Health inspection·December 13, 2024

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure food was appetizing and palatable for three out of three sampled residents (Residents 42, 33, and 208). This failure put the residents at risk for decreased food intake and decline in their nutritional status. Residents Affected - Few Findings: A review of Resident 42's face sheet (demographics) indicated she was admitted to the facility on [DATE] with a diagnoses of Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Chronic Pain Syndrome (CPS, persistent pain that last longer than 3 months) and Anemia (a condition where the body does not have enough healthy red blood cells). Resident 42's Brief Interview for Mental Status (BIMS, a short cognitive screening test used to assess a patient's mental status) score dated 11/1/24 was 14 over 15 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 33's face sheet indicated an admission date to the facility of 5/5/24 with a diagnoses of Dysphagia (difficulty swallowing), Essential Hypertension (high blood pressure) and Hyperlipidemia (HLP, a condition in which there are high levels of fat particles (lipids) in the blood). A review of Resident 208's face sheet indicated an admission date to the facility of 12/10/24 with a diagnoses of Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), Anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Cellulitis (a skin infection that causes swelling and redness). A review of the facility menu for lunch dated 12/11/24 indicated the entrée was oven crisp fish. During an interview on 12/11/24 1at 2:25 p.m., Resident 42 stated the fish served for lunch was dry and had no taste. During an interview on 12/11/24 at 1:12 p.m., after tasting the fish oven crisp on the sample meal tray, the Dietary Assistant (DA) agreed the fish oven crisp fish was dry and did not have a lot of taste. During an interview on 12/11/24 at 3:08 p.m., Resident 208 stated she took a bite of the fish and did not like it. Resident 208 stated the fish was dry and had no taste. During an interview on 12/11/24 at 3:17 p.m., Resident 33 stated he did not like the fish because it was too dry, was chewy and had no taste. During an interview on 12/12/24 at 2:51 p.m., the Registered Dietician (RD) stated she knew there was an issue with the fish that was served last Wednesday, 12/11/24, about being dry. The RD stated it was difficult to keep the fish moist due to it being thinly sliced. The RD stated if the fish was not moist, there was a risk resident might not eat it which could result to poor food intake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055412 If continuation sheet Page 2 of 5 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 055412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Ranch Post Acute 101 S Orchard Ave Vacaville, CA 95688 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 0804 Level of Harm - Minimal harm or potential for actual harm A review of the facility policy and procedure (P&P) titled Food Preparation, Healthcare Menus Direct 2023, the P&P indicated, .the food shall be prepared by methods that conserve nutritive value, flavor and appearance .prepared food will be sampled. The food and nutrition services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055412 If continuation sheet Page 3 of 5 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 055412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Ranch Post Acute 101 S Orchard Ave Vacaville, CA 95688 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record reviews, the facility failed to ensure: 1.Food items inside the refrigerator in the facility kitchen were labeled, open dated and had a use by date. These failures could lead to misidentification of food item and a potential for food borne illness (food poisoning) from consuming expired or spoiled items. 2.The utensils were stored in a sanitary condition when the drawers where utensils were stored were dirty with food crumbs and other residue from preparing food. This failure could result to cross contamination and the spread of bacteria. 3.A contaminated food item was not discarded properly. This failure could lead to consumption of unsafe food, diseases, and food borne illnesses. Findings: 1.During a concurrent observation and interview on 12/9/24 at 10:35 a.m., and 10:41 a.m., respectively, [NAME] 1 verified in refrigerator #1 the following items with no label and with no open and use-by-date (UBD): -sliced tomatoes -sliced meat in a clear plastic bag -cut up meat in a blue plastic bag - opened packaging containing hash browns that were taken off the original packaging Cook 1 stated items in the refrigerator should be labeled and should have open and UBD to ensure food items were identified properly, ensure freshness, ensure food served to the residents were not spoiled, and food items were safe for residents' consumption. During a concurrent observation and interview on 12/9/24 at 10:45 a.m., [NAME] 1 verified the carton of soy milk in refrigerator # 5 did not have an opened and used by date. [NAME] 1 stated the facility policy was to ensure items in the kitchen were clearly labeled, had opened and used by date. [NAME] 1 stated not labeling a food item and not placing an open or use by date on a food item, the facility policy was not followed. During an interview on 12/12/24 at 2:51 p.m., the Registered Dietician (RD) stated it was important to label with an open and use by date on food items to prevent food poisoning and food borne illness. The RD stated if the food item was not properly labeled and did not have an open or use by date, the facility policy was not followed. A review of the undated facility policy and procedure (P&P) Labeling and Dating of Foods, the P&P indicated, .all food items in the storeroom, refrigerator and freezer need to be labeled and dated .newly opened food items will need to be closed and labeled with an open date and use by date . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055412 If continuation sheet Page 4 of 5 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 055412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Ranch Post Acute 101 S Orchard Ave Vacaville, CA 95688 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 2.During a concurrent observation and interview on 12/9/24 at 10:52 a.m., [NAME] 1 verified drawer # 2, (drawer where utensils were stored) had a cooked macaroni noodle and was dirty. [NAME] 1 stated drawers should be clean and free of food debris because it could attract pests. [NAME] 1 stated pest droppings could make residents sick with infection, diarrhea (loose, watery stools that occur more frequently than usual) or stomach problems. Residents Affected - Some During an interview on 12/12/24 at 2:51 p.m., the RD stated it was important to ensure kitchen and utensils were clean to ensure residents do not get sick from cross contamination. The facility did not have policy specific for cleaning the storage for utensils. 3.During a concurrent observation and interview on 12/11/24 at 10:53 a.m., [NAME] 1 was prepping to cook brown rice and poured the brown rice into the greased pan. [NAME] 1 was observed to pour the brown rice back into the brown rice container. [NAME] 1 stated she should have discarded the brown rice instead of pouring it back into the rice container. [NAME] 1 acknowledged it was a mistake pouring the brown rice back in the rice container. During an interview on 12/12/24 at 2:51 p.m., the RD stated it was not acceptable to put back the brown rice in the container after it was already poured into a pan greased with oil. The RD stated [NAME] 1's action was a risk for cross contamination. The RD stated it was also a concern for allergy. The facility did not have policy specific for discarding contaminated food items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055412 If continuation sheet Page 5 of 5