Health inspection·November 18, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review, on 11/17/21, at 2:30 p.m., the Director of Nursing (DON) confirmed no care plan for dementia was done, but was revised on 11/17/21 at 1:52 p.m. When asked regarding the care plan, the DON stated, LNs should have done the care plan . The DON acknowledged and confirmed it was a deficiency. 2. According to the Resident Face Sheet, Resident 51 was admitted in the Fall of 2021 with diagnoses including an anxiety disorder. A review of Resident 51's clinical record included the following documents: An MDS, dated [DATE], described the resident as having no memory impairment, scoring 15 out of 15 possible points on the BIMS. The MDS also indicated the resident had an anxiety disorder. A MAR (Medication Administration Record), dated 11/21, indicated the resident had an order, dated 11/2/21, for alprazolam (an antianxiety medication), 0.25 mg (milligram, a unit of measurement) tablet, 1 tablet every 8 hours as needed for anxiety M/B (manifested by) the inability to relax for 14 days. According to the MAR, the medication was administered 15 times during the month. The MAR also indicated nursing monitored the resident's number of episodes of anxiety, and Resident 51 had 21 episodes during the month. In an interview, on 11/18/21 at 9:43 a.m., LN 4 confirmed Resident 51's diagnosis of anxiety and stated if she was receiving medication for the anxiety, she should have had a care plan. LN 4 confirmed there was no care plan for the resident's anxiety. In an interview, on 11/18/21 at 11:02 a.m., the DON stated there should have been an anxiety care plan in place for the resident. During a review of facility's policy and procedure (P&P) titled, CARE PLANNING/INTERDISCIPLINARY TEAM CARE PLANNING CONFERENCE, dated September 2012, the P&P indicated, To assure that all residents care needs are identified .those needs are care planned with corresponding .objectives and . interventions .All residents will have a comprehensive care plan to meet their individual needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 2 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to accurately and safely provide or obtain pharmaceutical services when medications were obtained from the pharmacy without the proper expiration dates and expired medications were not removed and destroyed according to facility policy. These failures increased the potential for administration of expired medications to residents. Findings: During a concurrent inspection of Medication Storage Room A and interview with Licensed Nurse (LN) 1 and 5, on 11/15/21 at 11:55 a.m., an expired vial of insulin (medication used to treat high sugar level in blood) was available with an open date of 10/13/21 (vials must be discarded 28 days after being opened per product box), a used box of oral fluticasone and salmeterol inhalation powder (combination of two medications used to help with breathing) with an incorrect expiration date of 5/1/22 (discard 1 month after removal from foil patch [first use] per product box), a used bottle of atropine eye drop (medication used to relieve pain caused by swelling and inflammation of the eye or to treat drooling) was dispensed by the pharmacy on 3/26/21 with a short expiration date label indicating to discard 60 days after opening with no written open date on the label. LN 1 and 5 both confirmed the insulin vial was expired, the oral inhalation powder had the wrong expiration date on the label, and the eye drops did not have an open date label and were possibly expired. During a phone interview with the facility's Consultant Pharmacist (CP) on 11/16/21 at 11:04 a.m., the CP stated the pharmacy should supply the correct expiration dates for eye drops, oral inhalers, and insulin products and the facility nurses should follow the facility's pharmacy policies. During an interview with Director of Nursing (DON) on 11/16/21 at 11:45 a.m. the DON acknowledged that expired medications had not been removed from the medication storage cart by licensed nursing staff in accordance with facility policy. The DON stated the staff needed more training and in-house services to know what expiration date to use for insulin, eyedrops, and oral inhalers. A review of the facility policy titled, Medication Administration, IIB-1 Specific Procedures for All Medications, effective date March 2018, indicated, .check expiration date on package/container. When opening a multi-dose container of a drug whose expiration date shortens on opening, place the date on the container. A review of facility policy titled, Section I: General Policies and Procedures, effective March 2018, indicated, .Outdated, contaminated or deteriorated medications .are immediately removed from the stock, disposed of according to procedures for medication disposal .The facility must label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and expiration date .drugs shall not be kept in stock after the expiration date on the label . A review of pharmacy policy titled, Dating of Containers When Opened, effective March 2018, indicated, Some medications require the container to be dated when opened and discarded a number of days after opening as defined by the manufacturer. In some instances the facility's pharmacy will put the expiration date of medications on the prescription label to correspond with the (new) expiration date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 3 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm as if the container was opened. This date will be based on the dispensing date of the medication and be XX day after dispensing .Eye Drops dispensed by the facility's pharmacy will automatically have the shortened expiration date put on the label on the eye drop container. There is no need to put a date opened on eye drops dispensed by the facility's pharmacy. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 4 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to implement their medication storage policies and procedures when: 1. The medication storage room's door was left opened and the medication refrigerator inside the medication storage room was unlocked. The controlled medications in the medication refrigerator were accessible to unauthorized individuals with the potential for drug diversion; and, 2. Expired medications were not removed and destroyed according to facility policy. These failures increased the potential for administration of expired medications to residents and access by unauthorized personnel to controlled medications. Findings: 1. During a concurrent observation and interview with Licensed Nurse (LN) 5 on 11/15/21 at 11:45 a.m., Medication Room A was observed unlocked with the door wide open. The medication refrigerator in Medication Room A was observed unlocked with four controlled medications (medications with potential for abuse and addiction) stored inside the refrigerator. During an interview with LN 5 on 11/15/21 at 11:55 a.m., LN 5 confirmed that the medication storage room and the medication refrigerator doors were not locked by one of the nurses after the morning medication pass. LN 5 also confirmed that controlled medications were stored in the medication refrigerator and accessible to others. During a phone interview with the facility's Consultant Pharmacist (CP) on 11/16/21 at 11:20 a.m., the CP stated the medication room and the medication refrigerator doors should be closed and locked. During an interview with the Director of Nursing (DON) on 11/16/21 at 11:40 a.m., the DON acknowledged that the doors should be closed and locked all the time. The DON also noted that the nurses did not see the sign on the refrigerator door that said .refrigerator door LOCKED at all TIMES . A review of the facility policy titled, Medication Storage in the Facility, effective date March 2018, indicated, .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access .Schedule II and V controlled medications are stored separately from other medications in a separate area under double lock. A review of facility policy titled, Section I: General Policies and Procedures, effective March 2018, indicated, .In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to keys. 2. During a concurrent inspection of Medication Storage Room A and interview with Licensed Nurse (LN) 1 and 5, on 11/15/21 at 11:55 a.m., an expired vial of insulin (medication used to treat high (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 5 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sugar level in blood) was available with an open date of 10/13/21 (vials must be discarded 28 days after being opened per product box), a used box of oral fluticasone and salmeterol inhalation powder (combination of two medications used to help with breathing) with an incorrect expiration date of 5/1/22 (discard 1 month after removal from foil patch [first use] per product box), a used bottle of atropine eye drop (medication used to relieve pain caused by swelling and inflammation of the eye or to treat drooling) was dispensed by the pharmacy on 3/26/2021 with a short expiration date label indicating to discard 60 days after opening with no written open date on the label. LN 1 and 5 both confirmed the insulin vial was expired, the oral inhalation powder had the wrong expiration date on the label, and the eye drops did not have an open date label and were possibly expired. During a phone interview with facility's Consultant Pharmacist (CP) on 11/16/21 at 11:04 a.m., the CP stated that the pharmacy should supply the correct expiration dates for eye drops, oral inhalers, and insulin products and the facility nurses should follow the facility's pharmacy policies. During an interview with Director of Nurses (DON) on 11/16/21 at 11:45 a.m. the DON acknowledged that expired medications had not been removed from the medication storage cart by licensed nursing staff in accordance with facility policy. The DON stated the staff needed more training and in-house services to know what expiration date to use for insulin, eyedrops, and oral inhalers. A review of the facility policy titled, Medication Administration, IIB-1 Specific Procedures for All Medications effective date March 2018, indicated, .check expiration date on package/container. When opening a multi-dose container of a drug whose expiration date shortens on opening, place the date on the container. A review of facility policy titled, Section I: General Policies and Procedures, effective March 2018, indicated, .Outdated, contaminated or deteriorated medications .are immediately removed from the stock, disposed of according to procedures for medication disposal .The facility must label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 6 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for a census of 66 when: Residents Affected - Few 1. A container of hardboiled eggs was unlabeled and undated; 2. A 5 lb (pounds, a unit of measurement) container of ready-made tuna salad was expired; 3. A bag of frozen dinner rolls was opened and undated; and, 4. Two containers of dried goods were stored past their expiration dates. These failures had the potential to cause/spread foodborne illnesses. Findings: 1. During a concurrent observation of the facility's refrigerators and interview with the cook, on 11/15/21 at 8:20 a.m., an unlabeled and undated container with approximately 12 hard-boiled eggs was in the refrigerator. The [NAME] (CK) stated she had opened the package of hard-boiled eggs that morning, had forgotten to label the container, and confirmed it should have been labeled. In an interview, on 11/15/21 at 12:18 p.m., the Food Services Supervisor (FSS) stated she expected all opened refrigerated foods were labeled with an open date. A review of the facility's policy titled, Labeling and Dating of Foods, dated 2020, stipulated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . 2. During a concurrent observation and interview, on 11/15/21 at 8:25 a.m., a 5 lb container of ready-made tuna salad opened on 10/27/21, with a use by date of 11/11/21 was in the refrigerator. The CK agreed it was expired and should have been discarded. In an interview, on 11/15/21 at 8:33 a.m., the FSS stated the ready-made tuna salad was safe for use until its expiration date. The FSS confirmed the tuna salad was expired and should have been discarded. A review of the facility's guideline titled, Refrigerated Storage Guide, dated 2019, indicated the maximum refrigeration time for the tuna salad was 3 days. 3. During a concurrent observation of the facility's freezers, and interview, on 11/15/21 at 8:38 a.m., an opened and unlabeled bag of approximately 30 frozen dinner rolls was in the freezer. The DM confirmed it was not labeled and dated, and stated it should have been. A review of the facility's policy titled, Procedure for Refrigerated Storage, dated 2018, stipulated, Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 7 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 4. During a concurrent observation and interview, on 11/15/21 at 8:55 a.m., a container of approximately 3 lbs of dried black eyed peas with an open date of 1/16/19 was on a shelf in the dry storage area. A container of approximately a 1/2 lb of dried small white beans labeled with an open date of 9/13/20 was also on the shelf. The FSS stated opened dried beans were stored for 1 year. The DM confirmed the beans were past their storage date and should have been discarded. Residents Affected - Few A review of the facility's guideline titled, Dry Goods Storage Guidelines, dated 2018, indicated opened dried beans were to be stored 1 year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 8 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for two of seventeen sampled residents (Resident 47 and Resident 51) when: 1. Resident 47's medical record did not contain a physician order for hospice (palliative - end of life) services and a comprehensive person-centered care plan for dementia (brain disease or injury marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) diagnosis; and, 2. Resident 51's medical record did not contain a comprehensive person-centered care plan for anxiety (a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks, and interfere with daily living) diagnosis. These failures decreased the potential for Resident 47 and Resident 51 receiving necessary care and services. Findings: 1. Resident 47 was re-admitted to the facility in late 2020 with multiple diagnoses, which included dementia and an encounter for palliative care. Resident 47's Minimum Data Sheet (MDS - an assessment tool), dated 10/11/21, indicated a Brief Interview for Mental Status (BIMS -a cognitive assessment tool) score of 4/15 indicating a very severe cognitive impairment. The MDS also indicated Resident 47 was assessed with dementia. During a concurrent observation and interview on 11/15/21, at 9:44 a.m., Resident 47 was lying in bed, looked alert, with flat affect. When asked if she's doing okay, Resident 47 stated, Yes. Resident 47 was not able to provide a meaningful conversation further. During a review of Resident 47's medical record, indicated no documented evidence of a physician order for hospice services and a care plan for dementia. During a concurrent interview and record review, on 11/17/21, at 12 p.m., with Licensed Nurse (LN) 6, Resident 47's medical record indicated no documented evidence of a care plan for dementia. LN 6 stated, [I] couldn't find a specific care plan for dementia [in resident's medical record]. During a concurrent interview and record review on 11/17/21, at 1:30 p.m., with LN 4, Resident 47's medical record indicated no documented evidence of a care plan for dementia. LN 4 stated, No care plan for dementia . During a concurrent interview and record review on 11/17/21, at 2:30 p.m., the Director of Nursing (DON) confirmed no care plan for dementia was done. During a concurrent interview and record review, on 11/17/21, at 5:09 p.m., with LN 5 and Medical Records Director (MRD), LN 5 and MRD acknowledged and confirmed Resident 47's medical record indicated no documented evidence of a physician order for hospice services. LN 5 and MRD stated, Yes, there is no physician order for [Resident 47]. The MRD and LN 5 acknowledged there should have been a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 9 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 0842 facility physician order for hospice services in the medical record. Level of Harm - Minimal harm or potential for actual harm 2. According to the Resident Face Sheet, Resident 51 was admitted in the Fall of 2021 with diagnoses including an anxiety disorder. Residents Affected - Some A review of Resident 51's clinical record included the following documents: A MDS, dated [DATE], described the resident as having no memory impairment, scoring 15/15 points on the BIMS. The MDS also indicated the resident had an anxiety disorder. A MAR (Medication Administration Record), dated 11/21, indicated the resident had an order, dated 11/2/21, for alprazolam (an antianxiety medication), 0.25 mg (milligram, a unit of measurement) tablet, 1 tablet every 8 hours as needed for anxiety M/B (manifested by) the inability to relax for 14 days. In an interview, on 11/18/21 at 9:43 a.m., LN 4 confirmed Resident 51's diagnosis of anxiety and stated if she was receiving medication for the anxiety, she should have a care plan. LN 4 confirmed there was no care plan for the resident's anxiety. In an interview, on 11/18/21 at 11:02 a.m., the DON stated there should have been an anxiety care plan in place for the resident. During a review of a facility's document titled, HEALTH INFORMATION MANAGEMENT GUIDELINES, dated 2015, indicated, .Initiate, facilitate and promote the attainment of high quality content of clinical records in accordance with .appropriate regulations .Assure conformance to statutes, regulations and standards .as they apply to clinical record information . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 10 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 0911 Level of Harm - Potential for minimal harm Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Based on observation and interview, the facility failed to ensure 13 resident rooms accommodated no more than 4 residents per room. Residents Affected - Some This failure had the potential to result in inadequate space for the provision of care. Findings: A variation was applied for and approved under §483.90(e)(1)(i) to accommodate 5 residents per room for 13 rooms (Rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214). The variation was continued after the 10/2019 recertification survey. Observations of these rooms were made throughout the survey . The rooms were uncluttered and residents had adequate space for safe mobility around each bed. Interviews were conducted with residents currently residing in the affected rooms and there were no complaints. The residents verbalized comfort and safety in the rooms. The Department recommends the continuation of the variation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 11 of 12 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, the facility failed to ensure 11 resident rooms (Rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as 145 sq. ft. for a two resident occupancy or 72.5 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of care. Findings: Observations were made throughout the survey of the rooms with two resident occupancy. The space was adequate to store assistive devices in the room (such as wheelchair and/or walker) to facilitate provision of care and needs. Interviews were conducted with available residents currently residing in the affected rooms. The residents verbalized the space was adequate for the provision of care. The Department recommends continuation of the waiver for the above mentioned rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 12 of 12