and determined what type of RNA exercises Resident 5 should be receiving and there was no new physician's order for RNA program for Resident 5 after the RNA order from [DATE] had expired. During an RNA program sheet and RNA program flowsheet record review for Resident 13, the RNA program sheet dated [DATE] indicated Resident 13 was on a RNA program for upper extremity strengthening beginning [DATE] for 4 weeks. The RNA program flowsheet record review for Resident 13 indicated she was participating on her RNA program from 6/2023, 7/2023, 8/2023, 9/2023 and 10/2023 even though there was no reassessment of her RNA program after it had expired on [DATE]. There was no form that would indicate the licensed therapist staff had reassessed and determined what type of RNA exercises Resident 13 should be receiving and there was no new physician's order for RNA program for Resident 13 after the RNA order from [DATE] had expired. During an RNA program sheet and RNA program flowsheet record review for Resident 17, the RNA program sheet dated [DATE] indicated Resident 17 was on a RNA program to prevent functional decline and to improve upper extremity strength for the next 12 weeks. The RNA program flowsheet record review for Resident 13 indicated she was participating on her RNA program from 6/2023, 7/2023, 8/2023, 9/2023 and 10/2023 even though there was no reassessment of the RNA program after it had expired on 6/2023. There was no form that would indicate the licensed therapist staff had reassessed and determined what type of RNA exercises Resident 17 should be receiving and there was no new physician's order for RNA program for Resident 17 after the RNA order from [DATE] had expired. During a concurrent interview, Resident 5's Restorative Nursing Program sheet and RNA flow sheet record review on [DATE] at 3:02 p.m., the Director of Nursing (DON) verified that based on the RNA flow sheet, Resident 5 was continually being seen by the RNA for the months of 9/2023 and 10/2023. However, the DON stated she was not able to locate a new RNA program form that would indicate Resident 5 was reassessed by a licensed therapist and a new physician order since the last order had expired 12 weeks from [DATE]. The DON stated once the resident's RNA program ended, the licensed therapist, the MDS coordinator and the RNA staff would meet to see if a resident still needs an RNA and if the previous program was still appropriate. The DON stated before initiating another program, the licensed therapist would reassess the resident and an order for an RNA would be requested from the physician. The DON was not able to locate Resident 5's new RNA program order from the physician. The DON stated the facility process was for the licensed therapist to write the program for RNA and then to have the physician sign off on the order. The DON verified there was no new RNA program order created for Resident 5 after it expired on 9/2023. During an interview on [DATE] at 3:18 p.m., the DON stated Resident 5 did not have an updated order for RNA program after 9/2023 but she should have one. The DON stated until a resident was reassessed for a new RNA program and a physician order had been obtained, the RNAs should not have continued working with a resident after their RNA program had expired. During an interview on [DATE] at 3:20 p.m., the DON verbally confirmed Residents 13 participates in his RNA program. The DON stated Resident 13 was missing reassessment of RNA program and a new physician order for RNA program when it expired on [DATE]. The DON stated there was no reassessment for an RNA program and there was no physician's order for Residents 13's RNA program for 7/2023, 8/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 5 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 9/2023 and 10/2023 after his RNA order expired on [DATE]. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 3:20 p.m., the DON verbally confirmed Residents 17 participates in her RNA program. The DON stated Resident 17 was missing reassessment of RNA program and a new physician order for RNA program when it expired on [DATE]. The DON stated there was no reassessment for an RNA program and there was no physician's order for Residents 17's RNA program for 7/2023, 8/2023, 9/2023 and 10/2023 after his RNA order expired on [DATE]. Residents Affected - Few During an interview on [DATE] at 4:30 p.m., the scheduler, who also worked as a RNA in the facility if needed, stated the rehabilitation director would design an RNA program appropriate for the resident and then they would teach the RNA staff on how to perform the exercises designed specifically for resident needs. The scheduler/RNA stated the RNA program had to be approved by the physician prior to the RNA staff performing the exercises. The scheduler/RNA stated the RNA should not continue working with a resident with an RNA program that had already expired. The scheduler/RNA stated in order to continue working with a resident, there should be a new RNA program per licensed therapist assessment and it should be approved by the physician. The scheduler/RNA stated it was dangerous to keep on doing the same RNA program for the resident without a licensed thertapist reassessing the resident and without the physician approving the program. The scheduler /RNA stated it was not safe. During an interview on [DATE] at 4:49 p.m., the Director of Rehabilitation (DOR) services stated the facility policy was for a licensed therapist to design an RNA program for a resident and then discuss with the RNA staff. The DOR stated the RNA program designed for a resident needed to be approved by a physician. The DOR stated RNA staff should not be working with a resident without an active RNA order because they would not know if the current program was still appropriate for the resident. The DOR stated if the RNA staff continued working with a resident using the previous RNA program that had expired, without a licensed therapist reassessing whether this program was still appropriate for the resident and without a valid physician's order, then the RNA program policy was not followed, and it becomes a safety issue. The DOR stated residents may be in an RNA program that was not appropriate for them. The DOR stated despite RNA staff continuing to work with Residents 5,13 and 17, their RNA orders were all expired. During an interview on [DATE] at 11:54 a.m., Unlicensed Staff O stated licensed therapist designs an appropriate RNA program based on the resident needs. Unlicensed Staff O stated once the licensed therapist designed a program for a resident, the RNAs would receive a form indicating what exercises the resident was supposed to be receiving. Unlicensed Staff O stated the RNA staff and the licensed therapist would go over the program together. Unlicensed Staff O stated the RNA program had an end date. Unlicensed Staff O stated staff should not continue to perform exercises on residents based on the program that just ended. Unlicensed Staff O stated prior to working with the resident again, the licensed therapist will reassess the resident to determine if the expired RNA program is still appropriate or if it needed to be updated. Unlicensed Staff O stated if the RNA staff continued to perform the same exercises as before without the licensed therapist reassessing the resident after the order had expired, it could lead to harm to resident and the residents could get hurt. Based on the facility's policy and procedure (P&P) titled Restorative Nursing Services, revised 7/2017, the P&P indicated residents will receive Restorative Nursing care as needed to help promote optimal safety and independence .restorative goals and objective are individualized and resident centered. 3. During an observation on [DATE] at 09:58 a.m., a medicine cup filled with an orange-colored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 6 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few liquid was seen on Resident 1's bedside table. Resident 1 was asleep on the bed, and there was no staff present in the room. A photo was taken of the unattended medicine on the bedside table. Licensed Staff I was observed in the hallway opposite Resident 1's room, with a medication cart. During a concurrent interview, Licensed Staff I stated she gave medications to Resident 1 this morning, and confirmed one medication was an orange-colored liquid. Upon review of the photo, Licensed Staff I stated it was the medication she gave earlier. Licensed Staff I stated Resident 1 did not want to take the medication then, so she left the medication at the bedside and went to another resident. When asked if medications were allowed to be left at a resident's bedside, Licensed Staff I stated she was going to go back. During an interview on [DATE] at 10 a.m., the DON stated medications were not allowed to be left unattended at the bedside. During a review of the facility policy and procedure titled, General Dose Preparation and Medication Administration, dated 2017, the policy and procedure indicated, Facility staff should not leave medications or chemicals unattended . During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: .Observe the resident's consumption of the medication(s). 2. A review of Resident 8's admission Record, indicated she was admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, unsteadiness on feet, abnormalities of gait (manner of walking) and mobility, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain. Cognition and brain function can be significantly affected), pain in right and left shoulder, hip and right knee, amongst others. A review of Resident 8's Annual MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated [DATE], indicated Resident 8 had a BIMS (Brief Interview of Mental Status) score of 6, meaning Resident 8 was severely cognitively impaired. A review of Resident 8's care plan indicated she was care planned for Alteration in Skin Integrity (Skin Health: meaning a skin integrity issue might mean the skin is damaged, vulnerable to injury or unable to heal normally), had a history of skin breakdown and care planned for Risk for Impaired Skin Integrity and at Risk for Pressure Injuries (injury to the skin and surrounding tissue) related to weakness, limited mobility, history of pressure injuries amongst others, initiated [DATE]. Interventions initiated [DATE] included use pillows, pads, or wedges to reduce pressure on heels and pressure points, assist with turning and repositioning routinely and as needed, and check skin for redness, skin tears, swelling or pressure areas. A review of Resident 8's Order Summary Report, dated [DATE], indicated Resident 8 had an order to Float Heels Bilaterally, start date [DATE]. A review of Resident 8's TAR (Treatment Administration Record) indicated to Float Resident 8's heels bilaterally, start date [DATE]. Nurses were checking once per shift. During multiple observations on [DATE] from 11:09 a.m. through 4:05 p.m., Resident 8 was positioned on her back and heels were not floating (A pressure injury measure whereby a patient's heel should be positioned in such a way as to remove all contact between the heel and the bed.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 7 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During and observation on [DATE] at 8:57 a.m., Resident 8 was on her back asleep. There was a pillow under Resident 8's knees but heels were not floating. During a concurrent observation and interview on [DATE] at 5:09 p.m., Unlicensed Staff E was asked if her knew Resident 8's heels needed to be floated. Unlicensed Staff E stated he worked for the Registry and did not get report from the off going CNA who took care of Resident 8 or his nurse so he did not know about Resident 8's heels needing to be floated. Asked Unlicensed Staff E to see if Resident 8's heels were floating. Observed two pillows were under Resident 8's knees but her heels were on the bed. Once Unlicensed Staff E placed a third pillow under Resident 8's knees/calves, Resident 8 heels were of the bed. Resident 8 stated she felt more comfortable now. During a concurrent observation and interview on [DATE] at 9:25 a.m., Unlicensed Staff P and surveyor checked on the position of Resident 8's heels. Resident 8 had two pillows under her knees, but her heels were on the bed. Unlicensed Staff P stated before breakfast Resident 8's heels were floating but she slid down. Unlicensed Staff P repositioned Resident 8. Unlicensed Staff P stated he received his knowledge/report about his assigned residents from both RNAs (Restorative nursing assistant: provides rehabilitative care to individuals recovering from illnesses or injuries). During an interview on [DATE] at 12:25 p.m., Licensed Staff Q stated she was responsible in making sure her residents are being taken care of properly. She gave CNAs report on their assigned residents and she checked on her residents periodically. Licensed Staff Q stated Resident 8 had been turned and her heels were floated, off the bed, but she did tend to slide. Licensed Staff Q stated Resident 8 refused to turn on her side. The facility Policy/Procedure titled, Repositioning, revised 5/2013, Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents . General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief . Interventions: 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 2. Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used, b. The condition of the skin, c. The overall condition of the resident, d. The response to the current repositioning schedule, and e. Overall treatment objectives. 3. Residents who are in bed should be on at least every two-hour repositioning schedule. 4. For residents with a Stage I or above pressure ulcer, an every two hour repositioning schedule is inadequate . 6. If ineffective, the turning and repositioning frequency will be increased . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 8 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure it had a medication error rate of less than 5%, when three of 30 medications were not given according to the physician's orders. This failure resulted in a 10% error rate and caused one unsampled resident (Resident 183) to be upset and have a bowel movement immediately after her meal, potentially losing the opportunity to absorb the nutrients from her food. Residents Affected - Some Findings: During a med pass observation on 10/25/23 at 8:36 a.m., Resident 183 walked back to her room from the Dining Room and sat on the edge of her bed as Licensed Staff I started to prepare medications by the doorway. Shortly after, Resident 183 stood up, stated she needed to go to the bathroom. Licensed Staff I dispensed a tablet of loperamide (used to treat diarrhea) and Eliquis (used to treat or prevent blood clots) into a medicine cup, and mixed a packet of cholestyramine powder (used to control bile acid-induced diarrhea due to short bowel syndrome) with approximately one-half cup of water. Resident 183 returned to bed, and as Licensed Staff I approached her with the medications, Resident 184 told Licensed Staff I, You're late. Resident 183 stated her medications were supposed to have been given an hour ago. Resident 184 received the three medications at 08:41 a.m. During an interview on 10/25/23 at 08:41 a.m., Licensed Staff I stated the three medications were given late, and confirmed they were scheduled for 07:30 a.m. During an interview on 10/25/23 at 8:50 a.m., Resident 183 stated part of her colon had been removed due to a history of bowel cancer. Resident 183 stated food would go through her body quickly, and she had lost weight since. Resident 183 stated her medications needed to be within a certain period of her meals, to help keep the food in system longer to help her absorb it better. Resident 183 stated she already had a bowel movement after breakfasting this morning, as Licensed Staff I was preparing her medications. Record review revealed Resident 183 was admitted to the facility with diagnoses including malignant neoplasm (cancerous tumor) of the colon, surgical aftercare following surgery on the digestive system, severe protein-calorie malnutrition and diarrhea. A review of Resident 183's Medication Administration Record (MAR), dated 10/1/2023-10/31/2023, the MAR indicated the following orders: Cholestyramine Oral Packet . Give 1 packet by mouth two times a day related to DIARRHEA . 30 mins before breakfast and avoid administration with other medications . Hours: 0730 (07:30 a.m.) . Eliquis Oral Tablet . Hours: 0730 (07:30 a.m.) . Loperamide HCl Oral Tablet . Give one tablet by mouth two times a day for Diarrhea 30 mins before breakfast and dinner . Hours: 0730, 1630 (4:30 p.m.). During an interview on 10/25/23 at 5:27 p.m., Director of Nursing (DON) stated medications should be administered within an hour of their scheduled time. During a review of the facility's policy and procedure titled, Administering Medications, dated April 2019, the policy and procedure indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 9 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietary staff observations, dietary staff interviews and dietary document review, the facility failed to ensure staff competency in relationship to dietary staff position as evidence by dietary staff not 1) knowing how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solution used to sanitize the kitchen countertops and sanitize the pots and pans in the manual three-compartment sink process (wash, rinse, and sanitize), 2) using the correct Cool Down Process for hot foods, 3) follow therapeutic diets when portion sizes were not plated correctly and meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed prior to being pureed, 4) serving pasteurized (heat treated to kill harmful bacteria such as salmonella) eggs, and 5) thawing meat according to the facility's policy/procedure. Failure to ensure comprehensive staff competency may result in practices associated with cross contamination, foodborne illness (comes from eating contaminated food) and providing meals that did not meet the nutritional needs of residents further compromising the resident's medical status. Findings: 1. During a concurrent observation and interview on 10/24/23 at 10: 40 a.m., Dietary Aide T, who was new, was washing the pots and pans using the three-compartment sink process (wash, rinse, and sanitize). Dietary Aide T stated he scrapped the dishes, washed, rinsed, sanitize, and let the pots and pans air dry. Dietary Aide T did not know anything about testing the water temp and quat sanitizer in the three-compartment sink process. During a concurrent observation and interview on 10/24/23 at 11:15 a.m., the Dietary Supervisor used the ph (potential of hydrogen: a measure of the acidity or alkalinity of a solution) test strips, which ranged from 0 to 6, to test the sanitizer solution located in the red sanitizer bucket. The sanitizer solution was used to sanitize all food contact surfaces and food contact equipment. The test strip read 4.5 to 5 ph, which the Dietary Supervisor stated was the same as 400 ppm (parts per million). The Dietary Supervisor stated the kitchen used a broad range quaternary (quat ammonium compound designed to kill germs) sanitizer solution to clean the countertops. The Dietary Supervisor stated the sanitizer buckets were changed every two hours and if the cook prepped meat, the cook changed the sanitizer bucket after cleaning the countertops. During an interview on 10/24/23 at 12:05 p.m. and 12:20 p.m., the Food and Beverage Manager was asked for the Sanitizer Test Logs for the sanitizer buckets and testing the sanitizer solution in the three-compartment sink process, but none were provided. When the Food and Beverage Manager was asked about the ph test strips used by the Dietary Supervisor to test the quat sanitizer solution, the Food and Beverage Manager stated he figured out the Dietary Supervisor used the wrong test strip. The Food and Beverage Manager tested the sanitizer solution in the red bucket using the quat test strips, which read 150 ppm. During a concurrent observation, interview, and dietary record review on 10/24/23 at 2:20 p.m., the Pot and Pan Test Strip/Sanitation Bucket Log, dated 10/23 and the Dish Machine Temperature Log, dated 10/23, both posted over the three-compartment sink indicated the ppm for the high temperature dishwasher and three-compartment sink sanitizer compartment read 400 ppm at breakfast, lunch and dinner 10/1/23 through 10/21/23. Dietary Aide S was asked why a quat solution was being tested in a high-temperature dishwasher (a high-temp dishwasher used a detergent and rinse aid, but no sanitizer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 10 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm solution). Dietary Aide S stated he was told to write 400 ppm on both the Pot and Pan Test Strip/Sanitation Bucket Log, and the Dish Machine Temperature Log. Dietary Aide S stated he had never tested the water in the dishwasher or the sanitizer compartment of the three-compartment sink process. Dietary Aide S stated he thought the company came every two weeks to test the dishwasher. The Wash cycle of the dishwasher read 140 degrees Fahrenheit and the Rinse cycle read 182 degrees Fahrenheit. Residents Affected - Many During an interview on 10/24/23 at 2:28 p.m., the Dietary Manager stated she taught Dietary Aide S to open the dishwasher after the rinse cycle and test the ppm, first thing in the morning before the first batch of dirty breakfast dishes were washed. During an interview on 10/24/23 at 2:35 p.m., Dietary Aide S stated he was told to put 400 ppm on the Pot and Pan Test Strip/Sanitation Bucket Log and the Dish Machine Temperature Log. Dietary Aide S stated he was never trained to test either the dishwasher water or the sanitizer solution in the three-compartment sink process. Dietary Aide S stated he was trained by another dishwasher who no longer worked at the facility, and he was training the new dishwashers. During a concurrent observation and interview on 10/24/23 at 2:45 p.m., the Certified Dietary Manager (CDM) tested the sanitizer solution used to clean the Pantry countertops. The CDM used a quat test strip, which she held in the sanitizer solution for 10 seconds, per instructions. The CDM stated the test strip read 150 ppm because the facility used a broad range quaternary sanitizer solution, with a safe range from 150 to 400 ppm. The CDM stated she was overseen by the Food and Beverage Manager, who was not a CDM. The CDM stated the Food and Beverage Manager had restaurant experience, but no kitchen experience for a skilled nursing facility (SNF). The CDM stated the Pantry used a low temperature dishwasher so a chlorine sanitizer solution was used for the rinse cycle, which tested 50 ppm. The CDM stated she did not know why the kitchen dietary staff would be testing a high temperature dishwasher for the ppm, because a high temperature dishwasher used a super high temperature during the rinse cycle to sanitize the dishes, not a chemical. During an interview on 10/25/23 at 3:55 p.m., the Food and Beverage Manager stated the Dietary Manager was in charge of production systems of the kitchen and competencies of the kitchen staff. The Food and Beverage Manager stated the Pot and Pan Test Strip/Sanitation Bucket Log for the three-compartment sink process and the Dish Machine Temperature Log looked like the 400 ppm was just penciled in. The Food and Beverage Manager stated a high temperature dishwasher did not need the ppm tested. During a concurrent observation, interview, and dietary record review on 10/25/23 at 9:10 a.m., the Food and Beverage Manager stated the dietary staff were using the produce wash (A vegetable using wash cleaning product designed to aid in the removal process of dirt, wax and pesticides from fruit and vegetables before they are consumed) test strips to test the quat sanitizer solution. Over the three-compartment sink, there was a chart explaining what the water temperature should be for wash, rinse and sanitizer compartments as well as the quat sanitizing solution range needing to be from 150-400 ppm. The Food and Beverage Manager tested the sanitizer solution in the three-compartment sink sanitizer compartment, which tested 200 ppm, not the 400 ppm, which had been written on the Pot and Pan Test Strip/Sanitation Bucket Log every shift/daily. The sanitizer bucket near the handwash sink closest to the stove used to sanitize the kitchen countertops tested zero. The Food and Beverage Manager stated the AM dietary staff shift started at 5 a.m., so the sanitizer bucket may not have been changed since the start of the AM shift. During an interview on 10/26/23 at 9:50 a.m., [NAME] V did not know how many seconds the quaternary test strip had to be held in the sanitizer solution before checking the ppm. [NAME] V stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 11 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm sanitizer bucket was changed every four hours (Dietary Supervisor had stated every two hours) and the quat test strip should be held in the sanitizer solution for 30 seconds (Per the quat tests strip kit, the strip should be dipped in the sanitizing solution for ten seconds for an accurate reading). [NAME] V could not find the Quat test strips to test the sanitizer solution. [NAME] V looked in the holder near the three-compartment sink, but the holder was empty. Residents Affected - Many During an interview on 10/26/23 at 3:30 p.m., the Food and Beverage Manager and Dietary Supervisor stated there were no logs for testing the quat sanitizing solution in the red buckets and the sanitizing compartment of the three-compartment sink process. Both stated there were no logs showing the ppm of the sanitizer solutions were tested regularly. The dietary document titled, Sanitizer Use Concentrations for Food Service and Food Production Facilities, revised 4/30/20, indicated: 1. The U.S. Food & Drug Administration Food Code 2017, states the following guidelines for sanitizing solutions . c. A quaternary ammonium compound solution shall have a minimum temperature and contact time based on the concentration as listed in the following chart: Concentration Range: 200 ppm or 150-400 ppm, Minimum Temperature: 75 degrees Fahrenheit, and Minimum Contact Time: 30 seconds . 4. Sanitation buckets must be established with appropriate sanitizing solution for quaternary solution, 150-400 ppm; or 200 ppm depending on the product used and manufacturer guidelines . 5. Sanitizing cloths should be placed in the sanitizing buckets to be used for sanitizing all work surfaces and equipment. 6. Dietary should change these buckets at least three (3) times a day and test with the appropriate litmus strips each time the solution is changed to ensure accurate levels of sanitizer . Reference: U.S. Food & Drug Administration Food Code 2017. The dietary document titled, Hydrion (QT-10) Quat Dispenser 0-400 PPM, (Instructions for use of using sanitizer test strips) obtained from (https://www.microessentiallab.com/) > Best [NAME] (https://www.microessentiallab.com/category/best-[NAME], indicated: Dip the strip into the sanitizing solution for 10 seconds, then instantly compare the resulting color with the enclosed color chart which matches concentrations of 0-100-200-300-400 ppm. Test solution should be between 65- and 75-degrees Fahrenheit. The dietary document titled, Clean Quick Broad Range Quaternary Sanitizer, (Product used by the dietary staff), indicated: This is an EPA-registered broad range, liquid quaternary sanitizer. It is EPA approved for food contact sanitizing from 150 to 400ppm . Task Areas: 3-compartment sink (sanitizer compartment), Smallware, Food preparation surfaces as part of wash/rinse/sanitize/air dry (W/R/S) process, All food contact surfaces as part of W/R/S process, and Food contact equipment and equipment parts as part of W/R/S process. 2. During an interview on 10/25/23 at 9:40 a.m., the Dietary Manager, who ran the food production systems of the kitchen, was asked about the cool down process for potato salad. The Dietary Manager stated after the potatoes were cooked, one would place the potatoes in the refrigerator for four hours, and the temperature of the potatoes should reach 45 degrees Fahrenheit. The Dietary Manager did not know the cool down process for hot foods. The hot food item needing to be cooled down should be placed covered in the refrigerator, cooled down to 70 degrees Fahrenheit or less within 2 hours and then cooled down to 41 degrees Fahrenheit or less within four hours. The facility Policy/Procedure titled, Cooling Monitor for Hazardous Foods, revised 5/20/20, indicated: Policy: Food handling rules for cooling hazardous foods should be used by Food and Nutrition or Dining Services department employees. Hazardous foods are defined as: Beans/Rice/Pasta, Bean Sprouts, Pies/Pastries, Eggs, Unpasteurized, Potatoes, Meats/Soy Protein/Drippings used for Sauces or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 12 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm Gravies, Cheese/Whipped Butter, Chicken/Shellfish, Dairy /Non-Dairy Agents, Cut-Leafy Greens and Tomatoes, Mayo Mixed Salads, Melons . 5. Using the Cooling Monitoring Form (FORM 406) or other designated form record emperature of food every hour. The food should be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours and cooled from 70 degrees Fahrenheit to 41 degrees Fahrenheit in an additional 4 hours . Residents Affected - Many 3. During an observation on 10/25/23 10:55, [NAME] U pulled the pot roast out of the oven, checked the temperature, which read 165.2 degrees Fahrenheit and sliced the pot roast. [NAME] U then placed two slices of pot roast in the blender for the two residents on a pureed diet without weighing the meat before adding the gravy and thickener nor was the sliced meat weighed for the other types of therapeutic diets (Regular Diet, Easy to Chew Diet, and Soft and Bite Size Diet, and CCHO/NAS (Consistent Carbohydrate diet: helps keep blood sugar levels stable/No Added Salt). A review off the Daily Spreadsheet, dated 10/25/23, for the lunch menu, indicated residents on a regular portion size should have been served three ounces of the pot roast and residents on small portion size, should have been served two ounces of the pot roast. During an interview on 10/26/23 at 3:30 p.m., the Food and Beverage Manager and Dietary Supervisor did not know meat such as chicken, beef and pork, and fish needed to be weighed in order to know how many ounces the resident was plated per the therapeutic spread sheet. The Food and Beverage Manager and Dietary Supervisor stated they did not know about portion size per therapeutic spread sheets. The Food and Beverage Manager and Dietary Supervisor stated they did not weigh the meat (beef, pork chicken, turkey), and fish, to make sure the residents were receiving the correct portion size per the therapeutic spread sheet. 4. During the initial tour of the kitchen on 10/23/23 at 9:50 a.m., there were non-pasteurized eggs in the walk-in refrigerator, which were not covered and had no received by date. The Dietary Manager stated they used the Cage Liquid Eggs for the SNF. The Dietary Manager stated they normally have pasteurized eggs for the SNF. A review of a dietary document titled, Refrigerated Storage Quick Reference Guide, revised 1/9/2020, indicated: Eggs, in shell fresh: stored for 2-3 weeks, in the refrigerator at 35 to 41 degrees Fahrenheir or less, and keep small end down to center yolks. Stored in covered container. During a concurrent interview and dietary record review on 10/25/23 at 9:40 a.m., the October Dietary breakfast menu, dated 10/22/23-10/28/23, and the Always Available Menu for breakfast, indicated residents had a choice of style of eggs they wanted served (scrambled, omelets, sunny side up, or over easy). When the Dietary Manager was asked if there was any resident wanting a fried egg, she stated two residents had a fried egg this morning. The Dietary Manager stated the two residents wanted to substitute for a fried egg, so she honored their substitution even though she used non-pasteurized eggs. The Dietary Manager stated she has seen pasteurized eggs in the past, but the Food and Beverage Manager stated he has never seen pasteurized eggs and he did not know the SNF residents had to have pasteurized eggs. The facility Policy/Procedure titled, HCFA Clarification on Resident Rights and Food Safety, revised 8/31/18, indicated: The following is a question-and-answer clarification of resident rights and food safety for the Health Care Financing Administration. 16. F151-Fl77 483.10 Resident Rights . Potentially hazardous foods must be under continuous time and temperature controls in order to prevent either the rapid and progressive growth of infectious or toxigenic microorganisms, such as Salmonella (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 13 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many found most often in poultry and eggs. Outbreaks of food borne illness involving eggs have been the result of improper refrigeration, cooking and holding temperatures . The facility Policy/Procedure titled, Egg Cookery and Storage, revised 5/20/2020, indicated: Policy: The Food and Nutrition or Dining Services department should ensure that eggs are prepared in a manner to preserve quality, maximize nutritional retention, and to be free of salmonella and acceptable to the resident. Procedure . 4. Do not use raw eggs as an ingredient in the preparation of uncooked, ready-to-eat menu items unless using pasteurized eggs. 5. Shell eggs must not be pooled. Pasteurized eggs should be substituted for shell eggs for such items as scrambled eggs, omelets, French toast, mousse, and meringue . 9. Pasteurized eggs in the shell may be cooked and served individually per resident's preference. 5. During an interview on 10/23/23 at 9:50 a.m., the Dietary Manager stated she would pull frozen meat out of the freezer on Friday so the meat could thaw in the refrigerator for three days (until Monday). If the meat was pulled from the freezer on Monday, the meat would thaw in the refrigerator until Thursday. The Dietary Manager stated the kitchen staff did not thaw by running water over the frozen meat. During a concurrent observation and interview on 10/26/23 at 3:30 p.m. three pork loins were placed in a plastic cylinder of water, located in the sink, and running water was flowing over the pork loins in order to thaw the pork loins. The pork loins were not submerged fully in the water per the thawing process. When it was pointed out to the Food and Beverage Manager the thawing pork loins was not completely submerge in the cylinder of water, he stated he did not realize meat had to be completely submerged in running water. The facility policy/procedure titled, Meat Cookery and Storage, revised 5/20/20, indicated: Policy: The Food and Nutrition Services Department should ensure that meat shall be prepared in a manner to preserve quality, maximize nutrient retention and to obtain maximum yield of product. Procedure . 2. Meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees Fahrenheit or less. Larger meats, such as whole turkeys may require additional thawing time. Date meat when pulled for defrosting During an interview on 10/25/23 at 10:15 a.m., the Registered Dietician (RD) stated the RD did monthly and quarterly audits of the kitchen, which showed the Food and Beverage Manager what needed to be corrected in the kitchen. The RD stated the Food and Beverage Manager was head of the entire Food/Beverage operations and he should know the SNF regulations. The CDM stated she has been down to the kitchen several times to provide input to the Food and Beverage Manager. The RD stated the Food and Beverage Manager was responsible for knowing the necessary food services of the SNF unit including food handling/process to prevent foodborne illness. The RD stated the Food and Beverage Manager should have known the residents on the SNF unit should only consume pasteurized eggs. The CDM stated she did inspections of the kitchen, made changes to the structure of the kitchen, explained to the cooks about the importance of following recipes and the therapeutic spread sheets, the cool down process, and the importance of maintaining logs for the sanitizer solution. The RD and the CDM stated residents should never be served non-pasteurized fried eggs because there could be harmful bacteria leading to residents becoming ill. During an interview on 10/26/23 at 10:15 a.m., the Food and Beverage Manager stated he oversaw all three areas of the facility, which included the SNF unit. The Food and Beverage Manager stated he had no background in the Food and Nutritional Services for SNFs. The Food and Beverage Manager stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 14 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many this was why there is a CDM, who also does the Dietary in-services regarding the SNF Dietary Regulations and Title 22 (California Code of Regulations). The Food and Beverage Manager stated he knew nothing about kitchen staff competencies acknowledging the skills the dietary staff were supposed to be proficient in pertaining to their job description. The Food and Beverage Manager stated he understand the quat sanitizer solution needed to be checked per the test strip kit instructions to make sure the ppm was within the recommended range, so the kitchen countertops were sanitized sufficiently to prevent foodborne illness. During an interview on 10/26/23 at 11:53 a.m., the CDM stated there were no dietary staff competencies. The facility job description titled, Director of Food and Beverage Services, updated 7/2015, indicated: General Summary: The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training and supervising all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. Principle Duties: Essential Job Duties: 1. Organizes, directs and supervises all dietary service functions in consultation with the Dietitian; 2. Maintains established dietary standards and policies and assists the Dietitian in establishing and revising dietary policies and procedure . 5. Prepares menus for distribution including processing diet changes, checking that menus for patients on special diets or with dietary restrictions comply with physicians' orders, identifying menus (normal diets and special diets) and planning meals accordingly; 6. Directs duties of Cook, etc. as required. Checks special diet trays . 8. Assures efficiency of food preparation and serving; compliance with local, state and federal standards; sanitation, and hygiene and health standards of personnel. 9. Oversees the selection, training, evaluating and disciplining of all dietary personnel. 10. Reviews and maintains required records and reports covering (a) number and kinds of regular and therapeutic diets, (b) prepared nutritional and caloric analyses of meals, costs of raw food and labor . Other Duties: . 5. Keeps appropriate records . 6. Monitors the care and the safe and sanitary use of supplies and equipment and all infection control policies and procedures . 8. Attends in-service training and education sessions as assigned . The facility job description titled, Dietary Manager, updated 7/2015, indicated: General Summary: The Health Center Dietary Manager is responsible for overseeing Health Center food service program and providing the level of supervision necessary to ensure that courteous and efficient service is delivered as well as high quality and nutritious foods. Principle Duties: Essential Job Duties: 1. Assists in the planning, scheduling and supervising of Health Center dietary personnel; 2. Assists in developing all menus for Health Center residents assessing preferences and nutritional needs. Assists in assuring staff education is provided to dietary personnel in accordance with the staff education plan plus provides on the job training for Health Center dietary personnel; 3. Assists in developing work assignments for all dietary personnel assigning specific jobs and spot checking work to ensure standards are met; 4. Assures that each resident's nutritional adequacy is met by utilizing the assurance of Nutritional Adequacy Policy; 5. Maintains pertinent and appropriate records, reports, schedules and studies as required by local, state and federal regulations and otherwise requested . The facility job description titled, Sous Chef, revision 8/2017, indicated: Position Summary: The Sous Chef provides full-scope, hands on production cooking in a community Culinary Services Department. Is responsible for maintaining a superior level of quality service and cleanliness at all times. Essential Job Functions: 1. Exemplify at all times Community standards of cleanliness, sanitation and operational organization; 2. Exhibit leadership, and management standards with all Culinary Services staff; 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 15 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0802 Level of Harm - Minimal harm or potential for actual harm Responsible for adhering to food quality, appearance and presentation standards at all times; 4. Produce and serve menu cycle programs that are compliant with required Nutritional/Dietary criteria as required by local regulations and correctly prepare diets provided per Policy and Procedure; Exhibit cooking standards of speed, accuracy, and efficiency. 6. Demonstrate knowledge in all areas of cooking preparation and production . General Job Function: . Observe infection control procedures . Residents Affected - Many The facility job description titled, Cook, updated 7/2014, indicated: . Principle Duties: Essential Job Duties: . 3. Prepares or directs the preparation of all food served, following standard recipes and special diet orders . Other Duties: 1. Maintains assigned workstation in a safe and sanitary condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 16 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to honor the food preferences for two of three residents sampled for food (Residents 1 and 4). These failures resulted in Residents 1 and 4 to feel ignored and frustrated as they were served food they disliked, which may lead to poor nutritional intake and unplanned weight loss. Findings: During an interview on 10/23/23 at 10:19 a.m., Resident 4 stated she was served eggs despite telling the staff that she disliked eggs. Resident 4 stated it was frustrating to be asked for food preferences if she was still going to be served eggs. During a concurrent observation and interview on 10/24/23 at 08:44 a.m., Resident 1 was seated up in bed for breakfast. On the tray was a plate with seasoned potatoes and a piece of toast, a glass of milk and a cup of tea was on the overbed table. The meal appeared untouched, and Resident 1 stated she was not a big breakfast person. When offered to at least have some milk, Resident 1 stated, I hate milk. A review of Resident 1's meal ticket, located next to the plate, indicated, Dislikes: COTTAGE CHEESE, EGGS (alone), MILK, YOGURT. Resident 1 stated she would always get milk with breakfast. A photo of Resident 1's meal ticket and tray contents were taken. During an interview on 10/25/23 at 09:35 a.m., Dietary Aide Y stated the dietary staff would refer to the menu spreadsheet and meal tickets when plating the residents' food. Dietary Aide Y stated it was the role of the Certified Nursing Assistants (CNAs) to get the hot and/or cold beverages as they pass the trays to the residents. Dietary Aide Y stated CNAs were supposed to check the meal tickets to know which beverage they were supposed to serve the residents. During an interview on 10/25/23 at 10:02 a.m., Unlicensed Staff J stated after the nurses have checked the plate, the CNAs would get the drinks, then bring the meal trays to the resident rooms. Unlicensed Staff J stated each tray had a meal ticket, which indicated what the resident's diet was, as well as foods that they like/dislike. Unlicensed Staff J stated she would look at the meal ticket to know which beverage to get. When shown the photo of Resident 1's meal ticket and tray, Unlicensed Staff J stated, That's not correct. The resident does not like milk. Whoever brought that tray to her room should not have put milk on her tray. During an interview on 10/25/23 at 10:47 a.m., the Registered Dietitian (RD) stated the meal tickets contained information such as the resident's diet order, allergies, preferences, and food choices. The RD stated the nursing staff was expected to look at the residents' meal tickets to confirm that the meal is correct, and that they are being served their preferred food. Upon review of the photo of Resident 1's meal ticket and tray contents, RD stated Resident 1's meal ticket indicated she did not like milk. RD stated Resident 1 should not have been served milk. During a review of the facility policy titled, Food and Nutrition Services, dated, October 2017, the policy indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Reasonable efforts will be made to accommodate resident choices and preferences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 17 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) meat not thawed according to the facility's policy and procedure, 2) the correct Cool Down Process for cooked meats was not followed per the facility's policy and procedure, 3) dietary staff did not know how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solutions, 4) non-pasteurized eggs were being used, 5) the kitchen floors and counter appliances looked dirty, 6) garbage cans in the prep food areas were not covered with lids and the garage bens outside were open and there was garbage surrounding the garbage bins, 7) opened dried food products were not labeled with an open date and use by date, 8) fresh produce located in bins in the refrigerator were not labeled with a received by date, 9) spoiled produce was not thrown away, 10) the high temperature dishwasher wash cycle was not running per the manufactures recommendation, 11) a portion of the kitchen wall near the ovens was not repaired, and 12) tiles were missing from the refrigerator to freezer door threshold of the walk-in refrigerator/freezer, blackened areas where the floor tiles were missng and the coupling was pulling away from the freezer side of the doorframe. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death. Findings: During the course of the survey from 10/23/23-10/27/23 through observations, interviews and dietary record reviews related to deficient practices in food service systems were noted, affecting all residents. These included: 1. Failure to ensure safe dietetic services as evidence by dietary staff not thawing meat according to the facility's policy and procedure (Cross Reference F802). 2. Failure to ensure safe dietary services as evidence by dietary staff not using the correct Cool Down Process for cooked foods and ambient food items like tuna for tuna salad (Cross Reference F802). 3. Failure to ensure safe dietary services as evidence by dietary staff not knowing how to test the quat sanitizer solution (Cross Reference F802). 4. Failure to ensure safe dietary services as evidence by dietary staff serving non- pasteurized eggs to residents (Cross Reference F802). 5. During the initial tour of the kitchen on 10/23/23 at 9:50 a.m., the kitchen floors including the food pantry floor looked dirty, the toaster had crumbs all over it, and the food processor looked spotty with food particles. During an observation on 10/24/23 at 10: 40 a.m., the kitchen floors looked dirty throughout the kitchen. The toaster had crumbs all over it, and meat slicer, mixer and food processor had food particles/splatter on them. None of the appliances were covered. During an interview on 10/25/23 at 3:55 p.m., the Food and Beverage Manager stated the Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 18 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Manager was in charge of production of the kitchen. The Food and Beverage Manger stated he along with the Dietary Supervisor did the deep cleaning of the kitchen. All dietary staff have cleaning assignments pertaining to the area of the kitchen they work. The Food and Beverage Manager stated cleaning this kitchen was a delicate subject with the dietary staff, so he and the Dietary Manger just did the weekly deep cleaning. The Food and Beverage Manger stated cleaning was built into the dietary staffs' position. The Food and Beverage Manager did not know if the kitchen appliances were cleaned thoroughly all the time. The Food and Beverage Manager stated there was a high turnover in the kitchen, so it was easier for him to clean the kitchen or the cleaning did not get done. During an interview on 10/26/23 at 3:30 p.m., the Food and Beverage Manager was asked to provide the kitchen cleaning logs 1/1/23 through 10/25/23. A review of the Cooks Closing Cleaning log, indicated there were no logs maintained or provided for 1/23 through 6/3/23. Starting 6/4/23 through 10/8/23, there were multiple days where Cooks Closing Cleaning Logs were not filled out to indicating if the cook completed their cleaning duties, which included, clean, sanitize and cover slicer, clean and cover stand mixer, sanitizer logs filled out for the day, and floors swept and mopped, amongst other duties. A review of the Dishwasher Closing Cleaning Logs, dated 1/1/23-1/21/23, 3/19/23-4/1/23, 6/12/23-6/25/23, 7/2/23-7/8/23, 7/24/23-7/31/23, 8/1/23-8/20/23, 8/28/23-9/7/23, indicated there were 23 days when the Dishwasher Closing Cleaning tasks were not done, 50 times when the kitchen floors were not swept and mopped and various other duties were not completed, and the week of 5/5/2023, 6/4/23-6/11/23, 6/19/23, 7/9/23-7/23/23, and 8/21/23-8/27/23, there were no Dishwashing Closing Cleaning Logs to showing any of the dishwasher duties were completed. During an interview on 10/26/23 at 10:15 a.m., the Food and Beverage Manager stated he oversaw all three areas of the facility, which included the SNF unit. The Food and Beverage Manager stated he had no background in the Food and Nutritional Services for SNFs. The Food and Beverage Manager stated this was why there is a CDM, who also does the Dietary in-services regarding the SNF Dietary Regulations and Title 22 (California Code of Regulations). The Food and Beverage Manager stated the cooks did not have time between prepping and cooking to clean their areas. The Food and Beverage Manager stated the dishwasher was supposed to sweep and mop the kitchen. The Food and Beverage Manger stated he really did not know SNF regulations. He had been a chef at five-star restaurants. The Food and Beverage Manger stated he just initiated a cleaning schedule and cleaning log on 9/2023. The food and Beverage Manager stated he did not know he was supposed to maintain cleaning logs. When the Food and Beverage Manager was asked how he could prove the various areas of the kitchen had been cleaned/sanitized daily without cleaning logs, the Food and Beverage Manger stated he understood. During an observation and based on pictures on 10/26/23 at 1:22 p.m., an opened garbage can to the right of the ice bin was placed against the ice machine near the ice bin. The right side of the ice machine looked dirty/splattered as well as the surrounding kitchen floor. A review of the of the kitchen log titled, Ice Machine - Monthly Sanitizing Log, 1/2023-9/2023, the ice machine was sanitized monthly. Note: Daily was crossed out and Monthly was written in. The facility dietary document titled, Daily and Weekly Cleaning Schedule, revised 11/2/2014, indicated: Weekly duties included for the ice machine bin to be washed and sanitized. There were no Weekly Ice Machine Logs and no Daily and Weekly Cleaning Schedules initiated with signatures presented, to indicate the ice machine bin was washed and sanitized weekly. During an observation and based on pictures on 10/26/23 at 1:29 p.m., ants were crawling up and down the kitchen wall, left of door trim leading into food pantry, across from the office. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 19 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility policy/procedure titled, Cleaning Schedules, revised 8/31/2018, indicated: Policy: The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional . Procedure: 1. The Director of Food and Nutrition Services or other qualified nutrition professional shall record all cleaning and sanitation tasks for the Food and Nutrition Services Department. 2. A cleaning schedule shall be posted with tasks designated to specific positions in the department. 3. All tasks shall be addressed as to frequency of cleaning. 4. The procedures to be used are listed in this Policy and Procedure Manual. 5. General Daily Cleaning Schedules and weekly cleaning schedules may be used or Cleaning Schedules (FORMs 751, 752, and 753 or other designated) form by position may be used. 6. On the Position cleaning schedules the Director of Food and Nutrition Services or other clinically qualified nutrition professional fills in the Position, the item to be cleaned, Frequency i.e. daily, day of week, or week 1, 2, 3, 4. 7. Under the days of the week or the weeks, the Director of Food and Nutrition Services or other clinically qualified nutrition professional can check off assignments completed or the employee can initial . The facility policy/procedure tilted, Food Processor, revised 3/31/2018, indicated: . 4. An absorbent cloth and mild detergent may be used to wipe the base clean . Note: This policy applies to food processors and similar products . The facility policy/procedure titled, Blender, revised 3/31/2018, indicated: . Sanitation of Equipment: . 6. Wash base with sanitizing solution and clean cloth. 7. Move machine base and sanitize table with sanitizing solution and clean cloth . The facility dietary document titled, Daily and Weekly Cleaning Schedule, revised 11/2/2014, indicated: Daily duties included cleaning the food processor/blender, toaster, mop kitchen, office storeroom and walk-in refrigerator/freezer floors, mop bucket empty and clean, Mops wash and clean, wipe walls in cooks' area, wash garbage cans and lids, all counters and cook's tables, amongst other duties. 6. During the initial tour of the kitchen on 10/24/23 at 10:40 a.m., the garbage cans by the food prep sink under the prep counter had no lids. During an observation on 10/25/23 at 9:15 a.m., the garbage cans used on the clean side of the kitchen did not have lids. During an interview on 10/25/23 at 3:55 p.m., the Food and Beverage Manager stated they have never covered the garbage cans located on the clean side of the kitchen, for prepped food waste. During an observation on 10/26/23 at 10:15 a.m., the garbage cans located on the clean side of the kitchen did not have lids. The facility had two garbage dumpsters, both dumpsters' lids were up, and there was trash surrounding the dumpsters. Note photos were taken of the garbage dumpsters on 10/26/23 at 10:37 a.m. The right dumpster still had a lid up. The facility policy/procedure titled, Garbage and Trash Cans, revised 5/20/2020, indicated: Sanitation of Equipment: 1. All food waste must be placed in covered garbage and trashcans . 4. Each time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 20 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the garbage and trash are emptied, the containers are to be thoroughly inspected inside and out and cleaned, if needed, with a hot detergent solution and then rinsed. 5. The dumpster area must be free of debris on the ground and the lid must be closed . 7.-9. During the initial tour of the kitchen on 10/24/23 at 9:50 a.m. the bananas stored in the food pantry looked brown, the dispenser of white dried beans and quinoa grain and the opened spices of whole celery, pumpkin spice, and nutmeg were not labeled with an open date. The Dietary Manager stated once a spice was opened, the container should be labeled with an opened date. The bins of fresh fruits and vegetables including carrots and cabbage located in walk-in refrigerator did not have have a received by date. Some of the red bell peppers had black spots and some of the strawberries in their original containers were moldy. The Dietary Manager stated normally fruits/vegetable bins would be dated indicating the received by date. During an observation on 10/24/23 at 10:40 a.m., the opened nutmeg, clover and celery salt spices stored over prep table were not labeled with an opened date. During a concurrent observation and interview on 10/25/23 at 9:15 a.m., the dry goods bins stored under the large portable medal table next to prep counters, which stored couscous, jasmine rice and breadcrumbs were not labeled. The dry goods bins stored under the counter where the prep appliances were located, which held rolled oats, sugar and flour were not labeled. The Dietary Manager stated all the dry goods bins should have been labeled with an open and use by date. During an interview on 10/25/23 at 9:30 a.m., the Food and Beverage Manager stated all food products should have been labeled. The Food and Beverage Manager stated the food products should be labeled with a received by date, an open date and use by date. The food and Beverage Manager stated he had a gun to tag all food products with the date they came in. The Food and Beverage Manger stated milk needed an open date and should be thrown away after 14 days but based on the use by date on the container of milk. The Food and Beverage Manger stated all other dairy products were to be held no more than seven days after opened. The Food and Beverage Manager stated the fruit/vegetable produce bins stored in the refrigerator should have the date the produce came in. A review of the dietary document titled, Refrigerated Storage Quick Reference Guide, revised 1/9/2020, indicated: Refrigerated food products stored in the refrigerator at 35-41 degrees Fahrenheit or less. Once whole or low-fat milk opened, store for one week. Berries stored unopened for one to two days. Carrots and red and green peppers one to two weeks. Heads of cabbage stored for one week. Fresh Fruits . 5. Most fruits should be used within 3 to 5 days . The facility policy/procedure, Food Storage, revised 8/29/23, indicated . Procedure: All products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. Use Use-By dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts (POLs 154a, 154b, 154c) found in this section. Refrigerated Storage Quick Reference Guide (DOC 409) may be used for a more efficient method of noting use by dates on products . Remember to cover, label, and date! A label may not be needed if in original packaging and product is identified on the package. Any expired or outdated food products should be discarded . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 21 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 10. During a concurrent observation, interview, and review of the high temperature dishwasher temperature recommendation for the wash cycle posted on the dishwasher machine and the Dish Machine Temperature Logs on 10/25/23 at 9:10 a.m., the Food and Beverage Manager checked the temperature of the wash and rinse cycle of the high temperature dishwasher. The Food and Beverage Manager stated the wash cycle temperature was 142 degrees Fahrenheit, The manufactures recommendations posted on the machine indicated the wash cycle temperature should be a minimum of 160 degrees Fahrenheit. The Dish Machine Temperature Log, dated 10/2023, indicated the high temp wash cycle was running 133 to 139 degrees Fahrenheit. The Food and Beverage Manager was going to have a service professional come out to look at the dishwasher. During a concurrent observation and interview on 10/26/23 at 10:15 a.m., the Food and Beverage Manager stated the dishwasher had a booster to heat the water faster and the booster heated the wash cycle to 185 degrees Fahrenheit. Dietary Aide S stated he checked and logged the high temperature dishwasher temperatures for the wash and rinse temperature cycle first thing in the morning, so the hot water may not have been heated all the way. The Food and Beverage Manager stated the service technician gave him test strips to check the wash cycle temperature. The Food and Beverage Manager placed a test strip on a plate and ran the dishwasher. The Food and Beverage Manager stated if the test strip turned pink, which it did, the temperature of the wash cycle supposedly reach 160 degrees Fahrenheit, though the wash cycle temperature gauge never reached 160 degrees Fahrenheit. The Food and Beverage Manger stated the wash cycle temperature gauge must be off. A review of the dietary documents titled, Dish Machine Temperature Log, dated 1/2023-9/2023, indicated the wash cycle temperature ran as low as 110 degrees Fahrenheit and only one time did it run at 160 degrees Fahrenheit. The majority of the times, the wash cycle ran in the 130s degree Fahrenheit. 11. During a concurrent observation and an interview on 10/24/23 at 11:50 a.m., the was a blue tarp covering the lower kitchen wall to the right of the ovens. The Food and Beverage Manger stated there was water damage from a busted pipe, which was fixed. Note photos were taken on 10/24 at 11:58 a.m. 12. During concurrent observation and interview on 10/24/23 at 12:05 p.m., the walk-in refrigerator/freezer had floor tiles missing from the refrigerator to freezer door threshold, blackened areas where tiles were missing on the floor of walk-in the refrigerator/freezer, and the coupling was pulling away from the wall on the freezer side of the doorframe. Note photos were taken on 10/24/23 at 12:03 p.m. During an interview on 10/25/23 at 03:32 p.m., the Registered Dietician (RD) stated the damage to the wall in the kitchen was because of a busted pipe. The RD stated both the wall damage and the repair needed in the walk-in refrigerator/freezer: tiles/frame of door leading between the refrigerator and freezer was in the works to be repaired. The RD state the Interim Administrator for the entire facility was working on the repair. The facility job description titled, Director of Food and Beverage Services, updated 7/2015, indicated: General Summary: The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training, and supervising all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 22 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Principle Duties: Essential Job Duties: 1. Organizes, directs and supervises all dietary service functions in consultation with the Dietitian; 2. Maintains established dietary standards and policies and assists the Dietitian in establishing and revising dietary policies and procedure . 8. Assures efficiency of food preparation and serving; compliance with local, state and federal standards; sanitation, and hygiene and health standards of personnel. 9. Oversees the selection, training, evaluating and disciplining of all dietary personnel . 11. Delegates authority to supervisory staff for task details to facilitate smooth flow of materials and services. Other Duties: . 5. Keeps appropriate records . 6. Monitors the care and the safe and sanitary use of supplies and equipment and all infection control policies and procedures . 8. Attends in-service training and education sessions as assigned . The facility job description titled, Dietary Manager, updated 7/2015, indicated: General Summary: The Health Center Dietary Manager is responsible for overseeing Health Center food service program and providing the level of supervision necessary to ensure that courteous and efficient service is delivered as well as high quality and nutritious foods. Principle Duties: Essential Job Duties: 1. Assists in the planning, scheduling and supervising of Health Center dietary personnel; . 3. Assists in developing work assignments for all dietary personnel assigning specific jobs and spot-checking work to ensure standards are met; . 5. Maintains pertinent and appropriate records, reports, schedules and studies as required by local, state and federal regulations and otherwise requested . Other Job Duties: . Performs specific work duties and responsibilities as assigned by supervisor . The facility job description titled, Sous Chef, revision 8/2017, indicated: Position Summary: The Sous Chef provides full-scope, hands on production cooking in a community Culinary Services Department. Is responsible for maintaining a superior level of quality service and cleanliness at all times. Essential Job Functions: 1. Exemplify at all times Community standards of cleanliness, sanitation and operational organization; 2. Exhibit leadership, and management standards with all Culinary Services staff; . General Job Functions: . 20. Accept assigned duties, instructions or correction in a cooperative manner, voicing concerns or disagreement in a professional manner through established chain of authority according to state procedures. 21. Perform incidental housekeeping and maintenance tasks as may arise during the course of regular duties, in order to maintain a clean, safe, pleasant environment for residents, visitors and staff. 22. Perform all other related duties as assigned in an effective, timely and professional manner . The facility job description titled, Cook, updated 7/2014, indicated: .Other Duties: 1. Maintains assigned workstation in a safe and sanitary condition; . 4. Performs specific work duties and responsibilities as assigned by supervisor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 23 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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** 5. During a concurrent observation and interview on 10/25/23 at 04:45 p.m. with Licensed Staff H outside of Resident 26's room, Licensed Staff H placed the glucometer on top of the medication cart after checking Resident 26's blood sugar. The glucometer was not disinfected after use. Licensed Staff H walked towards Resident 100's room with the cart and the used monitor. Licensed Staff H stated he was going to check Resident 100's blood sugar and proceeded to insert a test strip into the blood glucose monitor, until this Surveyor intervened. When asked if there was something he had to do before he used the used glucometer on Resident 100, Licensed Staff H stated he forgot to disinfect the machine. Licensed Staff H stated the glucometer was supposed to be disinfected after each patient use. Residents Affected - Many During an interview on 10/25/23 at 05:15 p.m., the IP stated blood glucose monitors should be disinfected after each use. During a review of the facility's policy and procedure titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated August 2009, the policy and procedure indicated, Reusable items are cleaned and disinfected or sterilized between residents . Based on observations, interviews and record reviews, the facility failed to maintain an effective infection prevention and control program when: 1. Staff were not following the facility's guidelines for Contact Precautions, donning and doffing of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), and appropriate hand hygiene with a resident who was positive for Clostridium Difficile infection (C. diff, also known as Clostridioides difficile or C. difficile, is a bacteria that causes diarrhea and inflammation of the colon. It is a contagious infection that is estimated to cause almost half a million infections in the United States each year. - Centers for Disease Control and Prevention), 2. Staff were not performing and offering hand hygiene (HH, a way of cleaning one's hands that substantially reduces potential harmful microorganisms on the hands) before and after meals for eight out of eight sampled residents (Residents 3, 7, 17, 21, 25, 27, 81 and 183), when serving meals in between residents in the dining room, between touching the dirty and clean dishes, and in between touching a resident's dirty napkin/clothing while serving another resident's dessert, prior to donning (act of putting on a garment or piece of equipment) gloves, 3. A staff wore the same gloves she used while preparing Resident 4's glucometer (small device that measures how much sugar is in the blood sample) and proceeded to don an isolation gown without discarding the used glove first, 4. One resident's (Resident 5) Yankauer opened suction tube set (a tool used to remove secretions from the mouth and throat) was not dated and labeled, and 5. A staff did not disinfect a glucometer in between use. These failures were breaks in infection control measures as non-disinfected glucometers and unlabeled suction tubes could harbor infectious microorganisms, and the inappropriate use of PPE and unclean hands could aid in the transmission of microorganisms from patient to patient, leading to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 24 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 - Many respiratory infections (infections of parts of the body involved in breathing), gastrointestinal infection (an infection of the bowel or gut) and C. Diff infection outbreak. Findings: 1. During a concurrent observation and interview on 10/23/23 at 11:14 a.m. with Unlicensed Staff J, a bright orange sign posted outside of Resident 9's room indicated, CONTACT PRECAUTIONS . EVERYONE MUST clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Unlicensed Staff J stated Resident 9 was on contact precautions for a C. Diff. infection. During an observation on 10/23/23 at 12:32 p.m., Unlicensed Staff G went into room [ROOM NUMBER] without any glove or gown on. During an interview on 10/23/23 at 12:33 p.m., Unlicensed Staff G stated it was ok to go into Resident 9's room without PPE if staff was not doing patient care. During a concurrent observation and interview on 10/25/23 at 3:21 p.m. with Unlicensed Staff W, Unlicensed Staff W exited Resident 9's room and used the wall-mounted ABHR (alcohol-based hand rub) on her hands. Unlicensed Staff W walked down the hall and was about to touch a binder at the nursing station until this Surveyor intervened. Unlicensed Staff W stated Resident 9 was positive for C. diff, and she double-gloved while inside the room then used the hand sanitizer after exiting the room. When asked if double-gloving and hand sanitizers were effective against C-diff, Unlicensed Staff W stated, I'll go wash my hands now. During a concurrent observation and interview on 10/25/23 at 3:26 p.m. with Unlicensed Staff X, Unlicensed Staff X went into Resident 9's room with only a pair of gloves and used the hand sanitizer after leaving the room. Unlicensed Staff X walked down the hall and stood outside the Dining Room where residents were located. Unlicensed Staff X stated she thought she did not need to wear a gown inside Resident 9's room as she only dropped off a menu by the resident's table and turned off his [overhead] light. Unlicensed Staff X stated she should have washed her hands with soap and water. During an interview on 10/25/23 at 3:25 p.m., Unlicensed Staff E stated staff should always perform HH prior to entering a resident's room. Unlicensed Staff E stated staff should wash their hands with soap and water after caring for a resident who tested positive for C. Diff and prior to staff leaving a resident room who tested positive for C. Diff. Unlicensed Staff E stated alcohol based hand rub was not effective against C. Diff infection. Unlicensed Staff E stated it was a safety issue if staff did not wash hands prior to leaving a resident room that had tested positive for C. Diff infection. Unlicensed Staff E stated not washing hands with soap and water after caring for a resident with C. Diff infection could result to C. Diff outbreak. During an interview on 10/25/23 at 4:26 p.m., the Infection Preventionist (IP) stated to prevent outbreak and contamination, a resident positive with C. diff infections was placed in Contact Precautions (intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or the patient's environment). The IP stated she expected staff to perform HH when coming out of the room of a resident who tested positive for C. Diff infection. The IP stated staff were directed to use the ABHR when they leave the room of a resident who tested positive for C. Diff infection, walk the hallway, and wash their hand with soap and water at the nurse station (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 25 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 sink. When asked if ABHR was effective in eliminating C. Diff, the IP stated no. When asked if there was a risk staff could touch a resident, staff or environmental fixtures while on the way to wash their hands at the nurse station sink, the IPN stated Yes, I get your point. The IP stated for an effective infection control measure, staff should be washing their hand with soap and water before leaving the room of a residents who tested positive for C. Diff. Residents Affected - Many 2. During an observation on 10/23/23 at 12:35 p.m., Licensed Staff A did not perform HH before she served soup to Resident 17 and lunch plate to Resident 27. Licensed Staff A wore gloves to scoop the ice, but no HH was performed prior to donning gloves. Licensed Staff A did not perform HH before she served the cup of ice to Resident 17. Licensed Staff A wore gloves without HH, then scooped the ice and with gloved hand and served the cup of ice to Resident 27. During a dining observation on 10/23/23 at 12:38 p.m., a Certified Nursing Assistant (CNA) did not use hand sanitizer to clean their hands in between delivering a resident a plate of food and serving coffee to another resident. A CNA placed dirty dishes in a dirty dish bin, then went to the dining room Pantry serving window, picked up two desserts and served the desserts to two residents. The CNA did not use hand sanitizer in between touching the dirty and clean dishes. During an observation on 10/23/23 at 12:39 p.m., Unlicensed Staff B did not perform HH prior to serving Resident 21 his lunch tray. Unlicensed Staff B did not offer HH to Resident 21 prior to eating his lunch. During an observation on 10/23/23 12:43 p.m., Unlicensed Staff B did not offer HH for Resident 7 after she finished her lunch. Licensed Staff A did not perform HH when she served desserts to Resident 7 and Resident 27. During a dining room observation on 10/23/23 at 12:44 p.m., a CNA placed dirty dishes in the dirty dish bin and did not use hand sanitizer to clean their hands afterward. A CNA gave a resident their dessert, retrieved a spoon for the resident, and tucked the resident's napkin over her blouse. The CNA then went to the dining room Pantry serving window, picked up a dessert and served another resident their dessert. The CNA did not use hand sanitizer in between touching one resident's dirty napkin/clothing and serving another resident their dessert. During a concurrent observation and interview on 10/23/23 at 1:00 p.m., there was no staff that offered HH to Resident 183 after she was done with her lunch. On the way out of the dining room, Resident 183 was asked about HH before and after meals. Resident 183 stated staff did not offer HH before and after meals. During an observation on 10/23/23 at 12:50 p.m., there was no staff that offered HH on Resident 7 after she finished eating her lunch. During an observation on 10/23/23 at 12:56 p.m., there was no staff that offered HH on Resident 25 after he was done eating his lunch. During an interview on 10/23/23 at 12:58 p.m., Resident 25 stated staff did not offer hand hygiene before and after meals. During an observation on 10/25/23 at 12:23 p.m., Unlicensed Staff G did not perform HH prior to taking Resident 81's lunch tray into her room. Unlicensed Staff G did not offer HH to the Resident 81 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 26 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 prior to eating her lunch. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/25/23 at 12:25 p.m., Resident 81 verified the staff did not offer HH prior to her eating her lunch. Resident 81 stated staff do not really offer HH to her before and after meals. Residents Affected - Many During an observation on 10/25/23 at 12:29 p.m., the Scheduler, who was also a Certified Nursing Assistant, did not perform HH prior to taking Resident 3's meal tray and bringing it in her room. The Scheduler did not perform HH prior to donning gloves to reposition Resident 3 in bed. During an observation on 10/25/23 at 12:30 p.m., Unlicensed Staff D was asked by the Scheduler to help reposition Resident 3 in bed. Unlicensed Staff D entered Resident 3's room without performing HH. The Scheduler proceeded to set up the lunch tray for Resident 3 while still wearing the gloves she used to reposition Resident 3 in bed. During an interview on 10/25/23 at 1:12 p.m., Resident 3 stated staff do not offer HH before and after meals. She stated they don't really ask to wash our hands, no. When asked if staff offered hand hygiene prior to eating her lunch today, she stated no. During an interview on 10/25/23 at 3:34 p.m., Unlicensed Staff F stated it was the facility's policy to ensure residents were offered HH before and after meals. Unlicensed Staff F stated if the staff did not offer HH before and after meals, it meant the facility policy was not followed. Unlicensed Staff F stated it was a safety issue if staff and residents were not performing HH because they could both spread germs that could result in infection. Unlicensed Staff F stated staff should wash their hands with soap and water after caring for a resident that tested positive for C. Diff. Unlicensed Staff F stated staff should wash their hands with soap and water before leaving the residents' room who tested positive for C. Diff. Unlicensed Staff F stated ABHR was not appropriate to use after caring for residents with C. Diff. Unlicensed Staff F stated, if staff only used an ABHR, the C. Diff bacteria could still be in staff hands and staff could pass it on to another staff or residents. Unlicensed Staff F stated this could result to a C. Diff outbreak. During an interview on 10/25/23 at 3:47 p.m., the IP stated it was the facility's policy for staff to offer HH before and after meals. The IP stated she was not surprised staff was not following strict HH protocol. The IP stated HH was a big issue with the facility. The IP stated it was a safety risk if residents were not offered HH before and after meals as this could result to infections. IP stated staff should be performing HH in between serving residents their meal trays. The IP stated if staff were not performing hand hygiene before delivering meal trays or setting up residents with their meal tray, it meant the facility policy was not followed. The IP stated staff should perform HH prior to donning gloves. The IP stated the proper sequence of donning PPEs include staff wearing an isolation gown first before donning gloves. The IP stated staff not performing HH before and after assisting residents with meals or staff serving and setting up residents their meal trays, staff not offering HH to residents before and after meals, staff not performing HH prior to donning gloves and improper sequence of donning PPEs could result to infection. The IP stated there could be a risk of cross contamination if HH policy was not being strictly adhered to. During an interview on 10/26/23 at 9:20 a.m., the IP stated she did spot check the staff in the dining room to make sure hand sanitizer was being used in between residents. The IP stated if a dining staff member touched a dirty dish, they needed to use hand sanitizer to clean their hands before retrieving and serving the next plate of food. The IP stated a dining room staff member should clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 27 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 - Many their hands with the hand sanitizer after touching a resident's dirty napkin/clothes and before serving another resident their plate of food. During an interview on 10/26/23 at 10:21 a.m., the Director of Nursing (DON) stated residents should be offered HH before and after meals. The DON stated staff should perform HH before entering a resident's room. The DON stated staff should perform hand hygiene prior to donning and doffing (to remove or take off) gloves. The DON stated staff should remove gloves and perform HH after repositioning a resident in her bed. The DON stated staff should perform HH before assisting residents with their meals or setting up residents' meal trays. The DON stated staff should be performing HH in between assisting residents. The DON stated not offering residents HH before and after meals, staff not performing hand hygiene in between assisting residents and staff not performing HH prior to donning gloves indicated the facility was not following the Handwashing policy. The DON stated not performing HH can increase risk of infection like gastrointestinal (GI) infection. The DON stated staff were instructed not to use Resident 9's bathroom for HH after they care for him. The DON stated staff were instructed to use ABHR before leaving Resident 9's room, walk the hallway and wash their hands with soap and water at the nursing station sink. The DON stated staff should not use ABHR when performing HH after caring for a C. Diff positive resident. When asked if ABHR was effective in eliminating C. Diff, the DON stated no. When asked if there was a risk staff could help another staff or resident in an emergency on the way to the nursing station, the DON stated yes. When asked how the staff should performed HH after Resident 9 had a bowel movement, the DON stated, I get it. The DON stated for infection control, it's better to have the staff wash their hand with soap and water before leaving Resident 9's room. During an interview on 10/26/23 at 11:53 a.m., the Certified Dietary Manager (CDM) stated the dining staff should always use hand sanitizer to clean their hands after resident contact or touching dirty dishes and before touching a clean plate of food. The CDM stated she had not done any in-services about Use of Hand Sanitizer for the Dining Staff. The Registered Dietician (RD) stated it was the responsibility of both nursing and the CDM to oversee dining staff was following proper hand hygiene. The facility job description titled, Dietary Manager, updated 7/2015, indicated: General Summary: The Health Center Dietary Manager is responsible for overseeing Health Center food service program and providing the level of supervision necessary to ensure that courteous and efficient service is delivered as well as high quality and nutritional foods . Other Duties: 1. Assists in providing on-the-job training for Health Center dining room personnel . 3. During an observation on 10/24/23 at 05:18 p.m., Licensed Staff K was noted wearing a glove while preparing the glucometer for Resident 9. Licensed Staff K was then observed donning an isolation gown while still wearing the gloves she used when preparing Resident 9's glucometer. During an interview on 10/24/23 at 5:29 p.m., Licensed Staff K verified she did prepare Resident 9's glucometer wearing gloves and did not change the gloves prior to donning an isolation gown. Licensed Staff K stated the facility protocol was to wear the gloves last. Licensed Staff K state she should have removed the used gloved, performed HH and then wear the gown and then don a new glove. Licensed Staff K also stated she did not wash her hand with soap and water prior to leaving Resident 9's room. Licensed Staff K stated she should have washed her hand with soap and water and not use the ABHR for hand hygiene. Licensed Staff K stated a break in the proper PPE sequencing and not following the appropriate HH after caring for residents with C. Diff was a safety issue and could result to infection breakout. Licensed Staff K stated it would be bad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 28 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 - Many During an interview on 10/25/23 at 3:15 p.m., Licensed Staff C stated staff should wash their hand with soap and water after coming out of Resident 9's room. Licensed Staff C stated using ABHR was not acceptable because it was ineffective against C. Diff infection. Licensed Staff C stated, if staff left Resident 9's room without washing their hand with soap and water, it would be a safety risk and the facility could be at risk for a C. Diff breakout. Licensed Staff C also stated if a staff was wearing a glove when preparing a resident medications, the staff should remove the glove after preparing the medication, perform hand hygiene before putting on the gown and the don a new pair of gloves last. Licensed Staff C stated this should be done for patient safety. During an interview on 10/25/23 at 4:26 p.m., the IP stated if a staff was wearing gloves when preparing Resident 9's medication or glucometer, the staff should remove this glove, perform HH, put on the isolation gown first then don a new glove. The IP stated if this was not the case, then the PPE protocol was not followed and there was a break in the infection control protocol. During a concurrent observation and interview on 10/26/23 at 12:00 p.m., the Maintenance Technician measured the distance between Resident 9's bedroom and the nursing station sink at 83.5 ft. The Maintenance Technician stated it was quite a walk between Resident 9's room and the nursing station. During an interview on 10/26/23 at 12:03 p.m., the DON was notified of the distance between Resident 9's room and the nursing station. The DON stated, Oh that's quite a distance. The DON stated for infection control measures, it would be best if staff wash their hands with soap and water in Resident 9's bathroom sink before going out of his room. A review of the facility's policy and procedure (P&P) titled Handwashing/Hand hygiene, revised 8/2019, the P&P indicated it considers hand hygiene as the primary means to prevent the spread of infections .wash hands with soap and water after contact with a resident with infectious diarrhea (the passage of three or more loose or liquid stools per day) not limited to C. Diff .use ABHR before and after direct contact with residents .before donning gloves .after contact with resident skin after removing gloves, before and after assisting residents with meals, before and after eating or handling food. A review of the facility's policy and procedure (P&P) titled Clostridium Difficile, revised 6/2010, the P&P indicated precautions will be taken while caring for residents with C. Diff to prevent it's transmission to others .staff will maintain vigilant hand washing with soap and water rather than ABHR for the mechanical removal of C. Diff spores from hands. A review of the Center for Disease Control (CDC, the agency responsible for controlling the introduction and spread of infectious diseases) guideline on sequence for putting on PPE, it indicated after performing HH, to don the gown first and wear the gloves last .if on contact precautions, everyone must clean their hands, including before entering and when leaving the room. 4. During a concurrent observation and interview on 10/24/23 at 3:48 p.m., Licensed Staff C verified through observation, Resident 5's suction canister had opaque liquid inside and the Yankauer suction set was opened but was not dated. Licensed Staff C stated these indicated these items were used. Licensed Staff C stated it was the facility's policy to ensure these items were dated. Licensed Staff C stated the suction set should be changed daily. When asked if she could identify when the last time was the Yankauer suction set and the canister was changed, Licensed Staff C stated no. Licensed Staff C stated not dating these items meant the facility policy was not followed and could lead to Resident 5 acquiring an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 29 of 30 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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 During an interview on 10/24/23 at 4:35 p.m., Licensed Staff K stated the canister and the Yankauer suction set needs to be changed daily and dated as it was changed per facility policy. Licensed Staff K stated, if the facility did not date these items, the staff would not know whether these were still appropriate to use. Licensed Staff K stated it was a safety issue if these items were not changed daily and staff used it. Licensed Staff K stated it could lead to Resident 5 acquiring respiratory infection. Residents Affected - Many During an interview on 10/25/23 at 4:26 p.m., the IP stated the suction machine canister and the Yankauer tubing set did not need to be dated because it would to be thrown away after each use. The IP stated this was the facility's policy for infection control purposes because bacteria grows rapidly in saliva. The IP stated not discarding the canister and the Yankauer tubing set after each use could result to resident acquiring a respiratory infection. The facility did not have a policy specific to when the Yankauer suction tubing should be changed. A review of Resident 5's physician order dated 4/11/23 indicated the suction tubing should be changed every 3 days and the suction tubing should be labeled and timed when changed. It also indicated Yankauer should be changed every day if used and should be labeled and timed when changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 30 of 30