Health inspection·September 12, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and interviews, it was determined the facility failed to ensure privacy of clinical information for one of 23 sampled residents (Resident (R) 41). This failure had the potential for other residents' clinical information to not be kept private. Residents Affected - Few Findings include: Review of R41's paper-based admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included a colostomy (a surgical procedure diverting the colon to an opening in the abdomen where fecal material is collected in a bag). Review of the Minimum Data Set (MDS) admission MDS with an Assessment Reference Date (ARD) of 09/10/18 revealed the resident required extensive assistance for activities of daily living, including the care of the colostomy. On 09/09/19 at 12:50 PM, a sign was observed over R41's bed that listed the supplies needed to provide care to the colostomy site. During an observation on 09/09/19 at 4:30 PM, the Director of Nursing (DON) verified that the sign over the bed revealed that R41 had a colostomy. The DON verified that this information was visible to other residents, visitors, and staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 2 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, it was determined the facility failed to ensure a clean and homelike environment for 14 rooms out of 26 sampled resident rooms. This failure had the potential for other resident rooms to not be maintained in a clean and homelike manner. Findings include: The following observations were made during an environmental tour with the maintenance supervisor on 09/12/19 that began at 2:45 PM and concluded at 3:25 PM. During this tour the maintenance supervisor confirmed these observations in an interview. 1. Observations of room [ROOM NUMBER] revealed the base of the bathroom door was scratched and scraped. Dirt build up was around the perimeter of the bathroom floor. 2. Observations of room [ROOM NUMBER] revealed the walls in the room and bathroom were scratched and patched. The floors in the bathroom and room were dirty and stained. 3. Observations of room [ROOM NUMBER] revealed the sliding glass doors in the room had a dirty, smeared window and a screen with a build-up of dirt. The bathroom door was scraped and chipped. The floor and walls in the room were dented, scraped, and stained. 4. Observations of room [ROOM NUMBER] revealed the sliding glass door was smeared with dirt and the screen had a build-up dust and had small holes in it. The floor and walls in the room were scratched, scraped and stained. 5. Observations of room [ROOM NUMBER] revealed the wall under the television was marked and scarred. The floors were dirty and stained. 6. Observations of room [ROOM NUMBER] revealed the base of the wall under the window was scarred and marked up. The wall in the center of the room under the television was scarred and marked. 7. Observations of room [ROOM NUMBER] revealed the sliding glass doors in the room had smeared dirt on the window and a build-up of dirt on the screen. The bathroom door was scraped and chipped. The floor and walls in the room were dented, scraped, and stained. 8. Observations of room [ROOM NUMBER] revealed that the bottom right edge of the door was scarred and chipped. The walls had areas of an unknown dried substance that was brown in color. 9. Observations in room [ROOM NUMBER] revealed the room floor and bathroom floor were dirty and stained. The room and bathroom walls were scratched, scraped, dirty, and patched. 10. Observations of room [ROOM NUMBER] revealed the over bed table was soiled with a large amount of an unknown dried brown substance. The floors in the room and bathroom were dirty, scratched, and stained. The door frames were scratched, peeling, and splintered in the bathroom and room. There was a hole on the outside surface of the bathroom door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 3 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 11. Observations of room [ROOM NUMBER] revealed the floors and walls were dirty, scratched, stained, and scraped. A piece of the floor molding was coming off. The sliding doors had dirty smeared glass and a build-up of dirt on the screen. 12. Observations of room [ROOM NUMBER] revealed the floors and walls in the room and bathroom were dirty, scratched, and stained. The baseboard was loose. The door frames were scratched, peeling, and splintered in the bathroom and room. The floor mat next to the resident who lived in C bed was dirty and torn. The overbed table near the C bed was dirty and had pieces of the table broken off. Event ID: Facility ID: 055222 If continuation sheet Page 4 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy, it was determined the facility failed to ensure an injury of unknown origin was investigated for one of 23 sampled residents (Resident (R) 25). This failure had the potential for other injuries of unknown origin to not be investigated. Residents Affected - Few Findings include: Review of R25's paper-based medical admission Record indicated the resident was admitted on [DATE] with diagnoses that included dementia. Review of the paper-based medical record revealed an SBAR (a nurse's note) dated 07/14/19 documenting a noted skin discoloration to the left superior orbital rim (upper lid crease). Review of the paper-based Minimum Data Set (MDS) annual assessment, dated 07/19/19, revealed the Brief Interview for Mental Status (BIMS) scored a three of 15, which indicated severe cognitive impairment. R25 was unable to express an accurate account of what occurred at the time the discoloration was identified. During an interview on 09/09/19 at 9:50 AM, the resident was confused and was unable to answer questions about the discoloration to the eye identified on 07/14/19. An interview with the Director of Nursing (DON) on 09/11/19 at 1:20 PM revealed there was no investigation completed when the resident was discovered with the discoloration of his eyelid. Review of the facility's abuse policy, revised September 2017, revealed injuries of unknown source were injuries that were not observed by anyone and the injury was located in an area not generally vulnerable to injury. The abuse policy stated that injuries of unknown origin are to be investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 5 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to ensure two of 23 sampled residents (Residents (R) 37 and R26) were positioned so they would be able to eat meals independently. This failure has the potential for other residents to not be positioned for independent dining. Residents Affected - Few Findings include: 1. Review of the paper-based medical record admission Record revealed R37 was re-admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and muscle weakness. Review of the paper Minimum Data Set (MDS) quarterly assessment, with an Assessment Reference Date (ARD) of 08/07/19, revealed the Brief Interview for Mental Status (BIMS) score was 11 of 15, which indicated a moderate amount of cognitive impairment. The assessment revealed the resident required supervision and setup help for meals. Review of the care plan, initiated 09/28/18, revealed the resident had a performance deficit with activities of daily living (ADL) related to muscle weakness, flaccid hemiplegia (loss of muscle movement), and cerebrovascular disease. The interventions included the resident was able to feed himself after setup for meals. On 09/09/19 at 1:15 PM, R37 was observed in his room trying to eat his lunch that was on a tray on the over bed table. The table was not positioned in front of the resident who was in his wheelchair. His left arm was flaccid on his lap. The resident stated he was having difficulty eating his lunch. The surveyor requested the Certified Nurse Aide (CNA)31 position the resident's lunch tray so he would be able to eat his meal. CNA31 verified in an interview on 09/09/19 at 1:15 PM the resident was having difficulty eating lunch because of the position of the tray. On 09/10/19 at 12:55 PM, R37 was observed in the wheelchair in his room attempting to eat lunch. The over bed table with his lunch tray was not positioned so the resident would be able to eat his lunch easily. The resident's left arm was flaccid on his lap and he was only able to use his right hand. CNA5 was requested to position the resident's lunch tray so he could reach and eat his lunch. CNA5 verified in an interview on 09/10/19 at 12:55 PM the lunch tray was not positioned to promote independent dining. 2. Review of the paper-based medical record admission Record revealed R26 was admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of the liver. Review of the paper MDS quarterly assessment, with an ARD of 07/23/19, revealed a BIMS score of 12 of 15, which indicated no cognitive impairment. The assessment revealed the resident required supervision and setup help for meals. Review of the self-care deficit care plan, initiated 11/16/18, revealed R26 had a deficit related to cirrhosis of the liver and movement disorder and required assistance with bed mobility. On 09/09/19 at 1:12 PM, R26 was observed in his bed. Two CNAs were observed putting the head of his bed up and setting up his tray. The resident was observed attempting to eat lunch. He was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 6 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 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 0676 Level of Harm - Minimal harm or potential for actual harm positioned high enough in the bed to enable him to eat independently. R26 stated it was difficult for him to eat. The CNAs were requested to reposition the resident so he would be able to eat independently. The CNAs repositioned the resident in bed and he was able to eat his lunch. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 7 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to provide assistance with meals to two of 23 sampled residents (Resident (R) 13 and R51). This failure had the potential for other residents to not receive assistance with dining. Residents Affected - Few Findings include: 1. Review of the paper medical record admission Record revealed R13 was admitted to the facility on [DATE] with diagnoses that dysphagia (difficulty swallowing). Further review of the paper medical record Nutrition Evaluation Form, dated 11/02/18, revealed R13 had chewing and swallowing difficulties related to dysphagia. The care plan, updated 02/11/19, revealed R13 required extensive assistance of one staff person for eating. Review of the paper Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 06/26/19 indicated that R13 required extensive assistance for bed mobility and eating. During an interview on 09/09/19 at 12:30 PM, Certified Nurse Aide (CNA) 11 stated that R13 required extensive supervision during meals due to her behavior of trying to get up from the chair. CNA11 stated that R13 usually ate her meals in her room but was brought to the dining room on weekends for more assistance with meals. 2. Review of the paper medical record admission Record revealed R51 was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. Further review of the paper medical record nutrition care plan, updated 07/03/19, revealed the resident was on required extra time to eat and needed assistance that included cueing. Observation on 09/09/19 at 1:00 PM, revealed R51 was sitting up in the wheelchair in her room with her lunch still in front of her since it was delivered at 12:30 PM. CNA28 was sitting next to the head of the bed of R2. He stated he was doing one on one with R2 who was sleeping in bed. R51 was seated next to CNA28 in the wheelchair eating the pureed lunch that was delivered at 12:30 PM. She was eating the pureed meal with her fingers. CNA28 stated R51 took a long time to eat. R51 was asked if she needed help eating and she said yes. CNA28 sat and fed the resident while the surveyor was in the room. Further observation on 09/09/19 at 1:15 PM, revealed R51's lunch tray had been removed. The Licensed Vocational Nurse (LVN) 57 checked the resident's tray which was returned to the cart and verified there was 75% of the resident's lunch that still remained on the dish. Observation on 09/10/19 at 12:05 PM, revealed R51 being assisted during her meal in the dining room. R51 took a long time to eat but ate most of the meal with the help of the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 8 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, it was determined the facility failed to provide one of one resident reviewed for risk of elopement (Resident (R) 2), 1:1 supervision in the sample of 23 residents. This failure had the potential of residents to not receive supervision for the risk of elopement. Findings include: Review the paper-based admission Record revealed R2 was admitted on [DATE] with diagnoses that included dementia and anxiety. Review of the risk of injury related to wandering care plan, dated 09/04/19, revealed R2 required 1:1 supervision. Review of a nursing staffing assignment sign-in sheet dated 09/09/19 and 09/10/19 revealed staff was continuously assigned to the resident from 7:30 AM to 7:30 PM. The staff was assigned to check the resident every hour on night shift. Review of the paper Minimum Data Set (MDS) annual assessment, with an Assessment Refence Date (ARD) of 08/21/19, revealed a Brief Interview of Mental Status (BIMS) score of three out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had wandering behavior four to six days of the assessment period. On 09/09/19 at 1:00 PM, R2 was observed lying in bed with Certified Nurse Aide (CNA)28 sitting next to her bed. CNA28 stated he was doing one to one supervision because the resident had a history of eloping. On 09/10/19 at 1:00 PM, R2 was observed walking through the halls of the facility without any staff with her. She was observed walking into the nurses' station. On 09/11/19 at 10:50 AM, R2 was observed sleeping in bed without any staff present. At the time of the observation, the Director of Nursing (DON) verified there was no staff with R2. During an interview on 09/11/19 at 10:50 AM, the DON verified that staff were to provide one to one supervision from 7:30 AM to 7:30 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 9 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to assess one of 23 sampled residents (Resident (R) 57) for bladder incontinence. This failure had the potential for residents not to be assessed for bladder incontinence and to not receive care to improve bladder function. Findings include: Review of the paper-based admission Record revealed R57 was admitted on [DATE] with diagnoses that included an infection following a surgical procedure and a urinary tract infection (UTI). Review of the paper 48-Hour Baseline Plan of Care Form, dated 08/15/19, revealed R57 required extensive assistance for toileting. The plan revealed the resident was incontinent (loss of bladder control). Review of the paper-based medical record Bladder Evaluation, dated 08/15/19, revealed R57 had Urge Incontinence (sudden loss of bladder control). The evaluation was not complete and did not include the treatment options to address the incontinence. Review of the paper-based Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/19, revealed a Brief Interview for Mental Status (BIMS) score of ten out of a possible 15, indicating moderate cognitive impairment. The resident was totally dependent of two or more people for bed mobility, toilet use, personal hygiene and bathing. The assessment revealed the resident was frequently incontinent of urine. Review of the care plan, dated 08/15/19, regarding incontinence of bladder included an intervention to check and change the adult brief every two hours and as needed for incontinence. This care plan did not include interventions to attempt improvement in bladder function. During an interview on 09/12/19 at 2:00 PM, the Director of Nursing (DON) verified the incontinence evaluation was incomplete and did not determine interventions appropriate to ensure an attempt to maintain and improve bladder function. The DON stated the expectation was to complete the bladder evaluation and implement the appropriate plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 10 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations and staff interview, it was determined the facility failed to post the nursing staff's total hours worked for the residents and visitors to read. The facility's failure to post the facility's total hours worked by nursing staff has the potential to report inaccurate information to the residents and visitors. Residents Affected - Many Findings include: Observation of the staff posting at the main entrance of the facility revealed the total hours worked by the nursing staff was blank for the day, evening, and night shifts for 09/09/19 and 09/10/19. During an interview on 09/11/19 at 3:00 PM, Staff 1 confirmed the posting on 09/09/19 and 09/10/19 did not include the hours worked by the nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 11 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, interviews, and review of the facility's policy, it was determined the facility failed to ensure contact isolation precautions were implemented and failed to prescribe an effective antibiotic for a urinary tract infection for one of eight residents reviewed for isolation (Resident (R) 57) in 23 sampled residents. This failure of staff not following contact precautions had the potential for spread of infections to other vulnerable residents. Residents Affected - Few Findings include: Review of the paper-based admission Record revealed R57 was admitted to the facility on [DATE] with diagnoses that included an infection following a surgical procedure and a urinary tract infection (UTI). Review of the paper 48-Hour Baseline Plan of Care Form, dated 08/15/19, revealed the resident was to be on contact precautions for the right hip wound and the UTI. Contact isolation precautions are used for infections that are spread by touching. Healthcare workers should wear a gown and gloves while providing care. Further review of the baseline care plan revealed R57 required extensive assistance for toileting and was incontinent of bladder. The Care Directive Form, dated 08/15/19, revealed the resident was on contact precautions for a UTI and wound infection. Review of the paper-based Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/19, indicated R57 was totally dependent of two or more people for bed mobility, toilet use, personal hygiene, and bathing. This MDS indicated R57 was frequently incontinent of urine. On 09/09/19 at 9:55 AM, R57 was observed in bed. Certified Nurse Aide (CNA)31 was with the resident and stated she just completed morning care. CNA31 had on no protective equipment other than gloves. CNA31 stated she was unaware the resident was on contact precaution for the UTI. CNA31 confirmed she changed the incontinent brief using gloves only. During an interview on 09/09/19 at 4:15 PM, the Director of Staff Development (DSD) and the Director of Nursing (DON) verified the urine culture, dated 08/09/19, was positive for Vancomycin Resistant Enterococcus (VRE-an infectious bacterium resistant to antibiotics). The laboratory results also indicated the right hip surgical wound drainage was positive for a Multidrug Resistant Organism (MDRO-infectious bacteria resistant to antibiotics). The DSD and DON verified the resident was not on contact isolation precautions despite having drug resistant infections that can be spread by exposure to body fluids such as urine and wound drainage. During an interview on 09/11/19 at 2:30 PM, the DSD stated that the antibiotic R57 was receiving effective against the MDRO but not the VRE in the urine. The DSD stated new orders were received from the physician to get another urine culture to determine if R57 still had a UTI and to continue the contact isolation until the results were returned. Review of the facility policy Transmission-Based Precautions (Isolation), dated May 2015, revealed transmission-based precautions were used whenever measures more stringent than standard precautions were needed to prevent or control the spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 12 of 13 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 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observations and interviews, it was determined the facility failed to ensure there was adequate space in the dining room for two of 23 sampled residents (Resident (R) 7 and R57). This failure had the potential for residents who preferred to eat in the dining room, but space could not accommodate them. Findings include: Continuous observations made on 09/09/19 from 11:55 AM to 12:05 PM revealed six residents in the main dining room. During an interview on 09/09/19 at 12:30 PM, CNA11 stated that not all residents were taken to the main dining room due to the size of the room. She verified there were six residents eating in the main dining room. During an interview on 09/09/19 at 1:15 PM, R57 stated he eats all his meals in bed because there isn't enough space in the dining room. During an interview on 09/12/19 at 5:40 PM, R7 revealed he normally ate in his room, he sometimes ate in the dining area but felt the space was limited. Observation on 09/10/19 at 12:00 PM, revealed 11 residents in the main dining room eating lunch. There was seating available for three more residents. Observation on 09/11/19 at 12:10 PM, revealed ten residents in the main dining room. There were five tables in the main dining room. At 12:15 PM, while in the main dining room, an interview with the Administrator confirmed there would only be enough room for about three more people to eat in the main dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 13 of 13