Health inspection·March 13, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 3/10/25 at 9:04 a.m. with the Social Services Assistant (SSA), the SSA verified the curtain did not reach around residents space and a vertical blind was missing, so that Resident 108 and Resident 53 did not have complete privacy. During an interview on 3/10/25 at 10:58 a.m. with Resident 53, Resident 53 stated, That missing slat bothers me. I've mentioned it several times [to staff]. I don't know why they haven't replaced it .You can see directly into [Resident 108 and Resident 53's] room from across the patio from another room. I've seen it [from another room across the courtyard]. Resident 1 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had moderate impairment of her memory. During a review of Resident 1's CP, titled ALTERATION IN ELIMINATION .ADL support for .toileting ., dated 1/17/25, the CP indicated Provide privacy . During a concurrent observation and interview on 3/10/25 at 9:30 a.m. with Resident 1, a slat was missing from the vertical blinds covering a window. Resident 1 stated, At night I don't like it because I think people are spying on me. I've seen people out there [on the patio] . Resident 10 was admitted to the facility in the fall of 2024 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 10's CP titled ALTERATION IN ELIMINATION .ADL support for .toileting ., dated 11/26/24, the CP indicated Provide privacy . During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident had severe memory impairment. During an observation on 3/10/25 at 9:58 a.m. Resident 10 was observed from the doorway of the bedroom while she was being changed. The privacy curtain was pulled forward on both sides but at the foot of the bed, the resident's perineal [the bottom region of your pelvic cavity] area was visible from the doorway. Resident 20's back, buttocks and perineal area were exposed. During a concurrent observation and interview on 3/10/25 at 10:01 a.m. with Certified Nurse's Assistant (CNA)1, CNA 1 acknowledged Resident 10 's bottom was exposed, yet CNA 1 continued to change Resident 10 without pulling the moveable curtain (available at the foot of a roommate's bed), as other people walked in the hallway past the open doorway of Resident 10's room. CNA 1 indicated the curtain was for use to provide privacy for each of the three residents in the room and verified it could be pulled across the foot of each bed. CNA 1 stated she didn't want to bother [to pull it across] because it got her roommate, upset when you move her stuff around. During an interview on 3/11/25 at 9:09 a.m. with Resident 10, Resident 10 was asked how the exposure made her feel. Resident 10 indicated she felt ashamed when people saw her being changed and wanted privacy. Resident 10 also indicated the staff only used the two side curtains. They did not cover the foot of the bed when they changed her. Resident 10 indicated even her roommates saw her when [staff] did not pull the curtains at the foot of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 2 of 8 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 03/13/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/10/25 at 10:22 a.m. with the Administrator (ADM), the ADM stated his expectations for privacy was, Residents should be given privacy when being changed or cared for. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON stated, Curtains should be pulled all the way around for privacy. Residents Affected - Some During a review of the Maintenance Log (ML), dated 1/25, 2/25 and 3/25, no entry was found for repair of the curtains or blinds in the rooms of Residents 108, Resident 53, or Resident 1. During a review of the facility policy and procedure (P&P), dated 2/24, the P&P indicated, 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, feeling of self worth and self esteem .promote and protect resident privacy, including bodily privacy during assistance with personal care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 3 of 8 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 03/13/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for one of three sampled residents (Resident 35) when two tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for drug diversion (when healthcare staff obtain and use prescription medicines illegally), and inaccurate monitoring of the amount and frequency of medications given to the resident. Findings: Resident 35 was admitted to the facility in 2019. Current principal diagnosis was acute respiratory failure (when the body does not get enough oxygen or there is too much carbon dioxide in the body). During a review of Resident 35's physician orders (PO) dated 3/13/25, the PO indicated, Percocet (oxycodone-acetaminophen, medications used to relieve pain) Oral Tablet 10-325 MG (milligram, unit of measurement, used for medication dosage and/or amount) Give 1 tablet .every 4 hours as needed for .pain. During a review of Resident 35's CONTROLLED DRUG RECORD (CDR), Individual Patient's Narcotic Record (a form that keeps count of the number of narcotics dispensed to a resident), indicated one tablet of Percocet was removed from the medication card (pre-packaged medications dispensed from a pharmacy) on 2/23/25 at 10:06 a.m. and one table of Percocet was removed on 2/27/25 at 6:45 p.m. During a review of Resident 35's MAR dated 2/1/25 - 2/28/25, the MAR did not show documentation of Percocet being administered on 2/23/25 at 10:06 a.m. or on 2/27/25 at 6:45 p.m. There were a total of two Percocet that were signed out from the narcotic medication card but were not documented as given to Resident 35. During a concurrent interview and record review on 3/13/25 at 10:39 a.m. with the Director of Nursing (DON) of Resident 35's records, the DON confirmed the CDR documentation did not match the MAR documentation. The DON confirmed there was no way of knowing if narcotics were given to Resident 35, and it should have been documented in the residents MAR if given. During a review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, dated 2001, the P&P indicated, Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 4 of 8 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 03/13/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 34) received a thorough monthly pharmacy medication regimen review (MRR). Residents Affected - Few This failure placed Resident 34 at risk for receiving unnecessary, ineffective, and/or excessive dose of Lorazepam (a psychotropic medication to treat anxiety). Findings: Resident 34 was admitted to the facility with diagnoses including thickening and hardening of the walls of the arteries in the brain and anxiety disorder. Review of the admission MDS (Minimum Data Set, an assessment tool) indicated the resident scored 5/15 in the BIMS (Brief Interview for Mental Status, a cognitive assessment) which suggested he had severe cognitive impairment. Review of Resident 34's medical record indicated the resident had a physician order, dated 5/31/24, for Lorazepam 0.5 MG (milligram) to give 1 tablet by mouth every 6 hours as needed for anxiety for 14 day(s). There was no physician order to renew Lorazepam 0.5mg 14 days after the 5/31/24 order until 10/12/24. Review of the Medication Administration Record (MAR) from May 2024 through October 2024 indicated Resident 34 received Lorazepam 0.5 mg until 10/3/24. During a concurrent interview and records review on 3/12/25 at 9 a.m., with the Director of Nursing (DON), the DON confirmed that as needed Lorazepam 0.5mg was ordered on 5/31/24 for a 14-day period, but it continued to be administered until 10/3/2024 for Resident 34 without a physician order for continuation. The DON also verified there had been no monthly MRR for Resident 34 from May 2024 through December 2024 and acknowledged the irregularities in Lorazepam administration could have been identified by the pharmacist, had the MMR been performed. In a telephone interview on 3/12/2025 at 2:12 p.m., with the Pharmacy Consultant (PC), the PC confirmed the monthly MRR was not provided for Resident 34 from May 2024 through October 2024 and acknowledged MRR should have been provided monthly. The PC stated, It [Lorazepam 0.5 mg] was ordered for 14 days, my understanding is that when it's written that way it should automatically stop [after 14 days]. During a review of the Facility's May 2019 policy and procedure (P&P), Medication Regimen Reviews, indicated, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .the Consultant Pharmacist provides a written report to the attending physicians .the report contains .d. The pharmacist's recommendation. During a review of the facility's P&P titled, Psychotropic Medications Use, dated April 8, 2022, the P&P indicated, .PRN orders for psychotropic drugs are limited to 14 days .Pharmacy will review psychotropic medication usage on admission, monthly, and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 5 of 8 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 03/13/2025 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 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 accurately label medications for a census of 61 when: 1. Resident 54's insulin order was not reflected correctly on the medication label, and 2. The medications lacked resident labels and open dates, and the label was unclear and difficult to read. These failures had the potential for residents to receive the wrong medications, incorrect dosages of medications, and expired medications. Findings: 1. During a concurrent observation and interview on 3/11/25 at 8:55 a.m. during medication administration with Licensed Nurse ( LN 1), LN 1 administered 14 units (unit of measurement) of Humulin N (is an intermediate-acting insulin given to help control blood sugar levels in people with diabetes [a chronic condition that affects the way the body processes blood sugar]) 100Units/ml (milliliter, unit of measurement) to Resident 54. The resident's medication label both on the box, and the vial indicated inject 10 units . LN 1 verified in Resident 54's Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident) included the physician order for Humulin N 14 units every morning and 14 units every night. LN 1 confirmed that Resident 54 had a change to their medication dosage and that it was not correctly reflected on Resident 54's medication label. During an interview on 3/13/25 at 10:46 a.m. with the Director of Nursing (DON), the DON was asked what the expectations were for labeling medications with a change in order. The DON stated, If the order changes, per policy, we need to place a sticker, 'change in direction', that will be put on the medication. The DON stated that the pharmacist should be called for a new, accurate resident label and that the label would be delivered during the scheduled delivery time. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated 2001, the P&P indicated, Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy .Labels for individual resident medications include all necessary information such as .cautionary statements .The nursing staff must inform the pharmacy of any changes in physician orders for a medication . 2. A concurrent observation and interview on 3/11/25 at 2:23 p.m. with LN 1, one of two medication storage carts was inspected. During the observation, one bottle of Biktarvy (a medication to treat human immunodeficiency virus [HIV]) 50 mg/200 mg/25 mg (milligram, unit of measurement), two Breyna Inhalation Aerosol (inhaler, a medication that is delivered in a fine mist and inhaled through the mouth and into the lungs) 160 mcg/4.5 mcg(microgram, unit of measurement), and one unidentifiable inhalation aerosol were found with no resident labels. One Symbicort Inhalation Aerosol 160 mcg/4.5 mcg was found with an resident label that was difficult to read. Two Anoro Ellipta Inhalation Powder (a dry, powdered form of medication that is inhaled into the lungs) 62.5 mcg/25 mcg, and one bottle of Lidocaine Viscous 2% Oral Topical Solution (a medication used to treat pain in the mouth or throat) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 6 of 8 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 03/13/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were found without open dates. LN 1 confirmed that the three inhalation aerosols and the Biktarvy were missing resident labels and Lidocaine and inhalation powder had no open dates, and one label on an inhalation aerosol were difficult to read. During an interview on 3/13/25 at 10:46 a.m. with the DON, the DON was asked what the expectations were regarding illegible labels, open date labeling, and medications with no resident label. The DON stated that you should be able to read the label. The DON confirmed that the label on the inhaler was difficult to read and needed to be replaced. The DON stated that if a medication was not labeled, the pharmacy needed to be contacted and the medication to be verified with the pharmacy. Further stating, The medication should be sent to the pharmacy for confirmation, and to be properly labeled. The DON stated once a medication was opened, an open date needed to be labeled on the medication. The DON confirmed that there were no open dates on the Lidocaine and both inhalation powders, and that she expected them to be discarded. The DON confirmed that the three inhalation aerosols had no resident labels. During a review of the facility's P&P titled, Labeling of Medication Containers, dated 2001, the P&P indicated, Medication labels must be legible at all times .Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. During a review of the facility's P&P titled, Storage of Medications, dated 2001, the P&P indicated, Drug containers that have missing, incomplete, improper or incorrect labels are returned to the pharmacy for proper labeling before storing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 7 of 8 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 03/13/2025 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 Based on observation, interview and record review, the facility failed to ensure infection prevention and control program were maintained and to provide a sanitary environment when two lounge chairs in the dining/activity room were worn out, threadbare and available for resident use. This failure increased the risk for the transmission of communicable diseases. Residents Affected - Few Findings: During an observation on 3/10/25 at 12:03 p.m., two large wing-back lounge chairs made of imitation leather were badly worn with mesh and foam showing through and available for use in the dining/activity room for use. Resident 51 was seen moving between and sitting in both lounge chairs. During a concurrent observation and interview on 3/10/25 at 12:05 p.m. with the Infection Preventionist (IP), the IP verified observation and stated, The lounge chairs used to be covered in leather. [The material] appears to be man made with the fabric lining and foam showing through. It can't be sanitized properly due to the mesh fabric. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON was asked her expectations and stated, When the furniture is worn, we need to replace because it [because we] can't sanitize it. During an interview on 3/13/25 at 10:03 a.m. with the Maintenance Supervisor (MS), the MS was asked if the worn lounge chairs had been put in the maintenance log and he stated, No one reported the two lounge chairs upholstery was deteriorating . During a further interview on 3/13/25 at 10:56 a.m. with the IP, the IP said, We were aware [of the deterioration of the lounge chairs] . The IP also indicated that multiple residents used the lounge chairs. During a review of the Maintenance Log, dated 1/25, 2/25 and 3/25, no request for repair or replacement of the two worn lounge chairs was found. During a review of the facility policy and procedure (P&P), titled Infection Control, revised 10/24, the P&P indicated The objectives of our infection control policies and practices are to .Prevent .infections in the facility .Maintain a .sanitary .environment for .residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 8 of 8