Health inspection·June 21, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interviews and record reviews, the facility failed to: 1. Ensure staff were aware of whom to report abuse allegations and the timeframe for reporting abuse allegations. 2. Report an abuse allegation timely, when two out of two abuse allegations (Residents 36 and 15's altercation and Resident 221's alleged abuse) were reported more than two hours later after the abuse allegation was made. These failures could lead to ongoing abuse and could result in residents feeling scared, upset, and frustrated. Findings: A review of Resident 36's face sheet (demographics) indicated an admission date of 1/14/21. His diagnoses include bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy and causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), Muscle Weakness and Cerebellar Ataxia (the inability to control voluntary muscle movements, which can cause problems with balance, walking (gait), speech, swallowing). Resident 36's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 4/20/24, score was 13 out of 15, indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). A review of Resident 15's face sheet indicated an admission date of 3/4/24. Her diagnoses included Muscle Weakness, Vascular Dementia (caused by a range of conditions that disrupt blood flow to the brain and affect memory, thinking, and behavior) and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task). Resident 15's BIMS, dated 3/6/24, score was 3, indicating severely impaired cognition. On 3/16/24 at approximately 6:30 p.m., there was an alleged physical altercation between Residents 36 and 15. The SOC 341 (a crucial document designated for reporting suspected abuse of elders and dependent adults in California) was not completed until 3/17/24, and was not reported to the California Department of Public Health (CDPH, the State Department responsible for public health in California), the Ombudsman (a person who investigates and attempts to resolve complaints and problems), and the local Police Department (PD) until 3/17/24. A review of Resident 221's face sheet indicated an admission date of 1/20/20, with a diagnoses of Hypertension (HTN, high BP), Depression (constant feeling of sadness or loss of interest) and Anxiety (feeling of fear, dread or uneasiness). Resident 221's BIMS, dated 1/20/24, score was 1 indicating severely impaired cognition. On 9/1/22 at approximately 2 PM, a family member of Resident 221 reported to the facility that Resident 221 may have been abused. The SOC 341 was not completed until 9/2/22, and was not reported to the CDPH, the Ombudsman, and the local PD until 9/2/22. During an interview on 6/19/24 at 8:59 a.m., the Central Supply/Medical Record Assistant (CS/MRA) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 2 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated abuse allegations should be reported to CDPH, but not all abuse allegations should be reported to the Ombudsman and the local PD. The CS/MRA stated abuse allegations should be reported within 24 hours of knowing about the abuse allegation. The CS/MRA stated an abuse allegation was important to be reported timely for resident safety and to prevent further abuse. During an interview on 6/19/24 at 9:10 a.m., Unlicensed Staff A stated abuse allegations should be reported to the Ombudsman and CDPH. Unlicensed Staff A stated local PD should be notified if the abuse allegation was physical or financial. Unlicensed Staff A stated abuse allegations should be reported to these agencies within four hours after an abuse allegation was made. Unlicensed Staff A stated, if an abuse allegation was not reported timely, the abuse could continue to happen, affect the resident negatively, and trust could be broken between the resident and the staff/facility. During an interview on 6/19/24 at 9:25 a.m., Unlicensed Staff B stated abuse allegations should be reported to the Ombudsman and maybe to the California Highway Patrol (CHP, the police force that has jurisdiction over all state highways). Unlicensed Staff B stated the timeframe of reporting an abuse allegation was within 24 hours of knowing about the abuse. Unlicensed Staff B stated, if an abuse allegation was not reported timely, the abuse could continue, and it became a safety risk for the resident. Unlicensed Staff B stated it could result in a resident feeling uncomfortable. During an interview on 6/19/24 at 9:40 a.m., Licensed Staff C stated abuse allegations should be reported to CDPH, local PD and the Ombudsman within two hours if there was an injury. Licensed Staff C stated abuse allegations that did not result in injury could be reported within 24 hours. Licensed Staff C stated, if an abuse allegation was not reported timely, injury could be worse, could result in death in extreme cases and abuse could continue. Licensed Staff C stated residents could be depressed and scared. During an interview on 6/19/24 at 10:19 a.m., the Infection Preventionist (IP) stated abuse allegations should be reported to the State and Law Enforcement when necessary-within 24 hours of knowing about the abuse allegation. The IP stated, not reporting an abuse allegation timely was a safety issue that could result in recurrence and injury. During an interview on 6/19/24 at 2:19 p.m., the Director of Nursing (DON) stated abuse allegations should be reported within two hours if there was an injury and within 24 hours if the alleged abuse did not cause injury. The DON stated it was important to report abuse allegations timely for residents' safety. During a concurrent interview, SOC 341, dated 3/17/24, and Abuse Investigation and Reporting record review, on 6/20/24 at 9:30 a.m., the Administrator stated abuse allegations should be reported with two hours if there was injury and within 24 hours if there was no injury. The Administrator verified the Abuse Investigation and Reporting policy indicated to report abuse allegations within two hours of discovery. The Administrator verified the abuse allegation reporting between Residents 36 and 15 was reported late. During an interview and SOC 341 record review on 6/20/24 at 1:55 PM, the Administrator and the Regional Director of Operations confirmed Resident 221's incident of alleged abuse was reported on 9/1/22 at 2 p.m., and CDPH was notified on 9/2/22 at 9:37 AM. The Administrator and the Regional Director of Operations also stated the alleged abuse was not reported within the two-hour timeframe as required by the facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 3 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0609 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised 4/2021, the P&P indicated all alleged violations of abuse neglect exploitation or mistreatment will be reported immediately but not later than two hours if the alleged violation involves abuse. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 4 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interviews and record reviews, the facility failed to ensure : 1. Staff were aware of the Baseline Care Plan (BCP, an initial person-centered care plan, completed within 48 hours of admission, that provides instructions for the care of the residents) completion timeframe. 2 .The BCP was completed timely for three out of three sampled residents (Residents 54, 60 and 28). These failures had the potential to lead to delayed or omitted care, missed medications or treatments, medical complications, and deconditioning. Findings: A review of Resident 54's face sheet (demographics) indicated an admission date of 3/21/24. Her diagnoses include Muscle Weakness, Lymphedema (a chronic disease marked by the increased collection of lymphatic fluid in the body, causing swelling) and Dysphagia (difficulty swallowing). A review of Resident 54's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 3/25/24, score was 14 out of 15 indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 54's BCP, dated 3/27/24, was completed late. A review of Resident 60's face sheet indicated an admission date of 5/28/24. His diagnoses include Primary Hypertension (HTN, high blood pressure), Type II Diabetes Mellitus (DM, a disease in which your blood glucose, or blood sugar, levels are too high) and Muscle Weakness. A review of Resident 60's BIMS, dated 6/1/24, score was 13, indicating intact cognition. Resident 60's BCP, dated 6/10/24, was completed late. A review of Resident 28's face sheet indicated an admission date of 3/15/22. His diagnoses include Primary Hypertension (HTN, high blood pressure), Muscle Weakness and Hyperlipidemia (HLP, too many lipids or fats in your blood). A review of Resident 28's BIMS, dated 3/28/24, indicated he had both short term and long-term memory impairment. Resident 28's BCP, dated 3/23/22, was completed late. During an interview on 6/20/24 at 12:45 p.m., the Director of Nursing (DON) stated she would have to check the facility's policy on BCP completion timeframe. During an interview on 6/20/24 12:57 p.m., Licensed Staff D stated the BCP should be completed within three days. Licensed Staff D stated BCP's were important and should be completed timely because it provided staff instruction on how to care for the residents safely. During an interview on 6/20/24 at 1:03 p.m., the Director of Rehabilitation Services (DOR) stated BCP should be completed within 24 to 48 hours. The DOR stated it was important BCP's were completed timely to provide staff a view of care and provide safe care to the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 5 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/20/24 at 1:15 p.m., the Director of Staff Development (DSD) stated BCP's should be completed within 48 to 72 hours. The DSD stated it was important BCP's were completed timely because these would provide information on how to care for the residents safely. During an interview on 6/20/24 at 1:23 p.m., the Social Services Director (SSD) stated she was part of the team that completed BCP's. The SSD stated the facility policy was to complete BCP's within 48 to 72 hours. The SSD stated it was important to complete BCP's timely so staff could provide safe care to the residents. During an interview on 6/21/24 at 9:53 a.m., the Infection Preventionist (IP) stated BCP's should be completed within 48 hours of admission. The IP stated it was important the BCP's were completed timely for residents' safety, because it guided the team on the direction of care that it needed to provide for the resident. A review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, revised 2/2024, the P&P indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 6 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to ensure that three of eight sampled residents, Resident 2, 38, and 51, received care and services that met their physical, mental, and emotional needs, and according to the facility's policy and procedure on answering call lights and repositioning, when these residents had to wait for a long time before they were assisted after pushing their call light buttons to request for assistance from their aides. These failures had the potential to result in skin breakdown, when the residents were left soiled in urine or feces (the material in a bowel movement), or when residents were left in a certain position for a significant amount of time and could also affect their emotional well-being. Residents Affected - Few Findings: A review of Resident 2's MDS (Minimum Data Set- is part of the federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) Section C- Cognitive (Cognitive means relating to the mental process involved in knowing, learning, and understanding things) Patterns, dated 2/22/24, indicated Resident 2 had a BIMS (Brief Interview for Mental Status) score of 14, (BIMS scores: 0-7= severe cognitive impairment; 8-12= moderate cognitive impairment; 13-15= cognition is intact). During an interview on 6/21/24, at 11:13 a.m., with Resident 2, she stated she waited as long as one hour after she pushed her call button on. She stated she pushed her call light button to be repositioned in bed. She stated she had a wall clock hanging on the wall to know how long it was taking for staff to respond to her call light. She stated she would scream for help, so the staff would respond to her call light. A review of Resident 38's MDS Section C, dated 5/11/24, indicated, Resident 38 had a BIMS score of 15, no cognitive impairment. During a concurrent observation and interview on 6/21/24, at 1:41 p.m., with Resident 38, inside her room, she stated she would wait for about ten minutes to about 45 minutes before a CNA (Certified Nursing Assistant) would come and assist her with care. She stated she usually called for assistance to use her BSC (bedside commode) for a bowel movement. She stated the longest she had to wait was about an hour. She stated she knew it was about an hour because she had a wall clock hanging on the wall. This was observed by the Surveyor, the wall clock was working and was showing the right time of the day. When the resident was asked if she had an accident while waiting for assistance to use the BSC for a bowel movement, she stated she did not, but sometimes she stated she had already lost the urgency to have a bowel movement. A review of Resident 51's MDS Section C, dated 4/19/24, indicated, Resident 51 had a BIMS score of 15, no cognitive impairment. During an interview on 6/21/24, at 11:32 a.m., Resident 51 stated one time during the NOC (night) shift, she called for assistance to have incontinence care, and she waited for around 45 minutes to an hour before somebody come to help her. She stated she knew how long she was waiting because she had wall clock hanging on the wall in front of her. During an interview with the facility's Director of Nursing (DON) on 6/21/24, at 12:23 p.m., she stated it was her expectation that residents' call lights were responded to as promptly as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 7 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of a facility policy and procedure (P&P) titled, Answering Call Lights, dated March 2023, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. A review of a facility policy and procedure (P&P) titled, Repositioning, dated 2/2024, indicated under General Guidelines, Repositioning is a common, effective intervention for reducing the risk of skin breakdown, promoting circulation, and providing pressure relief. Event ID: Facility ID: 055499 If continuation sheet Page 8 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure the nurses were following the Physician's Order for pain medication for one out of two sampled residents (Resident 37), when the nurses administered a pain medication that was not appropriate for the pain level Resident 37 was reporting. This failure could result in unrelieved pain, worsened pain, impaired mobility, and residents feeling upset, angry and frustrated. Residents Affected - Some Findings: A review of Resident 37's face sheet (demographics) indicated an admission date of 3/21/24. Her diagnoses include Chronic Pain Syndrome (CPS, a long-standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition), Essential Hypertension (HTN, high blood pressure) and right Tibial fracture (a break in the shinbone). Resident 37's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 4/30/24, score was 15 out of 15 indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). A review of Resident 37's Physician Order Summary (POS, doctor's order including medications, treatments, laboratory tests) for 6/2024, indicated staff to monitor and assess level of pain using the following pain scale (PS, a way to rate or measure your pain): 0=no pain, 1 to 3=mild pain, 4 to 6=moderate pain and 7 to 10=severe pain, with a start date of 3/12/24, and an order for Acetaminophen 325 milligram (mg, a unit of weight) two tablets every six hours as needed for mild pain (1-3 PL), with a start date of 3/12/24. A review of Resident 37's Electronic Medication Administration record (EMAR, used to record drugs administered to patients in a healthcare facility) for 5/2024, indicated Resident 37 had an order for Hydrocodone-Acetaminophen 10-325 milligram (mg, a unit of weight) one tablet every 12 hours as needed for moderate pain, with a start date of 5/24/24. A review of Resident 37's EMAR for 5/2024, indicated she received Hydrocodone Acetaminophen 10-325 mg one tablet every 12 hours as needed for moderate pain (PS 4 to 6 out of 10), when she was reporting severe pain (PS 7 to 10) on these dates: 5/25/24, while her reported PS was 7 out of 10, on 5/27/24, while her reported PS was 7 out of 10, on 5/30/24, while her PS was 8 out of 10, and on 5/31/24, while her reported PS was 7 out of 10. A review of Resident 37's EMAR for 5/2024, indicated she received Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6 out of 10). Resident 37 received this medication on 5/3/24, twice while reporting a PS of 5 out of 10, and 4 of 10, on 5/18/24, while reporting a PS of 5 out of 10, on 5/22/24, with a PS 6 out of 10, on 5/23/24, with a PS 5 out of 10, on 5/24/24, with a PS of 6 out of 10, on 5/31/24, with a PS of 4 out of 10. A review of Resident 37's EMAR for 6/2024, indicated she received Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6 out of 10) on these dates: 6/2/24, while reporting a PS of 4 out of 10, on 6/9/24, while reporting a PS of 4 out of 10, on 6/12/24, while reporting a PS of 6 out of 10, and on 6/13/24, while reporting a PS of 4 out of 10. During a concurrent interview, POS dated 6/2024, EMAR dated 5/20/24, and 6/2024, record review, on 6/20/24 at 2:36 p.m., Licensed Staff D verified staff were using this PS to assess residents' pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 9 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some level: 0=no pain, 1 to 3=mild pain, 4 to 6=moderate pain and 7 to 10=severe pain. Licensed Staff D also verified the EMAR for 5/2024, indicated Resident 37 received the following medications: Hydrocodone Acetaminophen 10-325 mg one tab every 12 hours as needed for moderate pain (PS 4 to 6), when she was reporting severe pain (PS 7 to 10) on these dates: 5/25/24, while her reported PS was 7 out of 10, on 5/27/24, while her reported PS was 7 out of 10, on 5/30/24, while her PS was 8 out of 10, and on 5/31/24, while her reported PS was 7 out of 10; Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6). Licensed Staff D verified Resident 37 received this medication on 5/3/24, twice while reporting a PS of 5 and 4, on 5/18/24, while reporting a PS of 5, on 5/22/24, with a PS 6, on 5/23/24, with a PS 5, on 5/24/24, with a PS of 6, on 5/31/24, with a PS of 4. Licensed Staff D also verified Resident 37's EMAR for 6/2024, indicated she received Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6) on these dates: 6/2/24, while reporting a PS of 4, on 6/9/24, while reporting a PS of 4, on 6/12/24, while reporting a PS of 6, and on 6/13/24, while reporting a PS of 4. Licensed Staff D stated that this information indicated the Physician's Order was not followed. Licensed Staff D stated it was important the Physician's Order was followed to ensure Resident 37 was receiving adequate pain relief. Licensed Staff D stated, if a resident's pain was not relieved, it could result in decline in general, residents would not be participating in therapy, and there would be delayed wound healing. Licensed Staff D stated pain decreased quality of life, and it was important that residents were comfortable and not in pain. During a concurrent interview, POS dated 6/2024, EMAR dated 5/20/24, and 6/2024 record review, on 6/20/24 at 2:39 p.m., Licensed Staff E verified staff were using this PS to assess residents pain level: 0=no pain, 1 to 3=mild pain, 4 to 6=moderate pain and 7 to 10=severe pain. Licensed Staff E also verified the EMAR for 5/2024, indicated Resident 37 received the following medications: Hydrocodone Acetaminophen 10-325 mg one tab every 12 hours as needed for moderate pain (PS 4 to 6), when she was reporting severe pain (PS 7 to 10) on these dates: 5/25/24, while her reported PS was 7 out of 10, on 5/27/24, while her reported PS was 7 out of 10, on 5/30/24, while her PS was 8 out of 10, and on 5/31/24, while her reported PS was 7 out of 10; Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6). Licensed Staff E verified Resident 37 received this medication on 5/3/24, twice while reporting a PS of 5 and 4, on 5/18/24, while reporting a PS of 5, on 5/22/24, with a PS 6, on 5/23/24, with a PS 5, on 5/24/24, with a PS of 6, on 5/31/24, with a PS of 4. Licensed Staff E also verified Resident 37's EMAR for 6/2024, indicated she received Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6) on these dates: 6/2/24, while reporting a PS of 4, on 6/9/24, while reporting a PS of 4, on 6/12/24, while reporting a PS of 6, and on 6/13/24, while reporting a PS of 4. Licensed Staff E stated this information indicated the Physician's order was not followed. Licensed Staff E stated it was important the Physician's Order was followed to ensure Resident 37 was receiving adequate pain relief. Licensed Staff E stated pain could decrease quality of life and could have a negative emotional impact on the resident. During a concurrent interview, POS dated 6/2024, EMAR dated 5/20/24, and 6/2024, record review, on 6/20/24 at 2:53 p.m., Licensed Staff C verified staff were using this PS to assess residents pain level: 0=no pain, 1 to 3=mild pain, 4 to 6=moderate pain and 7 to 10=severe pain. Licensed Staff C also verified the EMAR for 5/2024, indicated Resident 37 received the following medications: Hydrocodone Acetaminophen 10-325 mg one tab every 12 hours as needed for moderate pain (PS 4 to 6), when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 10 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was reporting severe pain (PS 7 to 10) on these dates: 5/25/24, while her reported PS was 7 out of 10, on 5/27/24, while her reported PS was 7 out of 10, on 5/30/24, while her PS was 8 out of 10, and on 5/31/24, while her reported PS was 7 out of 10; Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6). Licensed Staff C verified Resident 37 received this medication on 5/3/24, twice while reporting a PS of 5 and 4, on 5/18/24, while reporting a PS of 5, on 5/22/24, with a PS 6, on 5/23/24, with a PS 5, on 5/24/24, with a PS of 6, on 5/31/24, with a PS of 4. Licensed Staff C also verified Resident 37's EMAR for 6/2024, indicated she received Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6) on these dates: 6/2/24, while reporting a PS of 4, on 6/9/24, while reporting a PS of 4, on 6/12/24, while reporting a PS of 6, and on 6/13/24, while reporting a PS of 4. Licensed Staff C stated this information indicated the Physician's Order was not followed. Licensed Staff C stated the Physicians Order should always be followed. Licensed Staff C stated it was important for Resident 37 to be comfortable. Licensed Staff C stated pain could cause decreased quality of life. Licensed Staff C stated unrelieved pain could result in residents' feeling frustrated and upset. During a concurrent interview, POS dated 6/2024, EMAR dated 5/20/24, and 6/2024, record review, on 6/20/24 at 4:09 p.m., the Minimum Data Set Coordinator (MDSC) verified staff were using this PS to assess residents pain level: 0=no pain, 1 to 3=mild pain, 4 to 6=moderate pain and 7 to 10=severe pain. The MDSC also verified the EMAR for 5/2024, indicated Resident 37 received the following medications: Hydrocodone Acetaminophen 10-325 mg one tab every 12 hours as needed for moderate pain (PS 4 to 6), when she was reporting severe pain (PS 7 to 10) on these dates: 5/25/24, while her reported PS was 7 out of 10, on 5/27/24, while her reported PS was 7 out of 10, on 5/30/24, while her PS was 8 out of 10, and on 5/31/24, while her reported PS was 7 out of 10; Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6). MDSC verified Resident 37 received this medication on 5/3/24, twice while reporting a PS of 5 and 4, on 5/18/24, while reporting a PS of 5, on 5/22/24, with a PS 6, on 5/23/24, with a PS 5, on 5/24/24, with a PS of 6, on 5/31/24, with a PS of 4. MDSC also verified Resident 37's EMAR for 6/2024, indicated she received Acetaminophen 325 mg two tablets every six hours as needed for mild pain (PS of 1 to 3), even though she was reporting moderate pain (PS 4 to 6) on these dates: 6/2/24, while reporting a PS of 4, on 6/9/24, while reporting a PS of 4, on 6/12/24, while reporting a PS of 6, and on 6/13/24, while reporting a PS of 4. The MDSC stated these information indicated staff were not following the physician's order. The MDSC stated pain decreased quality of life. The MDSC stated it was important to follow Physician's Order. The MDSC stated not following a Physician's Order for pain management could result in increased pain, and unrelieved pain. During an interview on 6/20/24 at 4:23 p.m., Resident 37 stated Acetaminophen would not alleviate her pain if she was experiencing moderate pain. A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 2/2024, the P&P indicated to implement the medication regimen as ordered, carefully documenting the result of the intervention FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 11 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm During an observation, interviews, and record reviews, the facility failed to ensure residents were served food items that were palatable and at the right temperature, for four out of four sampled residents (Residents 30, 6, 38, and 43). These failures could put the residents at risk for loss of appetite, frustration, malnutrition (condition that develops when the body is deprived of vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ), and weight loss. Residents Affected - Some Findings: A review of Resident 30's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 3/18/24, score was 1, indicating severely impaired cognition (the mental process involved in knowing, learning, and understanding things). A review of Resident 6's BIMS, dated 3/22/24, score was 15, indicating intact cognition. A review of Resident 38's BIMS, dated 5/11/24, score was 15, indicating intact cognition. A review of Resident 43's BIMS, dated 5/11/24, score was 13, indicating intact cognition. During an interview on 06/17/24 at 3:29 p.m., Resident 30 stated food served at the facility had no taste and was served cold. During an interview on 6/17/24 10:35 a.m., Resident 6 stated he had issues with food served at the facility. Resident 6 stated the food was unpalatable. Resident 6 stated foods items that were supposed to be hot were served cold most of the time. During an interview on 6/17/24 at 10:41 a.m , Resident 43 stated food served in the facility was not great. Resident 43 stated sometimes food was served cold. Resident 43 stated the food had no taste. During an observation on 6/19/24 at 9:10 a.m., Unlicensed Staff A stated it was important to ensure residents' food was palatable and at the right temperature. Unlicensed Staff A stated, if food served was not palatable and hot foods were served cold, it could result in residents not eating the food, which could result in weight loss or malnutrition. During an interview on 6/19/24 at 9:25 a.m., Unlicensed Staff B stated food should be palatable and served at the right temperature because if not, then the residents would not eat the food, which could result in weight loss and emotional changes. During an interview on 6/19/24 at 9:39 a.m., Licensed Staff C stated the facility was the residents' home, and the residents needed to receive food that was nutritious, palatable and at the right temperature. Licensed Staff C stated this meant hot food was served hot and cold food should be served cold. Licensed Staff C stated, if food served was not palatable and hot foods were served cold, residents may not eat the food which could result in weight loss or malnourishment. During an interview on 6/19/24 at 10:08 a.m., Resident 38 stated food served in the facility was not nutritious and had no taste. Resident 38 stated often, she did not eat the food served to her. Resident 38 stated the facility served poor quality food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 12 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 Residents Affected - Some During an interview on 6/19/24 at 10:19 a.m., the Infection Preventionist (IP) stated it was important for residents to receive food that was palatable and at the right temperature, for bacteria prevention. The IP stated, if food served was not palatable and hot foods were served cold, it could result in poor healing, weight loss, and decreased appetite. The IP stated this could affect residents' health negatively. During an interview on 6/19/24 at 2:17 p.m., the Director of Nursing (DON) stated, if food served was not palatable and hot foods were served cold, it could affect residents negatively, residents may not eat the food, and residents would not be happy. During a test ray with the Dietary Supervisor (DS) on 6/19/24 at 12:37 p.m., the temperature taken by the DS showed pureed breaded fried chicken with gravy was 84 degrees, and the breaded fried chicken was at 82 degrees. The DS verified the breaded fried chicken was very salty, the meat was dry, tough, and chewy. The DS stated the breaded fried chicken and the pureed breaded fried chicken with gravy, was cold and not hot, and their temperature was not in range. The temperature taken by the DS showed the spinach temperature at 100 degrees. The DS verified the spinach was bland and lacked taste. The DM stated the spinach did not meet the temperature requirement. The DM stated the food was not palatable and was not served in the right temperature. The DM stated residents might not eat the food which could result in weight loss and malnutrition. During an interview on 6/20/24 at 10:31 a.m., the Registered Dietician (RD) stated the facility did not have an acceptable temperature range, when food was served to the residents at meal times and they depended on palatability alone. The RD stated 82 degrees temperature for a breaded fried chicken was a lower temperature than she would like. A review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, the P&P indicated, Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs taking into consideration the preferences of each residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 13 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interviews and record reviews, the facility failed to ensure residents were not receiving food items that they did not like, for one out of three sampled residents (Residents 117). This failure could result in Resident 117 not eating the food and could put Resident 117 at risk for weight loss and inadequate nutrition. Findings: A review of Resident 117's face sheet indicated his admission date as 6/6/24, with diagnoses of Dysphagia (difficulty swallowing), Muscle Weakness and Essential Hypertension (HTN, high blood pressure). A review of Resident 117's lunch diet ticket on 6/19/24 at 12:03 p.m., indicated he disliked breaded food. A review of the menu for 6/19/24, indicated lunch included breaded fried chicken. During a concurrent observation and interview on 6/19/24 at 12:04 p.m., [NAME] 1 stated she had already finished plating for Resident 117, and verified she added a breaded fried chicken on his lunch tray. [NAME] 1 stated his meal tray was already placed in the meal cart. [NAME] 1 verified Resident 117 disliked breaded food items and should not be served with breaded chicken. [NAME] 1 stated she would update the plate and remove the breaded fried chicken. [NAME] 1 stated it was important to follow residents' preferences. [NAME] 1 stated, if a resident's meal included an item that he disliked, the resident might not eat the food. [NAME] 1 stated residents' would be upset and frustrated. [NAME] 1 stated this could cause weight loss and malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). During an interview on 6/19/24 at 12:07 p.m., the Registered Dietician (RD) verified Resident 117 listed breaded food items as one of his dislikes. The RD verified the fried chicken prepared for lunch was breaded. The RD stated it was important to ensure residents did not received items they disliked. The RD stated, if Resident 117 received food items that he disliked, it could lead to Resident 117 not eating the food. The RD stated residents should not be receiving food they disliked, keeping them happy. During an interview on 6/19/24 at 12:10 p.m., [NAME] 2 stated it was important to ensure Resident 117 did not receive food items which he disliked. [NAME] 2 stated, if residents received a food item they disliked, residents may not eat the food, which could result in weight loss and malnutrition. During an interview on 6/19/24 at 12:32 p.m., the Dietary Supervisor (DS) stated residents should not be receiving food items they disliked. The DS stated, if residents received a food item they disliked, it could lead to residents not eating the food item, which could result in weight loss and malnutrition. A review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, undated, the P&P indicated, Each resident is provided with nourishing, palatable, well balanced diet that meets his or her daily nutritional and special dietary needs taking into consideration the preferences of each residents .reasonable efforts will be made to accommodate resident choices and preferences . the multidisciplinary staff, including the nursing staff, the attending physician and the dietician will assess each residents nutritional needs, food likes, dislikes and eating habits as well as physical, functional and psychosocial factors that affect eating and nutritional intake and utilization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 14 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 refrigerated items in the kitchen were clearly labeled, easily identified, and dated. These failures could compromise food safety and could lead to residents getting sick with gastrointestinal (GI, made up of organs that food and liquids travel through when they are swallowed, digested, absorbed) illness such as Salmonella (an infection with Salmonella bacteria that causes diarrhea- passage of three or more liquid stools, fever and stomach pains), Gastroenteritis (stomach flu) and food poisoning (an illness caused by eating contaminated food). Findings: During a concurrent observation and interview on 6/17/24 at 9:25 a.m., the Dietary Supervisor (DS) verified the following items in the three-door refrigerator had no use-by or discard date: vanilla extract, chocolate syrup and a yellow mustard. There was also a bin that contained sandwiches for lunch alternates for the day, which had no labels, no date on when it was made and had no use-by date. [NAME] 3 verified the sandwiches were not labeled or dated. [NAME] 3 identified the sandwiches in the bin as peanut butter and jelly and grilled cheese sandwiches. The DS verified the tub of macaroni salad had no date on when it was made and had no use-by date. The DS stated this should be thrown away. The DS verified the two-door freezer had unlabeled items which staff had removed from the original packaging. The DS identified one of these as pork ribs. The DS verified it had no use-by date. The DS also verified there was another item removed from its original packaging, unlabeled, which the DS identified as crabby cakes. The DS verified it was not labeled and had no open or discard-by date. The DS stated, per facility policy, all food items and condiments in the refrigerator should be clearly labeled, with open and discard dates. During an interview on 6/19/24 at 11:30 a.m., Dietary Aide 1 (DA 1) stated all food items in the refrigerator had to be clearly labeled with open and discard dates. DA 1 stated food items should be clearly labeled to ensure the right food was going to be served to the residents. DA 1 stated the reason for dating food items was to ensure residents were not served food items that were spoiled, which could lead to residents getting sick. DA 1 stated food items should have a date on when to discard so staff knew when to discard food items for residents' safety. During an interview on 6/19/24 at 11:35 a.m., [NAME] 1 stated food items should be clearly labeled to ensure the right food was going to be served to the residents. [NAME] 1 stated food items in the refrigerator and freezer should be clearly labeled with open and discard dates for residents' safety. [NAME] 1 stated food items were discard-dated to ensure food served to the residents was safe for consumption. [NAME] 1 stated, not putting in the open and discard dates could lead to serving residents food that was spoiled, which could result in Salmonella and food poisoning. During an interview on 6/19/24 11:40 a.m., [NAME] 2 stated food items in the refrigerator and the freezer should be clearly labeled and should have an open and discard dates. [NAME] 2 stated this was important to ensure residents' safety. [NAME] 2 stated a discard date was important to ensure residents were not served food items that were spoiled and could make them sick. [NAME] 2 stated it was important to ensure food items were clearly labeled to ensure the right food was going to be served to the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 15 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 6/20/24 at 11:24 a.m., the Registered Dietician (RD) stated food items in the refrigerator and freezer should be clearly labeled, easily identifiable and with open and use-by dates, per facility policy. The RD stated items should be clearly labeled to make sure they were using the right food and with use-by dates to ensure the facility was not serving food that was already spoiled. A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, undated, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices . all food stored in the refrigerator or freezer will be labeled, covered and dated. Event ID: Facility ID: 055499 If continuation sheet Page 16 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to ensure: Residents Affected - Some 1. Perishable food items from home, stored in the refrigerator for the residents, was dated and labeled with the resident's name. 2. Staff were aware on the facility's policy on when to discard refrigerated food items from home. These failures could lead to cross-contamination, and unsafe and unsanitary storage of food, which were a safety risk that could lead to accidental ingestion of expired food items and food being served to the unintended residents. Findings: During a concurrent observation and interview on 6/18/24 at 2:45 p.m., the Director of Nursing (DON) stated it was important to label the food with residents' names, date when it was opened and date when to discard. The DON stated it was important to label the food with residents' names so that the food would go to the right resident. The DON stated food in the refrigerator was discarded after three days from opening to prevent residents from getting sick. The DON verified the following items were not labeled with the residents' names: -vanilla flavored chocolate chip ice cream -tub of milk and cookie ice cream -a cup of unlabeled frozen yogurt -2 tubs of opened whipped topping -grapes -box of boost -2 fruit cups -1 bottle of peach beverage -2 boost drinks -1 opened bottle of ranch dressing -2 bottles of nutritional drinks -a tub of opened cream cheese The DON verified the following items were not dated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 17 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0813 -a cup of unlabeled frozen yogurt Level of Harm - Minimal harm or potential for actual harm -2 tubs of opened whipped topping -a tub of opened cream cheese Residents Affected - Some -3 tubs of opened ice cream The DON verified there was an opened bottle of ranch dressing in the refrigerator that had an open date of 4/12/24. The DON stated this should be discarded and was past the discard date. During an interview on 6/19/24 at 9:10 a.m., Unlicensed Staff D stated perishable food from outside needs to be labeled with name and room number, dated on when it was received, or opened and when to discard. Unlicensed Staff D stated perishable food items should be discarded when they did not have names on them and if they smelled bad. Unlicensed Staff D stated this was important for residents' safety to make sure food is not spoiled and they did not get sick. Unlicensed Staff D stated it was important to make sure food items were labeled with residents' names to make sure food was served to the right person. During an interview on 6/19/24 on 9:25 a.m., Unlicensed Staff B stated food items from outside should be labeled with residents' names and room number, should be dated on when they were received or opened and should be dated on when to discard. Unlicensed Staff B stated opened perishable food items should be discarded in three to five days. Unlicensed Staff B stated it was important to label the food items with the resident's name to ensure safety and to ensure they would not be given to another resident who was not supposed to have the food based on their diet. Unlicensed Staff B stated, if the resident received a food item that had a wrong diet texture, the resident could choke. Unlicensed Staff B stated it was important to identify the discard date for safety, as this could prevent staff from giving residents' spoiled food items. During an interview on 6/19/24 at 9:39 a.m., Licensed Staff C stated it was important to clearly label the food items with the resident's name to ensure it was given to the right resident, for safety reasons. Licensed Staff C stated it was also important to label the food on when it was received or opened and when to discard, for resident safety and to prevent residents' from consuming food that was spoiled. During an interview on 6/19/24 at 10:19 a.m., the Infection Preventionist (IP) stated food items in the residents' refrigerator had to be labeled with names, dated on when received or opened and dated on when the food should be discarded, for safety. The IP stated, if these were not done, the, Food From Home, policy was not followed. The IP stated, not dating the food items could be a risk for bacteria growth. The IP stated it was important to ensure food items were clearly labeled with the resident's name to prevent mix-up of residents and to ensure food items were served to the right resident. During an interview on 6/20/24 at 10:25 a.m., the Registered Dietician (RD) stated food items brought from home should be clearly labeled with the resident's name, received or open dated and once opened, should be discarded in three days to ensure food was still safe for consumption. The RD stated names should be clearly labeled to ensure the food went to the right resident. A review of the facility's policy and procedure (P&P) titled, Food from Home, undated, the P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 18 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0813 Level of Harm - Minimal harm or potential for actual harm stated, There is a refrigerator for holding perishable food from outside the facility .the food must be dated and labeled with resident's name .the food could only be kept for 3 days in the refrigerator to avoid food borne illness .some food items are labeled with manufacturer use by date, this date may be used only if the food item is not opened, once opened they will be dated with the date opened and discarded after 3 days. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 19 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 observations and interviews, the facility failed to ensure: Residents Affected - Some 1. Hand hygiene (HH, hand-washing with water and plain or antiseptic soap or rubbing hands with an alcohol-based product in the form of a gel to clean hands and remove dirt, bacteria, and viruses) was offered and provided, for seven out of seven sampled residents (Residents 18, 29, 28, 10, 54, 1 and 14). 2. Utensils were cleaned thoroughly and stored under sanitary conditions, when there was a plate on the plate warmer noted with dried food, and kitchen utensils were not properly dried prior to storing in the drawer. These failures could lead to residents getting sick with infection if they were not offered or provided HH before and after meals. Dishes and utensils that have not been thoroughly cleaned, rinsed, and dried could result in cross-contamination and bacteria growing on dishes and utensils, which could result in residents' getting sick. Findings: 1. During an observation on 6/17/24 at 12:13 p.m., Resident 18 was not offered or provided HH prior to eating her lunch. During an observation on 6/17/24 at 12:14 p.m., Resident 10 was not offered or provided HH prior to eating her lunch. During an observation on 6/17/24 at 12:15 p.m., Resident 29 was not offered or provided HH prior to eating her lunch. During an observation on 6/17/24 at 12:16 p.m., Resident 28 was not offered or provided HH prior to eating her lunch. During an observation on 6/17/24 at 1:16 p.m., Resident 14 was wheeled out of the dining room by Unlicensed Staff B. Resident 14 was not offered or provided HH after eating her lunch. During an interview on 6/19/24 at 8:59 a.m., the Central Supply/Medical Records Assistant (CS/MRA) stated the facility policy was to offer and perform HH to the residents before and after meals. The CS/MRA stated if the HH was not offered and not done for the residents, then the facility policy was not followed. The CS/MRA stated, not washing residents' hands could result in residents getting sick with infection such as Clostridium Difficile (CDiff, a highly contagious bacteria that causes diarrhea-passage of three or more liquid, watery stools in a 24 hour period) and diarrhea. The CS/MRA stated it was important to ensure residents' hands were clean before and after meals to prevent transfer of bacteria from hands to mouth, which could make residents sick. During an interview on 6/19/24 at 9:10 a.m., Unlicensed Staff A stated it was the facility's policy was to ensure residents were offered HH before and after meals. Unlicensed Staff A stated, if the HH was not done or offered to the residents before and after meals, then the facility policy was not followed. Unlicensed Staff A stated, not performing HH for the residents before and after meals could result in residents getting sick with food poisoning and diarrhea. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 20 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/19/24 at 9:25 a.m., Unlicensed Staff B stated HH should be offered or provided for the residents before and after meals. Unlicensed Staff B stated, if the HH was not done, it meant the facility policy was not followed. Unlicensed Staff B stated, not providing or offering HH to the residents was a safety risk and could lead to cross-contamination, which could result in food-borne illness, such as Salmonella and Cdiff. Residents Affected - Some During an interview on 6/19/24 at 9:40 a.m., Licensed Staff C stated it was the facility's policy to offer or perform HH for the residents before and after meals. Licensed Staff C stated, if HH was not done, then the facility's HH policy was not followed. Licensed Staff C stated this could put residents at risk for infection of the eyes and GI illness such as Cdiff. During an interview on 6/19/24 at 10:20 a.m., the Infection Preventionist stated it was the facility's policy to ensure HH was offered or performed for the residents before and after meals. The IP stated, if this was not done, then the policy was not followed. The IP stated, not performing or offering HH to residents before and after meals put the residents at risk for spread of bacteria between residents, residents potentially getting sick with GI illness and respiratory (organs involved in breathing) illness. During an interview on 6/19/24 at 10:45 a.m., Resident 54 stated staff did not offer or assist her with HH before and after meals. During an interview on 6/19/24 at 11:35 a.m., Resident 1 stated staff did not offer nor assist him with HH before or after meals. During an interview on 6/19/24 at 2:20 p.m., the Director of Nursing (DON) stated residents' hands should be washed before and after meals, and that was the protocol. The DON stated not ensuring residents hands were clean or not washing resident hands before and after meals, put residents at risk for possible infection. A review of the facility's policy and procedure (P&P) titled, Hand-washing/ Hand Hygiene, revised 2/2024, the P&P indicated the facility considered HH as the primary means to prevent the spread of infections .to use an alcohol based hand rub containing at least 62 percent (%, per hundred) alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after eating or handling food 2. During a concurrent observation and interview on 6/17/24 at 9:19 a.m., [NAME] 3 verified she stored the steamer bars and utensils in the drawers while still wet. [NAME] 3 stated the steamers bars and the utensils should not be kept in the drawer while they were still wet. [NAME] 3 stated this was an infection control issue. [NAME] 3 stated these items should be dried before keeping in the drawers to prevent mold from forming. During a concurrent observation and interview on 6/17/24 at 9:20 a.m., the Dietary Supervisor verified some utensils in the drawer were still wet when stored in the drawer. The DS stated, keeping wet items in the drawer was a health hazard. During an interview on 6/19/24 at 11:30 a.m., Dietary Aide 1 (DA 1) stated kitchen utensils and steam support bars should be thoroughly dried before keeping in the drawers, for sanitary purposes and to prevent mold from forming. DA 1 stated, if a kitchen utensil was stored while it was not thoroughly dried, it could result in build up of bacteria which could contaminate residents' food and could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 21 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 result in residents getting sick. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/19/24 at 11:35 a.m., there was a plate on the plate warmer noted to have a yellow tinged dried food. Residents Affected - Some During a concurrent observation and interview on 6/19/24 at 11:35 a.m., [NAME] 1 verified the plate on top of the plate warmer was not thoroughly cleaned and was noted with yellow-tinged food material which she identified as a possible egg remnant. [NAME] 1 stated it was not acceptable to use dirty plates, due to contamination, and a dirty plate was unsanitary. [NAME] 1 stated, using a dirty plate could lead to a resident getting sick. [NAME] 1 stated kitchen utensils should be thoroughly dried before storing in the drawer, to prevent bacteria build up. [NAME] 1 stated it was important to ensure kitchen utensils were thoroughly dried before storing, for residents' safety, since wet utensils could harbor bacteria which could cause residents to get sick. During an interview on 6/19/24 at 11:40 a.m., [NAME] 2 stated it was not acceptable to have a dirty plate on the plate warmer. [NAME] 2 stated this might mean the plate was not thoroughly washed and sanitized. [NAME] 2 stated dirty plates could contaminate residents' food which could result in residents getting sick. [NAME] 2 stated kitchen utensils were not supposed to be stored until they were fully air dried. [NAME] 2 stated wet utensils could harbor bacteria and could contaminate residents' food, which could result in residents getting sick or ill with gastrointestinal (GI, made up of organs that food and liquids travel through when they are swallowed, digested, and absorbed) disease. During a concurrent observation and interview on 6/19/24 at 11:47 a.m., the Registered Dietician (RD) stated it appeared like there was an old food item on the plate at the top of the plate warmer which she identified as dried egg. The RD stated this should not be used because it was unsanitary, it was an infection control issue, and residents could get sick. During an interview on 6/20/24 at 10:51 a.m., the RD stated utensils should be air dried before keeping in the drawer. The RD stated, keeping wet utensils in the drawer could cause cross-contamination and could lead to residents getting sick. The facility did not have an infection policy and procedure specific to dishwashing and storing of utensils. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 22 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility failed to ensure the kitchen floor was in good repair, when the linoleum (a hard, washable floor covering formed by coating burlap or canvass with linseed oil, powdered cork, and resin, and adding pigments to create the desired colors and patterns) floor on multiple parts of the kitchen area (by the gas stove, door leading to the hallway, the sink) was coming apart and its edges were raised off the floor. This failure could be an infection control issue due to difficulty in ensuring the floor was adequately cleaned and sanitized. This failure could also be a safety issue due to being a trip hazard. Residents Affected - Few Findings: During a concurrent observation and interview on 6/17/24 at 9:19 a.m., [NAME] 3 verified the linoleum floor was falling apart on different parts of the kitchen area. [NAME] 3 stated the kitchen floor should always be clean, and the floor should always be in good repair. [NAME] 3 stated she tripped on the linoleum floor by the gas range every time she went to work. [NAME] 3 stated, the linoleum flooring not being in good repair was a trip hazard and was a safety issue. During a concurrent observation and interview on 6/19/24 at 9:25 a.m., the Dietary Supervisor (DS) verified the floor was dirty, and the linoleum floor was coming apart. The DS stated the kitchen area should always be clean for health and sanitary reasons. The DS stated, a dirty kitchen could lead to residents getting sick. During an interview on 6/17/24 at 9:35 a.m., the DS stated it was not acceptable to have the linoleum floor in the kitchen falling apart. The DS stated this was an infection control issue since the floors could not be cleaned and sanitized adequately, and dirt could get into the crevices where the linoleum was coming apart. During a concurrent observation and interview on 6/19/24 at 11:30 a.m., Dietary Aide 1 (DA 1) verified the linoleum floor on different parts of the kitchen was falling apart and was a safety hazard. DA 1 stated it was not acceptable to have the linoleum flooring coming apart because it meant the floor could not be sanitized or cleaned thoroughly. DA 1 stated this was an infection control issue since the kitchen area should always be clean. DA 1 stated dirt and debris could get inside the crevices of the linoleum edges where it was coming apart. During an interview on 6/19/24 at 11:35 a.m., [NAME] 1 stated the kitchen floor should be clean at all times. [NAME] 1 stated it was not acceptable to have dirty floors, for sanitary purposes. [NAME] 1 stated it was not acceptable to have a linoleum floor falling apart, for infection control purposes and sanitary purposes. [NAME] 1 stated it was also a safety hazard as staff could trip on the edges of the broken linoleum floor. [NAME] 1 stated there was no way to adequately clean and sanitize a floor with broken linoleum, as dirt could get inside the broken linoleum edges. [NAME] 1 stated this was a big infection control issue. During a concurrent observation and interview on 6/19/24 at 11:40 a.m., [NAME] 2 stated the kitchen floor should always be clean, and it was not acceptable to have a linoleum floor in the kitchen that was falling apart. [NAME] 2 stated this was a safety risk because it put staff at risk for tripping on the edges of the linoleum. [NAME] 2 stated it was also a risk for staff not to be able to clean the floor or sanitize the floor adequately. [NAME] 2 stated dirt could get inside the linoleum floor. [NAME] 2 stated it was an infection control issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 23 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 6/20/24 at 9:30 a.m., the Administrator stated the linoleum floor in the kitchen needed repair. The Administrator stated this was a safety hazard for the staff. A review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 8/2022, the P&P indicated, The Maintenance Department is responsible in maintaining the buildings, grounds and equipment in safe and operable manner at all times .functions of the maintenance personnel include, but not limited to maintaining the building in good repair, maintaining the grounds, sidewalks etc. Event ID: Facility ID: 055499 If continuation sheet Page 24 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure the kitchen was free of flies. This failure posed a health risk, as flies carry diseases such as Salmonella (a group of bacteria that can cause diarrhea-passage of three or more liquid stools, in humans) and Cholera (an infectious disease that causes severe watery diarrhea), which could contaminate the food stored, prepared and served to the residents in the facility. Residents Affected - Few Findings: During an observation on 6/19/24 at 12:05 p.m., the Dietary Supervisor (DS) and the Registered Dietitian (RD) both verified there was a fly in the kitchen. During a concurrent observation and interview on 6/19/24 at 12:11 p.m., [NAME] 2 verified there was a fly hovering in the kitchen. [NAME] 2 stated this was not an isolated incident, and flies could be seen in the kitchen from time to time. [NAME] 2 stated there should be no flies in the kitchen area. [NAME] 2 stated the facility could only do so much, and although they have a fan blower, it was not enough to keep the flies away. [NAME] 2 stated it was not acceptable to have flies in the kitchen for sanitary and infection control purposes. [NAME] 2 stated flies could contaminate food and could result in residents getting sick. During a concurrent observation and interview on 6/19/24 at 12:15 p.m., [NAME] 1 verified there was a fly hovering in the area where she was plating for residents' lunch. [NAME] 1 stated it was not acceptable to have flies in the kitchen. [NAME] 1 stated flies carried germs and bacteria. [NAME] 1 stated flies could land on residents' food and contaminate it. [NAME] 1 stated this could result in residents' getting sick. During an interview on 6/19/24 at 12:16 p.m., Dietary Aide 1 (DA 1) stated, from time to time, there would be flies in the kitchen. DA 1 stated this was not acceptable because flies carried diseases and germs. DA 1 stated it was unsanitary to have flies in the kitchen. DA 1 stated, if the fly got into the residents' food, residents could get sick. During an interview on 6/19/24 at 12:32 p.m., the DS stated the kitchen would have flies from time to time. The DS stated it was not acceptable to have flies in the kitchen. The DS stated this was a sanitation issue. The DS stated flies carried pathogens and bacteria, and if the fly landed on residents' food, it could cause health issues and could cause gastrointestinal (GI, made up of organs that food and liquids travel through when they are swallowed, digested, and absorbed) illness. During an interview on 6/20/24 at 9:30 a.m., the Administrator stated he was aware there was a fly in the kitchen, yesterday. The Administrator was aware there was a broken Plexiglas above the air conditioning unit. The Administrator stated the fly could have entered through that broken Plexiglas. The Administrator stated it was an infection control issue to have flies in the kitchen area where residents' food was prepared. During an interview on 6/20/24 at 10:31 a.m., the RD verified there was a fly in the kitchen, yesterday. The RD stated it was not as bad as they had it before. The RD stated there was a health risk if flies were present in the kitchen area. A request for the facility's policy and procedure (P&P) for Pest Control and Management was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 25 of 26 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 055499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky Point Care Center 625 16th Street Lakeport, CA 95453 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 0925 requested, but was not provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055499 If continuation sheet Page 26 of 26