Health inspection·December 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the DON on 12/15/23, at 9:59 AM, the DON stated staff needed to sit down while assisting residents with their meals for positioning and to be at the residents' level. The DON stated her expectations were for staff to be in a seated position when assisting residents with meals. A review of the facility policy titled, DIGNITY AND RESPECT, revised March 2023, the policy indicated, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Residents' private space and property shall be respected at all times . Event ID: Facility ID: 055833 If continuation sheet Page 2 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 61's admission RECORD indicated Resident 61 was admitted to the facility in 2022 with diagnoses which included, acute and chronic respiratory failure (disease that can cause shortness of breath, anxiety, and confusion), muscle weakness, and polyneuropathy (nerve disease that causes a decreased ability to move and feel). Residents Affected - Few During an observation on 12/12/23, at 8:46 AM, Resident 61 was observed lying in bed with no call light visible. When asked to demonstrate call light use, Resident 63 attempted to reach his call light multiple times without success. During an observation and interview on 12/12/23, at 9:03 AM, the Director of Staff Development (DSD) confirmed Resident 61's call light was not in reach. The DSD obtained Resident 61's call light from underneath his pillow behind his left shoulder. The DSD stated the call light should be in reach for Resident 61 to obtain assistance when he needed it. The DSD further stated if Resident 61 could not reach his call light he could potentially fall or have unmet needs. A review of Resident 61's care plan, initiated 9/7/22, indicated, .The resident has self-care deficit with ADL [activities of daily living, activities related to daily care] functions .r/t [related to] weakness .Be sure call light is within reach and encourage to use it for assistance. Respond promptly to all requests for assistance . During an interview on 12/15/23, at 9:16 AM, the DON stated the facility's policy indicated call lights should be answered as soon as possible to ensure the resident needs did not go unmet. The DON further stated it was her expectation that staff were always checking to ensure call lights were in reach of the residents. The DON stated if the call light was not in reach there was the potential risk of falls and other unmet needs. The DON further stated staff should always follow the call light policy. A review of a facility policy and procedure (P&P) titled, RESIDENT CALL SYSTEM, revised March 2023, indicated, .When the resident is sitting in his/her chair or confined to his/her bed, be sure to provide resident with call light access .Resident call systems should be accessible to residents while in their bed . Based on observation, interview, and record review, the facility failed to ensure call lights (devices used to communicate a need for assistance) were within reach for 2 of 29 sampled residents (Resident 36 and Resident 61) when: 1. Resident 36's call light was on the floor; and, 2. Resident 61's call light was tucked under his pillow. These failures had the potential for Resident 36 and Resident 61's needs to be unmet, a delay in care, and to cause physical and psychosocial harm due to their inability to call for assistance. Findings: 1. A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility in 2022 with diagnoses which included dementia (impairment of brain function including loss of memory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 3 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and judgment), difficulty in walking, and glaucoma (an eye disease that can cause vision loss and blindness). During a concurrent observation and interview on 12/12/23, at 1:45 p.m., with Licensed Nurse (LN) 6 in Resident 36's room, Resident 36 was observed lying in bed and the call light was on the floor. LN 6 confirmed Resident 36's call light was on the floor and should not be. LN 6 stated Resident 36 knew how to use the call light to ask for help, and Resident 36 had the potential to fall if it was not within reach. A review of Resident 36's Care Plan titled, The resident is at risk for falls r/t [related to] history of fall prior to admission, Gait/balance problems, Dementia, muscle weakness . initiated on 3/3/22 indicated interventions which included, .Call light is within reach and encourage the resident to use it for assistance as needed .Keep call lights within reach at all times .Promote safe environment with .a working and reachable call light . During an interview on 12/14/23, at 2:27 p.m., the Director of Nursing (DON) stated the call light should be within a resident's reach and not on the floor. The DON further stated the risk of a call light not within a resident's reach were resident safety, needs not being met, and delay of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 4 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 out of 29 sampled residents (Resident 63) rights related to treatment preferences were known and documented in their physician orders and care plans when: Resident 63's cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure) status order and care plan did not match the CPR preferences listed on her Physician Order for Life Sustaining Treatment (POLST, a written medical order from a physician specifying the types of treatment an individual wants to receive during a serious illness). This failure had the potential risk for Resident 63's preferences regarding emergency treatment to not be followed. Findings: A review of Resident 63's admission RECORD, indicated Resident 63 was admitted to the facility in July of 2023 with diagnoses which included chronic obstructive pulmonary disease (COPD, long term lung disease that causes shortness of breath and cough). A review of Resident 63's POLST, signed by the physician on [DATE], indicated, .Attempt Resuscitation/CPR .Full Treatment-primary goal of prolonging life by all medically effective means . A review of Resident 63's Order Review History Report, dated [DATE]-[DATE], indicated, .DNR [do not resuscitate] selective treatment . A review of Resident 63's care plan initiated on [DATE], indicated, .No code/DNR (Do not resuscitate) as chosen by resident .Respect Resident/responsible party/surrogate decision maker wishes if there are any changes to it and notify physician . During a concurrent interview and record review on [DATE], at 1:38 PM, licensed nurse (LN) 3 confirmed Resident 63's preferences as indicated on her POLST did not match her orders. LN 3 stated Resident 63 had updated her POLST in November and the orders and care plan should have been revised immediately to ensure Resident 63 received CPR per her wishes. During an interview on [DATE], at 9:42 AM, the Director of Nurses (DON) stated it was her expectation that the residents' orders and care plans would be updated immediately after the POLST was signed by the physician. The DON further stated in an emergency the staff needed to know the residents' preferences. The DON stated if the documentation was not updated the residents were at risk of not receiving CPR per their wishes. During an interview on [DATE], at 11:12 AM, the Nurse Consultant (NC) stated discrepancies between the POLST and CPR orders had the potential risk of residents not receiving life sustaining treatment as per their preference. The NC further stated the orders and the care plan should have been updated immediately after the physician signed the POLST to inform the staff of what to do in an emergency. During a concurrent interview and record review, on [DATE], at 11:12 AM, with the NC, the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 5 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete policy and procedure titled, CARDIOPULMONARY RESUSCITATION (CPR), revised [DATE], was reviewed. The policy indicated, .Physician orders supporting resident wishes for CPR are obtained as soon as possible after admission or a change in a resident preference or condition, to facilitate staff in honoring residents' choices .Resident wishes to receive CPR are documented in the medical record, physician's orders, and care plan so staff know what actions to take when an emergency arises . The NC confirmed the policy was not followed for Resident 63. Event ID: Facility ID: 055833 If continuation sheet Page 6 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Based on interview, and record review, the facility failed to ensure 1 of 29 sampled residents' (Resident 1) Pre-admission Screening Resident Review (PASSR, a screening tool used to evaluate an individual who may have a mental disorder or intellectual disabilities) was updated when Resident 1 received an additional diagnosis, other schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), on 2/3/23. This failure had the potential to result in Resident 1 not receiving additional mental health services. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2021 with diagnoses which included bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode) and other schizophrenia. A record review of Resident 1's clinical document titled, Preadmission Screening and Resident Review (PASRR ) Level 1 Screening Document, dated 3/3/21, indicated, Level 1 - Negative, meaning at the time a Level 2 screening was not necessary. A record review of Resident 1's admission Record indicated on 2/1/23, Resident 1 received a new diagnosis, Other Schizophrenia (characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. During a concurrent interview and record review with the Director of Nursing (DON) on 12/14/23, at 10:36 AM, the DON stated when there was a new mental health diagnosis a Resident Review Established Change (RREC) needed to be done. The DON confirmed the RREC was not done for Resident 1 and it should have been done on February 2023 due to Resident 1's new diagnosis of other schizophrenia. The DON stated completing the RREC was important because it checked if the resident was stable. The DON further explained completing the RREC for Resident 1 may lead to additional mental health services. A review of the facility policy titled, Pre-admission Screening Resident Review (PASSR), revised 3/7/23, indicated, .If there has been a significant change in the individual's condition at any point, the individual must receive a new Level 1 screening .The Facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MD [mental disability] ID [intellectual disability] experiences a significant change in mental or physical status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 7 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility did not ensure a safe environment for 6 out of 29 sampled residents (Resident 1, Resident 6, Resident 83, Resident 43, Resident 101, and Resident 462) when: 1. Resident 1, Resident 6, Resident 83, and Resident 43's smoking paraphernalia were not stored correctly, 2. Resident 43 was smoking in the designated smoking area with an oxygen tank; and, 3. Resident 101 and Resident 462's fall care plan interventions for landing mats at the bedside were not implemented. These failures had the potential to result in avoidable injuries for Resident 1, Resident 6, Resident 83, Resident 43, Resident 101, Resident 462, and the potential to affect all residents' safety in the facility. Findings: 1a. During a concurrent observation and interview on 12/12/23, at 9:54 AM, in the [NAME] Hallway, Resident 1 was observed with a lighter and cigarette on his wheelchair. Resident 1 stated he got his lighter from somebody out there and pointed in the direction of the smoking area. Resident 1 further stated he was an assisted smoker and was not supposed to be smoking unsupervised. Resident 1 explained he was smoking unsupervised, and no staff were present to make sure he did not burn himself. During an interview with the Administrator (ADM) and Resident 1 on 12/12/23, at 10:02 AM, in the [NAME] Hallway, the ADM stated Resident 1 should not have the cigarette and lighter and retrieved the cigarette and lighter from Resident 1. The ADM explained Resident 1 required assistance with smoking and should not have the cigarette. Resident 1 stated he had his cigarettes in a lockbox and he should not have the lighter. The ADM stated Resident 1 could be at risk for injury because he needed assistance due to left sided weakness. A review of Resident 1's clinical document titled, Smoking Risk Assessment, dated 11/8/23, indicated, .High Risk (Unsafe to smoke) .Resident has had increased difficulty with getting to and from the smoking area. Administrator explained due to this difficulty it was appropriate for him to return to the assisted smoking schedule. He expressed his understanding and agreement . A review of Resident 1's Care Plan, dated 11/8/23, indicated, .Resident is an assisted SMOKER. At risk for injury .Resident will have minimum risk from burns/injury related to smoking .Resident will be assisted by staff during smoke breaks .Supervise while smoking . A review of the facility document titled, .Smoking Rules Assisted Smokers, indicated, .All smoking paraphernalia will be managed by staff . 1b. During an observation on 12/13/23, at 9:36 AM, in Resident 6's room, Resident 6 was observed to take out two lighters out of his pocket, five lighters were noted in a jar on his nightstand, and a pack of cigarettes on his overbed table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 8 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with licensed nurse (LN) 4 on 12/13/23, at 9:40 AM, in Resident 6's room, LN 4 stated Resident 6 should not have the lighters and cigarettes. LN 4 explained the lighters and cigarettes should be in a lockbox. LN 4 further explained the lighter and cigarettes should not be there because there was a risk for fire. A review of Resident 6's clinical document titled, Smoking Risk Assessment, dated 12/1/23, indicated, .Low Risk (Safe to smoke) . A review of Resident 6's Care Plan, dated 9/21/23, indicated, .Will adhere to facility smoking safety policy . A review of the facility document titled, Resident Smoker Contract Independent Smoker .I understand I must keep my smoking paraphernalia secure for the safety of the other residents in the facility. Lock boxes are available from the facility to be loaned to the resident to secure items . 1c. During an observation on 12/12/23, at 11:19 AM, in Resident 83's room, Resident 83 appeared to be sleeping. A large, 16-ounce (unit of weight) bag of pipe tobacco was noted to be on the floor by Resident 83's bed. During an interview on 12/12/23, at 1:15 PM, in Resident 83's room, Resident 83 confirmed he had been keeping the tobacco on the ground. Resident 83 explained social services came by and gave him a lockbox to put his tobacco in today. During an interview with LN 4 on 12/12/23, at 1:32 PM, LN 4 confirmed Resident 83's tobacco was on the ground prior to receiving the lockbox. During an interview with the Social Services Director on 12/12/23, at 1:20 PM, the SSD stated she gave Resident 83 a lockbox. The SSD explained Resident 83 should be storing his tobacco in a lockbox. A review of Resident 83's clinical document titled, Smoking Risk Assessment, dated 8/26/23, indicated, .Low Risk (Safe to smoke) . A review of Resident 83's Care Plan, revised 12/5/23, indicated, .Will adhere to facility smoking safety policy . A review of the facility document titled, Resident Smoker Contract Independent Smoker .I understand I must keep my smoking paraphernalia secure for the safety of the other residents in the facility. Lock boxes are available from the facility to be loaned to the resident to secure items . 1d. A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility in the beginning of 2023 with diagnoses which included chronic obstructive pulmonary disease (COPD, a group of disease that cause airflow blockage and breathing related problems) and respiratory failure with hypoxia (not enough oxygen in the blood to reach the tissues). A review of Resident 43's Order Review History Report, indicated Resident 43 had a physician order for Oxygen @ [at] 2 LPM [liters per minute] via nasal cannula [a small flexible tube that contains two open prongs intended to sit just inside the nostrils] . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 9 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with Resident 43 on 12/12/23, at 2:08 p.m., Resident 43 stated she was a smoker. Resident 43 further stated, I always keep my own lighter. Resident 43 was observed to grab her small black bag from her bed and pulled out 1 cigarette and 1 lighter. During an interview with LN 7 on 12/13/23, at 3:44 p.m., LN 7 stated a resident who was an assisted smoker should not have any smoking paraphernalia at their bedside or on them. LN 7 further stated they had a lockbox at the East Nurse Station where they kept assisted smoker residents' paraphernalia. LN 7 explained Resident 43 was an assisted smoker. During a concurrent observation and interview with LN 7 on 12/13/23, at 4 p.m., at the East Nurse Station, LN 7 confirmed Resident 43 had no smoking paraphernalia stored in the lockbox. During a concurrent observation and interview with LN 7 on 12/13/23, at 4:03 p.m., in Resident 43's room, Resident 43 was observed in bed and pulled out 1 lighter from a small black bag. LN 7 confirmed Resident 43 had smoking paraphernalia at the bedside and should not. LN 7 stated the risk was the resident's safety. During an interview with the ADM on 12/13/23, at 4:14 p.m., the ADM stated residents who were assisted smokers should not have smoking paraphernalia at the bedside. The ADM further stated assisted smokers who had smoking paraphernalia with them at the bedside had the potential for injury, resident safety, and fire. A review of Resident 43's Smoking Risk Assessment, dated 12/3/23, indicated, .High Risk (Unsafe to smoke) .Forgetful/Confused . A review of Resident 43's Care Plan, dated 12/4/23, indicated, .Resident is an assisted SMOKER. At risk for injury .Resident will have minimum risk from burns/injury related to smoking .Will adhere to facility smoking safety policy . A review of the facility undated document titled, [name of facility] Smoking Rules Assisted Smokers, indicated, .All smoking paraphernalia will be managed by staff . During a review of the facility's policy and procedure (P&P) titled, SMOKING POLICY, revised March 2023, the P&P indicated, .To promote the safety of the smoking resident .Smoking material(s) for residents requiring supervision will be labeled and kept at the nurses' station . 2. During a concurrent observation and interview on 12/13/23, at 4:06 p.m., with CNA 3 in Resident 43's room, Resident 43 stated she wanted to go outside to smoke. Resident 43 was observed getting out of bed and walked to a wheelchair. An oxygen tank was observed inside a black bag tied to the back of the wheelchair with a blanket partially covering the top of the oxygen tank. Resident 43 had a nasal cannula attached to the oxygen tank. CNA 3 was observed to wheel Resident 43 out of the room and down the hall towards the designated patio smoking area. During an observation on 12/13/23 at 4:08 p.m., Resident 43 and CNA 3 were noted in the the designated patio smoking area. Resident 43 was observed sitting in the wheelchair with the nasal cannula resting below Resident 43's chin. Resident 43 was further observed lighting up a cigarette while the oxygen tank was still tied to the back of the wheelchair. CNA 3 was observed standing next to Resident 43. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 10 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 12/13/23, at 4:14 p.m., with LN 7 near the designated smoking area, LN 7 confirmed Resident 43 had an oxygen tank in the designated smoking area and should not. LN 7 stated the risk was a fire or explosion. During an interview with the ADM on 12/13/23, at 4:14 p.m., the ADM stated an oxygen tank was not allowed to be in the designated smoking area and the risk was a fire and injury. A review of Resident 43's Care Plan dated 12/4/23, indicated, .Resident is an assisted SMOKER. At risk for injury .Resident will have minimum risk from burns/injury related to smoking .Will adhere to facility smoking safety policy .No Oxygen in the designated smoking area . During a review of the facility's policy and procedure (P&P) titled, SMOKING POLICY, revised March 2023, the P&P indicated, .To promote the safety of the smoking resident .Oxygen is not permitted in designated smoking areas . 3a. A review of Resident 101's admission RECORD indicated he was admitted to the facility in 2023 with diagnoses which included metabolic encephalopathy (a condition that can cause confusion, behavioral changes, and weakness), muscle weakness, and difficulty in walking. A review of Resident 101's clinical document titled, SBAR [Situation, Background, Assessment/Appearance, Request]: Change of Condition, dated 12/6/23, indicated, .Staff found resident lying on the floor by his bed, facing the footboard. Stated he is rushing and hit his head under the bed .Order to send to ER [emergency room] for further eval and treatment . A review of Resident 101's care plan initiated on 12/6/23, indicated, .The resident has had an actual fall .The resident will resume usual activities minimizing the risk of injury .Poor Balance Unwitnessed fall .Landing mat [mat used to reduce the risk of fall related injuries] at bedside . During a concurrent observation and interview on 12/13/23, at 10:34 AM, Resident 101 was observed lying sideways in his bed. LN 3 confirmed Resident 101 did not have a landing mat on the floor beside his bed. LN 3 stated the purpose of the landing mat was to prevent injuries. LN 3 further stated Resident 101 was at an increased risk of injury including a fracture from a fall. LN 3 stated Resident 101's care plan indicated a landing mat at the bedside. LN 3 further stated the care plan should always be followed. During an interview with the Director of Nurses (DON) on 12/15/23, at 9:36 AM, the DON stated assessments were performed after a fall to ensure resident specific interventions were care planned and implemented. The DON further stated landing mats were used to prevent injuries from a fall and if the mat was not in place Resident 101 was at a higher risk of sustaining an injury.The DON explained the purpose of the care plan was to direct resident care and ensure appropriate interventions were in place. The DON stated it was her expectation that staff would follow all care plan interventions. 3b. A review of Resident 462's admission RECORD indicated Resident 462 was admitted to the facility in 2023 with diagnoses which included muscle weakness and difficulty in walking and mobility. During a concurrent observation and interview on 12/12/23, at 2:45 PM, in Resident 462's room, Resident 462 was observed sitting in bed, being fed by Family member (FM) 1. FM 1 stated Resident 462 attempted to stand up on his own and fall. FM 1 further stated Resident 462 lost strength following a recent illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 11 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 462's Care Plan dated 11/29/23, indicated, .the resident is at risk for falls r/t (related to) weakness, pain, new placement, unsteady gait .Will minimize risk of injury from falls .Landing mat [mat used to reduce the risk of fall related injuries] at bedside . During a concurrent observation and interview on 12/14/23, at 9:30 AM, in Resident 462's room with CNA 1, CNA 1 confirmed there were no landing mats at Resident 462's bedside. CNA 1 stated landing mats were a care plan intervention for residents at risk for falls. CNA 1 further stated landing mats should be on the floor beside Resident 462's bed to prevent injury from a fall. During a subsequent observation on 12/15/23, at 9:58 AM, Resident 462 was observed resting in bed. There were no landing mats on the floor at Resident 462's bedside. During an interview with the DON on 12/15/23, at 11:45 AM, the DON stated residents who were identified at risk for falls were provided interventions which included placing the bed in low position, landing mats at the bedside, and monitoring residents' cooperation with the interventions. The DON further stated it was her expectation if the care plan indicated an intervention for a landing mat at the bedside, the intervention would be implemented immediately. The DON explained if a landing mat was not placed beside the bed of a resident who was determined to be a fall risk, this placed the resident at risk for further injury from a fall. A review of the facility policy and procedure titled, FALL MANAGEMENT PROGRAM, revised March 2023, indicated, .INTENT To ensure the facility provides an environment that is free from accident hazards over which the facility has control .Resdients at risk for falling shall have a care plan that identifies individual risk factors and person-centered interventions, based on risk factors .The facility nursing staff .shall update the residents plan of care accordingly to reduce the risk of further occurences of a fall and/or to reduce the risk(s) for significant injury related to falling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 12 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 of 14 residents (Resident 46) receiving oxygen in the facility, received oxygen consistent with professional standards of care when Resident 46 had an oxygen concentrator that was not free of dust and debris. Residents Affected - Few This failure had the potential to result in respiratory illness and infection in Resident 46. Findings: During a concurrent observation and interview with licensed nurse (LN) 4 on 12/12/23, at 11:08 AM, in Resident 46's room, Resident 46's oxygen concentrator filter was noted to have a large amount of dust and debris. LN 4 confirmed there was a large amount of dust and debris. LN 4 explained the filter should not be dusty. LN 4 further explained the dust and debris could cause upper respiratory infections and cough. During an interview with the Director of Nursing (DON) on 12/15/23, at 10:03 AM, the DON stated it was important to keep the oxygen concentrator free of dust and debris due to infection control and the risk for additional respiratory issues. A review of an undated oxygen concentrator manual, indicated, .Air Filter-Prevents dirt, dust and lint from entering your unit .Cabinet Filter-It is critical to inspect the cabinet filter on a routine basis. Remove the cabinet filters, clean with mild soap or detergent, rinse thoroughly and ensure filters are dry before reinstalling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 13 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure safe medication handling for a census of 99 when: Residents Affected - Few 1. Facility did not ensure safe storage and handling of hazardous medications (drugs that pose short-or long-term harm upon exposure to human via skin or inhalation); and, 2.Facility did not ensure prescription medication delivery receipts were signed and accounted for by a licensed nurse (LN). These failures could contribute to unsafe medication handling and possible drug diversion (illegal or abuse of prescription drugs). Findings: 1a. During a medication administration observation for Resident 66, in the East station of the facility with LN 5 on 12/12/23, at 4:44 p.m., LN 5 poured Valproic acid (or Depakote- a medicine to control seizures) in a medicine cup with bare hands for administration via G-tube (or Gastrotomy tube- a tube inserted through the belly that delivers nutrition and medication directly to the stomach). During a review of Resident 66's medical record titled, Medication Administration Record, (or MAR- listed medications and times for the nurse to administer per doctor's order) dated 12/23, the MAR order for Valproic acid liquid indicated, Valproic Acid Oral Solution .(Valproate Sodium) Give 5 ml (milliliter- measure of volume) by mouth three times a day related to OTHER SEIZURES (abnormal brain activity); pls(please) wear proper PPE(Personal Protective Equipment like gowns, gloves, eye protection) .-start date-11/14/2023 . During a review of Resident 66's Valproic acid prescription label on an original amber colored bottle dated 11/14/23, the label had no yellow colored Hazardous Drug alert that could be easily recognized. The label had a small black and white colored print in the lower portion of the label, which was not easily recognizable. Additionally, the Valproic acid bottle had red spillage stains on the outer surface of the bottle. During an interview with LN 5, in the East Hall, on 12/13/23, at 4:15 p.m., LN 5 confirmed she was not using gloves during the handling and administering of liquid Valproic acid. LN 5 stated she was not aware of this drug being hazardous and the bottle did not have recognizable yellow sticker. The bottle was not stored with a proper hazardous handling sign in a zip lock bag. 1b. During a concurrent interview and inspection of the East 1 medication cart with LN 6, on 12/12/23, at 10:42 a.m., a bottle of Megestrol liquid (or Megace- hormonal therapy drug used to treat cancer and used to help with appetite) labeled as hazardous medicine was not stored safely in a zip lock bag. LN 6 with bare hands, removed the name label from the bottle and poured the remaining liquid medicine in the garbage attached to the medication cart with bare hands along with the empty bottle of Megace. LN 6 then took the full garbage bag out and there was a hole noted in the bag. LN 6 acknowledged the finding and stated the medication was completed and the bottle was almost empty. During an interview on 12/14/23, at 4:30 p.m., with the Director of Nursing (DON) in her office, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 14 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when asked about hazardous medication storage and handling, the DON stated the hazardous medication should have been stored in the zip lock bags. The DON further stated the nurses should have followed the MAR instructions and the label on the medicine while handling the hazardous drugs. 2.During a concurrent interview and medication storage inspection with LN 6, on 12/12/23, at 10:30 a.m., at the [NAME] Nurse station, the medication delivery receipts binder was not signed and dated by nursing staff upon pharmacy delivery to the facility. Further inspection of the delivery receipts indicated narcotic opioid (drugs with highest risk of abuse or diversion) medications were not signed and dated when received by nursing staff. LN 6 confirmed the findings and stated the receipts should have been signed by the receiving nurse. During a review of the facility's policy and procedure ( P&P) titled, SAFEGUARDING CONTROLLED SUBSTANCES, revised March 2023, indicated, .The facility has established guidelines for safe handling, receiving, storing, administering, reconciling, and safeguarding controlled substances .When controlled substances are delivered from a pharmacy, they shall be verified .and signed by a licensed nurse and the delivery driver .receipt .of controlled substances will be documented on a disposition log [records basic information about the medicines destroyed] and signed by two nurses . During a review of the facility's P& P titled, PROVIDER PHARMACY REQUIREMENTS, dated 2007, indicated, .The provider pharmacy is responsible for rendering the required service in accordance with local, state, and federal laws and regulations .and professional standards of practices .The provider pharmacy agrees to perform .assisting the nursing care center, as necessary, in determining the appropriate acquisition, receipt .of all medications .providing medications packaged in accordance with the nursing care center's needs and equipment requirements . Review of the drug information for Valproic acid, last accessed via Lexicomp (a drug information database) on 12/19/23, the information indicated to handle valproic acid as a hazardous drug as follow Hazardous Drugs Handling Considerations; Hazardous agent (NIOSH .National Institute for Occupational Safety and Health (NIOSH) conducts research and makes recommendations for the prevention of work-related injury and illness) .Use appropriate precautions for receiving, handling, administration, and disposal .Gloves (single) should be worn during receiving, unpacking, and placing in storage. NIOSH recommends single gloving for administration of intact tablets or capsules. NIOSH recommends double gloving, a protective gown, and (if there is a potential for vomit or spit up) eye/face protection for administration of an oral liquid/feeding tube administration. Review of the drug information for Megace (Megestrol), last accessed via Lexicomp on 12/19/23, the drug information indicated the following: Hazardous Drugs Handling Considerations: Hazardous agent (NIOSH .). Use appropriate precautions for receiving handling, storage, preparation, dispensing, transporting, administration, and disposal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 15 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure a high dose of Ergocalciferol [Vitamin D product; helps the body absorb calcium and phosphorous (vital minerals) for healthy bones and used in the treatment of diseases caused by a hormonal imbalance like hypoparathyroidism (a hormone that regulated mineral absorption)] was reassessed for continued use in 1 out of 5 residents (Resident 95) sampled for unnecessary medications. Residents Affected - Few This failure could result in unsafe medication use, accumulation of medication in the resident's body and adverse effects. Findings: During a review of DailyMed (drug information site by US National Institutes of Health, NIH, which provides trustworthy information about marketed drugs) drug information on Ergocalciferol (a Vitamin D product) 50,000 units (a unit for measuring vitamins), last accessed on 12/19/23, via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e58cfb46-f8a7-4327-bbe8-da4d4be2bd1d, the drug information indicated, Therapeutic dosage should be readjusted as soon as there is clinical improvement. Dosage levels must be individualized, and great care exercised to prevent serious toxic effects .When high therapeutic doses are used progress should be followed with frequent blood calcium determinations .Adequate dietary calcium is necessary for clinical response to vitamin D therapy. Further review of the drug information section on Adverse Reactions, indicated the following possible side effects: Gastrointestinal (abdominal effect): Nausea, anorexia (no appetite to eat), constipation .anemia, weight loss. During a review of Resident 95's electronic medical record titled, Medication Administration Record, (or MAR, a document listed medication orders and administration) dated 12/23, the MAR indicated a doctor's order for the high dosage vitamin D as follows: Ergocalciferol Oral Capsule 1.25 MG (50,000 units; same as Vitamin D; MG and units are unit of measure): Give 1 capsule by mouth one time a day every Wed (Wednesday) for supplement -Start Date- 5/31/23. Further review, the order did not have a duration of use. During a review of Resident 95's electronic medical record under the Orders section on 12/13/23, the record indicated Vitamin D 50,000 units order was originally initiated on 4/17/23 as supplement and had continued for over 7 months. The order section did not include any order for calcium supplement to improve clinical response to vitamin D therapy. During a review of Resident 95's electronic medical record titled, Nursing Progress Notes, under the Assessment Summary, dated 11/14/23, at 12:39 PM, the note indicated 10% (or about 22 lbs., lbs. a measure of weight; % is fraction of 100) weight loss from 5/29/23 to 11/14/23. Further review of Resident 95's electronic MAR dated 12/2023, the MAR indicated an order for metoclopramide (or Reglan, a medication used for nausea) since 6/1/23 for treatment of nausea and vomiting. During a review of Resident 95's nursing plan of care or Care Plan, last reviewed on 12/14/23, the plan of care included ergocalciferol (vitamin D) use as supplements/nourishments and vitamin/minerals as ordered under the resident's nutritional risk section. The plan called for Monitor labs as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 16 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0757 available. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Consultant Pharmacist (CP) note to Medical Doctor (MD) 1, dated 8/2/23, the note indicated Resident 95 was on a relatively high-dose vitamin D 50,000 units weekly (equivalent of 7000 units/day) since 5/31/23. Vitamin D 50,000 units given weekly is generally recommended for treating deficiency for 6-8 weeks .Maintenance dose of Vitamin D is generally 800-2,000 units/day; May consider rechecking vitamin D [redacted] level to determine if current vitamin D should be continued. The note was signed by a provider as Agree and was dated on 8/4/23. Residents Affected - Few During a review of Resident 95's electronic medical record titled, Lab Result Record, dated 9/18/23, the lab report for vitamin D level was listed as 72 ng/mL (nanogram/milliliter- a measure of quantity or level in blood). The lab report also included the following guideline: Deficiency (means body have very low level): <20 ng/mL (< means Less than); Insufficiency (means the body did not have adequate level): 20-29 ng/mL; Sufficiency: =>30 ng/mL (> more than). Further review did not show any note or comments if the lab results were reviewed or acknowledged by a medical provider. In a telephone interview with MD 1 on 12/15/23, at 1:22 PM, MD 1 stated she did not order this medication and she would have limited the duration of use. MD 1 stated the high dose Vitamin D should have been re-assessed after 4 weeks of use. During a review of the facility's policy titled, Medication Monitoring, dated 1/23, the policy indicated Resident-specific MRR (Medication Regimen Review) recommendations and findings are documented and acted upon by nursing care center and/or physician .The nursing care center follows up on the recommendations to verify that appropriate actions has been taken. Recommendations shall be acted upon within 30 calendar days .For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or reject all or some of the report and should document his or her rationale . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 17 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, and record review, the facility failed to ensure antipsychotic medication (drugs used to treat mood and mental health disease) use, diagnosis (medical or mental indication), and monitoring was based on standards of practice in 2 out of 18 residents (Resident 5, Resident 61) when: 1. Resident 5 did not have a specific diagnosis for the use of an antipsychotic medication called Zyprexa (a mind-altering antipsychotic drug); and, 2. Resident 61 was documented as having a diagnosis of schizophrenia for resistive to care as documented in the medical record for use of Risperdal (a mind-altering antipsychotic drug). These failures could result in unsafe medication use and/or treatment of mental health or behavior issues. Findings: 1. During a review of Resident 5's electronic medical record titled, History and Physical, (a comprehensive review of medical conditions) written by Medical Doctor (MD) 1, dated 11/20/23, the record indicated, a medically complex patient, who was admitted with generalized weakness and a history of kidney, heart issues and seizure (a disease causing burst of uncontrolled electrical activity in the brain and muscle twitching or stiffness) while not having the mental capacity to care for self. During a review of Resident 5's electronic medical record titled, Medication Administration Record, (or MAR- document listed medication use and nursing monitoring documentations) dated 12/23, the record indicated a psychotropic medication was prescribed for an unspecified psychosis (psychosis refers to a collection of symptoms that affect the mind) as follows: Olanzapine Oral Tablet 20 MG .(or Zyprexa, a drug used to treat mental illness; MG is unit of measure); Give 1 tablet by mouth one time a day related to UNSPECIFIED PSYCHOSIS .m/b (manifested by) angry outburst .-Start Date- 11/18/23. Further review of Resident 5's medical record from Hospital A, dated 11/16/23, the record did not give an indication for use of Zyprexa which was a medication prior to admit to the hospital. During a review of a communication note from the facility's East Nurse Station to MD 1's office, dated 11/20/23, the communication note indicated patient (Resident 5) is on olanzapine (with) no diagnosis. Can we get psychosis dx (diagnosis) for med (medication) use? The record further indicated a handwritten note Yes with initials and dated 11/20/23. In a telephone interview with MD 1 on 12/15/23, at 1:29 PM, the MD 1 stated the psychosis was a collection of symptoms and not specific to the resident's mental issues or diagnosis. During a review of Resident 5's MAR, dated 12/23, the record indicated behavior monitoring for use of olanzapine as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 18 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few OLANZAPINE: Monitor episodes of DEMENTIA (memory loss) .WITH PSYCHOTIC DISTURBANCE M/B (Manifested By) angry outburst. every shift -Start Date- 11/17/23. The behavior monitoring diagnosis was not the same as the documented diagnosis for the use of Zyprexa. In an interview with Director of Nursing (DON) in her office on 12/15/23, at 2:20 PM, the DON acknowledged the nurse-doctor communication, and stated it was the physician who made an assessment on the documenting diagnosis for residents. 2. During a review of Resident 61's medical record titled, History and Physical, (or H&P, a summary of medical, physical, and mental health issues) dated 9/2/22, written by Medical Doctor (MD) 1, the H&P indicated a medically complex resident with recent heart attack surgery, blood sugar disease, and seizure among other medical conditions. The H&P did not indicate any mental health diagnosis for Resident 61. During a review of Resident 61's medical record titled, Medication Administration Record, (or MAR, a document listed medication orders and documentation of care by nursing staff) dated 12/23, the MAR indicated an order for a mind-altering medication for schizophrenia (a mental disease that could cause delusions and/or hallucinations) as follows: Risperdal Oral Tablet 0.5 MG (or Risperidone, drug use to control mood; MG is milligram, a measure of the unit); Give 1 tablet by mouth two times a day related to PARANOID SCHIZOPHRENIA m/b (manifested by) resistive to care -Start Date- 6/22/23. Further review of the MAR indicated no behavior issues related to Risperdal use and resistive to care documented in the record. During a review of Resident 61's admission record from Hospital B, dated 8/31/22, the record did not indicate any mental health diagnosis for the use of Risperdal. During a review of Resident 61's mental health consult written by Nurse Practitioner for mental health (NP-M), dated 1/6/23, the record indicated a telehealth visit (visit via video conference) follow up, the note indicated, Resident 61 is talkative and aware of his diagnosis of paranoid schizophrenia .Not endorsing .AVH (Auditory/Visual Hallucination, or hearing/seeing unreal things). The record on section titled, Assessment ., indicated three mental health diagnoses including Schizophrenia- rule out paranoid type by patient endorsement. In a telephone interview with MD 2 who oversaw Resident 61's mental health care, on 12/15/23, at 2:02 PM, the MD 2 stated he had the initial telehealth encounter on 11/18/22 and endorsed history of schizophrenia based on the resident's statement. MD 2 could not comment on why his tele-visit documentations was not part of the electronic medical records. MD 2 stated that he did not talk to family members for more background information when the resident's BIM score was documented to be 9 (BIMS stands for Brief Interview for Mental Status and used to get a quick snapshot of how well one functioning cognitively at the moment; the BIM score is from 0-15; with 0 to 7 points: Suggests severe cognitive impairment; 8 to 12 points: Suggests moderate cognitive impairment; 13 to 15 points: Indicates cognitive intactness.) In a telephone interview with Resident 61's Responsible Party (RP) on 12/15/23, at 8:49 AM, the RP stated Resident 61 had a history of mood swings and bipolar but was never told he had schizophrenia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 19 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0758 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 61's nursing plan of care or Care Plan, the document indicated, The resident is on (risperidone) (Antipsychotic Medications) r/t (related to) schizoaffective disorder/psychosis manifested by: behaviors of (resistive to care). Mood disorders (e.g. mania, bipolar disorder), Schizo-affective disorders; Date Initiated: 9/1/22.Attending MD and responsible party fully aware with the use of psychotropic meds. The care plan did not identify any areas that Resident 61 resisted care. Residents Affected - Few During a review of the facility's policy titled, Psychotropic Medication ., with a revision date of 3/23, the policy indicated, the intent was To provide staff with guidelines to ensure each resident attains and maintains .an environment that prohibits the use of chemical restraint .and not required to treat a resident's medical symptoms. The policy further indicated, a definition for Indication for use as the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer recommendations and/or clinical practice guideline, clinical standards of practice, medication references . The policy on the Guidelines section indicated, Residents who have not used psychotropics drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosis and documented in the clinical record. During a review of an undated facility's policy titled, Medical Director-Services Provided, the policy indicated the medical director Oversee all services provided .and physician Medical Consultants .Review and evaluate medication profile of patients and write prescription . During a review of the facility's policy titled, Develop-Implement Comprehensive Care Plan, dated 3/23, the policy under Refusal of Treatment, indicated, A resident may choose to refuse services or treatments that staff believes may be indicated to assist the resident reaching .or to keep the resident safe. When a resident's choice to decline care or treatment pose a risk to the resident's health or safety, the comprehensive care plan must .Identify the care or services being declined; attempts to find alternative means to address the identified risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 20 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 99 residents. The facility had a total of four errors out of 44 opportunities which resulted in a facility wide medication error rate of 9.09 %. Medication administration observations were conducted at varied times, in random locations throughout the facility. Residents Affected - Few These failures had the potential to result in unsafe medications use and not following the doctor's orders. Findings: 1. During a medication administration observation in the West-2 wing of the facility with Licensed Nurse (LN) 4, on 12/12/23, at 9:05 a.m., LN 4 administered Resident 57's medications. The administered medications included a total of six pills, one eye drop, one inhaler (breathing treatment), and one nasal (nose) spray that were due at 9 a.m. on a daily basis. During a review of Resident 57's medical record titled, Medication Administration Record, (or MAR; listed medications and times for the nurse to administer per doctor's order) dated 12/23, the MAR indicated, Advair .inhalation (a combination of two drugs in one used to treat breathing difficulty) .1 puff inhale two times a day -Start Date- 3/15/23 was due at 9 a.m. Further review of the MAR and the facility's document titled, Medication Admin Audit Report[ a computer report that documented the exact time the medication was documented as given] indicated that LN 4 marked and signed off on Advair as being given at 9:18 a.m., when it was not observed to be given, along with the other medications that were due at 9 a.m. During an interview with LN 4 in the [NAME] Hall, on 12/13/23, at 2:23 p.m., LN 4 acknowledged Resident 57's Advair was due at 9 a.m., and was not given during medication observation from 9:05 a.m. to 9:35 a.m. 2.During a medication administration observation in the East station of the facility with LN 5, on 12/12/23, at 4:06 p.m., LN 5 administered Resident 76's medications. The administered medications included 7 pills that were due at 5 p.m. on a daily basis and one pill called Lasix (water pill) that was not due at 5 p.m. During a review of Resident 72's medical record titled, Medication Administration Record, dated 12/23, the MAR indicated, .Furosemide .[ Lasix] .Give 1 tablet by mouth one time a day .-Start date-4/13/23 . was due at 9 a.m. on a daily basis. Further review of the MAR indicated Resident 72 was out of the facility at 9 a.m. on 12/12/23. During a review of the facility's document titled, Medication Admin Audit Report, indicated, Lasix was given at 7:36 a.m. by another morning nurse. LN 5 was observed giving Lasix at 5 p.m. and the audit report did not show any documentation of the administration. During an interview with LN 5 in the East Hall, on 12/13/23, at 4:14 p.m., LN 5 confirmed Resident 72's Lasix was due at 9 a.m. LN 5 stated Resident 72 went out of the facility for a procedure in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 21 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0759 Level of Harm - Minimal harm or potential for actual harm morning. LN 5 stated there was no order to give the morning medicine in the evening. LN 5 stated she was not sure why she gave Lasix to Resident 72 at 5 p.m. 3. During a medication administration observation in the East station of the facility with LN 5, on 12/12/23, at 5:01 p.m., LN 5 administered Resident 262's one medication called Atorvastatin (cholesterol medication). Residents Affected - Few During a review of Resident 262's medical record titled, Medication Administration Record, dated 12/23, the MAR indicated, .Atorvastatin .Give 1 tablet by mouth at bedtime .-Start date 11/29/23 . was due at 8 p.m. and was observed to be given at 5 p.m. During an interview with LN 5 in the East Hall, on 12/13/23, at 4:14 p.m., LN 5 confirmed Resident 262's Atorvastatin was due at 8 p.m., and was given at 5 p.m. three hours earlier than the scheduled time. LN 5 stated Resident 262 wanted her Atorvastatin before dinner and LN 5 did not document the need for administration time change. 4. During a medication administration observation in the East station of the facility with LN 5, on 12/12/23, at 5:16 p.m., LN 5 administered three medications to Resident 76 along with the nutritional supplement via G- tube (or Gastrotomy tube- a tube inserted through the belly that delivers nutrition and medication directly to the stomach). During a review of Resident 76's MAR, dated 12/2023, the MAR indicated, .Metoprolol [a medicine to control blood pressure] .Give 1 tablet .two times a day .-Start date- 10/17/2023 . was due at 5 p.m. on 12/12/23. Further review of the MAR and the facility's document titled, Medication Admin Audit Report, indicated that LN 5 documented Metoprolol was given at 5:50 p.m. when it was not observed to be given, along with the other medications that were due at 5 p.m. During an interview with LN 5 in the East Hall, on 12/13/23, at 4:19 p.m., LN 5 confirmed Resident 76's Metoprolol was due at 5 p.m., and was not given during medication observation from 5:16 p.m. to 5:50 p.m. LN 5 stated, she gave Metoprolol with the next tube feeding at 11:20 p.m. on 12/12/23. During an interview with the Director of Nursing (DON) in her office, on 12/14/23, at 4:29 p.m., the DON stated the nurses were expected follow the facility's policy on medication administration. Review of the facility's policy and procedure titled, ADMINISTERING MEDICATIONS, revision date 2022, the policy indicated, To provide employees with guidelines for the safe and timely administration of medications per physician order .Medications must be administered in accordance with the orders. Medications must be administered in accordance with state and federal guidelines The policy further indicated, .The licensed nurse must check the label three times to verify right resident, right medication, right dosage, right time and right method(route) of administration before giving the medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 22 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices for one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stored resident's medication and supplies) with a census of 99 when: 1.Expired (outdated) medications were stored in the medication storage room and medication carts; and, 2.A medication refrigerator located in the facility's [NAME] station was overcrowded and the temperature was 50 degrees upon opening. These unsafe medication storage practices could contribute to medication error and unsafe medication use. Findings: 1 a. During a concurrent observation and interview on [DATE], at 9:50 a.m., in the facility's [NAME] station medication room with Licensed Nurse (LN) 3, a Flu vaccine (a shot to prevent against Flu) bottle was expired on [DATE] while it was stored in the active storage area. LN 3 confirmed the finding and stated it should have been discarded. 1b. During a concurrent interview and inspection of the East- 1 medication cart with LN 6 on [DATE], at 11 a.m., the following were acknowledged by LN 6: i. An opened insulin Lantus (insulin- medication to treat diabetes or blood sugar) bottle was labeled with an opened date of [DATE] and was expired after 28 days of beyond the use date. LN 6 confirmed the insulin bottle was expired and should have been discarded. ii. An opened Levemir (insulin) bottle was labeled with an open date of [DATE] and was expired after 42 days of beyond the use date. LN 6 acknowledged it was expired and should not be in the cart. iii. An unopened and undated insulin Basaglar (Lantus) pen was not refrigerated. LN 6 confirmed it should have been in the refrigerator for long term storage, and not in the medication cart. iv. A box of inhalation medication called Breo Ellipta (medicine to treat breathing difficulty) was dated with an opened date of [DATE]. The manufacturer's label on the package indicated, discard the inhaler 6 weeks after opening. LN 6 confirmed the finding and stated the inhalation medicine should have been discarded and reordered. 1c. During a concurrent interview and inspection of the West- 1 medication cart with LN 7 on [DATE], at 2:45 p.m., the following findings were acknowledged by LN 7: i.An opened insulin Basaglar pen was not labeled with an open date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 23 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 ii.An opened insulin Lantus Solostar (insulin) had no open date. Level of Harm - Minimal harm or potential for actual harm iii. A box of inhalation medication called Breo Ellipta was dated with an opened date of [DATE]. The label on the box was covering the manufacturer's information. LN 7 confirmed the inhalation medicine was good for 6 weeks. LN 7 then stated the nurses should have used the pharmacy provided medication table (a document with instructions from pharmacy about the inhalation medicine use) to look for the beyond use date after opening each product. LN 7 stated the expired medicine should not be in the cart. Residents Affected - Few iv. A box of inhalation medication called Wixela (a combination of two drugs in one used to treat breathing difficulty) was not dated and was out of the foil package. The manufacturer's label on the package indicated, Discard .1 month after removal from the foil pouch. 2. During a concurrent interview and inspection of the facility's [NAME] station medication room with LN 3 on [DATE], at 9:50 a.m., a dormitory style refrigerator (a small combination refrigerator and freezer unit) was overfilled and overcrowded with the temperature noted to be 50 degrees Fahrenheit (temperature scale) upon opening. LN 3 acknowledged the findings. A review of the refrigerator temperature monitoring log posted on the outer side of refrigerator door, dated 12/23, the document indicated, Refrigerator temperature should be between 36-46 degrees. During an interview on [DATE], at 2:20 p.m., with the Director of Nursing (DON) in her office, the DON stated she expected the nursing staff to follow facility's guidelines or policy on dating multidose products upon opening and regularly checking the medication storage area for outdated products. During a review of the facility's policy and procedure (P&P) titled, LABELING OF BIOLOGICALS AND STORAGE OF BIOLOGICALS, revised [DATE], indicated, .The facility, in coordination with the licensed pharmacist, provides accurate labelling to facilitate precautions and safe administration of medications, and safe and secure storage .The medication label at a minimum includes the medication name .the expiration date .A multidose vial has been opened or accessed .the vial should be dated and discarded within 28 days .A multidose vial has not been opened or accessed .it should be discarded according to the manufacture's expiration date . The policy further indicated, The facility's safe medication storage includes the provision of appropriate environmental control, including exposure to improper temperature . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 24 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review, the facility failed to ensure the correct measuring scoops were used when [NAME] 1 did not measure the small portion diets correctly for 8 residents who received small portions. This failure resulted in plating unknown quantites of lunch items including starch with a potential to negatively impact the residents' nutritional status. Findings: During an observation in the kitchen on 12/14/23, at 11:50 AM, [NAME] 1 was observed serving small portions without using the appropriate scoops. During an interview with [NAME] 1 on 12/14/23, at 12:38 PM, [NAME] 1 confirmed she did not use the appropriate scoops to measure the small portions and she should have. During an interview with the Certified Dietary Manager (CDM) on 12/24/23, at 12:46 PM, the CDM stated they should measure the small portions. The CDM explained it was important to make sure the residents were getting the correct nourishment. During an interview with the Registered Dietitian (RD) on 12/14/23, at 1:54 PM, the RD stated portion sizes were important due to nutrition concerns such as to make sure the residents were receiving the right amount of nutrition. A review of the facility document titled, Food Production Chart, dated 2019, indicated, .Always use scoops or ladles for accurate portion control . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 25 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was prepared in accordance with professional standards of food service safety for 90 out of 99 residents receiving food from the kitchen when: 1. Pureed food was taste tested using the same spoon, 2. All food items for the lunch meal on 12/14/23 were not temped (process for taking temperatures of prepared food items using a calibrated kitchen thermometer); and, 3. The food preparation sink did not have an air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink) located under the food preparation sinks (where fruits, vegetables and other foods are prepared). These failures had the potential to expose 90 residents of a census of 99 to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: 1. During a concurrent observation and interview with [NAME] 1 in the kitchen on 12/14/23, at 11:15 AM, [NAME] 1 was observed preparing the pureed (blended food) food items. [NAME] 1 stated she always taste tested the pureed food items and was observed stepping away and retrieving a plastic white spoon. [NAME] 1 was further observed preparing the Barley puree, after obtaining the correct consistency, [NAME] 1 used the white spoon to taste test the barley and the placed the spoon down on the counter that was covered with parchment paper. [NAME] 1 was then observed preparing the first batch of pureed spinach and when the spinach was the correct consistency, [NAME] 1 used the same white spoon from the barley taste test and dipped it in the pureed spinach and tasted it. During an interview with [NAME] 1 on 12/14/23, at 11:33 AM, prior to [NAME] 1 pouring the pureed spinach into the tray for the steam table, [NAME] 1 was asked if she used the same spoon she used to taste test the barley. [NAME] 1 confirmed she was using the same spoon and threw out the batch of pureed spinach. [NAME] 1 explained she should have used a different spoon. [NAME] 1 further explained using a new spoon was important due to contamination. During an interview with the Registered Dietitian (RD) on 12/14/23, at 12:46 PM, the RD explained it was important to use separate spoons due to cross contamination (what happens when bacteria or other microorganisms are unintentionally transferred from one object to another) and food safety concerns. A review of the facility policy titled, Proper Food Tasting, dated 2019, the policy indicated, .Cooks are required to taste all food prior to serving .Proper tasting procedures are followed to avoid contamination of the resident food .Proper tasting procedures include .In the two-spoon method, a large spoon is used to take a sample of food from the container .The sample is placed in a serving dish or directly into a smaller spoon, which is used for tasting .Separate spoons are used for each item tasted . 2. During an observation of the kitchen tray line with [NAME] 1, on 12/14/23, at 11:55 AM, [NAME] 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 26 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 - Few was observed temping (taking the temperature of the food) the food items on the tray table. [NAME] 1 did not take the temperature of the two items on the steam table for the mechanical diet including the barley and the fish. During an interview with [NAME] 1, on 12/14/23, at 12:03 PM, [NAME] 1 stated she should have temped the barley and fish and she had not. During an interview with the Certified Dietary Manager (CDM), on 12/14/23, at 12:46 PM, the CDM confirmed all food items on the steam table needed to be temped to ensure the foods reached the correct temperature. During an interview with the RD on 12/14/23, at 1:54 PM, the RD stated the importance of temping the food was to ensure the food got to the correct temperature to prevent bacteria from growing and getting residents ill. A review of the facility policy titled, Thermometers, dated 2019, the policy indicated, .The cook will test the temperatures of all food, both hot and cold, just prior to serving . 3. During a concurrent observation and interview of the initial tour of the kitchen with the CDM on 12/12/23, at 8:21 AM, it was noted that the food preparation sink did not have an air gap. The CDM confirmed the food preparation did not have an air gap. During an interview with the RD on 12/14/23, at 1:54 PM, the RD stated an air gap prevented back flow of contaminated water into the food preparation sink, which would contaminate the food. The RD explained it was a food safety hazard to have a food preparation sink without an air gap. The RD further explained a resident could get food born illnesses if contaminated water gets onto the food. A review of the Food and Drug Administration (FDA) document titled, Food Code, dated 2017, in section, 5-202.13 Backflow Prevention, Air Gap, the Food Code indicated, .During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue. To prevent the introduction of this liquid into the water supply through back siphonage, various means may be used. The water outlet of a drinking water system must not be installed so that it contacts water in sinks, equipment, or other fixtures that use water. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. (https://www.fda.gov/media/110822/download) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 27 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe infection control and prevention practices with a census of 99 when: Residents Affected - Few 1. Safe infection control practices were not followed for cleaning and disinfecting a shared glucometer (a device used to measure blood sugar) in-between resident care for Resident 66; and, 2. Staff did not follow hand hygiene (cleaning and sanitizing hand) in-between resident care for Resident 57 and Resident 82, and Resident 72. These failures could pose health safety risks and spread of infection in the facility. Findings: 1. During a medication administration observation with Licensed Nurse (LN) 5 on 12/12/23, at 4:35 PM, in the facility's East hallway, LN 5 gathered the blood sugar measurement supplies plus a glucometer into the Resident 66's room. LN 5 then placed the supplies and glucometer on Resident 66's bed sheet, with gloved hands, LN 5 poked one left middle finger with a lancet (a sharp small needle) and squeezed the finger to get blood. LN 5 then soaked the test strip attached to the glucometer with blood to measure the blood sugar. Once out of the room, LN 5 removed her gloves and placed the glucometer on top of medication cart without cleaning and proceeded with Resident 66's medication administration task. LN 5 then placed the glucometer inside the medication cart drawer before moving to the next resident in the East hallway. In an interview with LN 5 in the East Hallway, on 12/13/23, at 3:55 PM, LN 5 acknowledged that she forgot to wipe, clean, and sanitize the glucometer after use. LN 5 then explained how it should have been cleaned and sanitized. In an interview with the facility's Infection preventionist (IP) in her office, on 12/13/23, at 3 PM, the IP stated the facility had two glucometers in each medication cart and nursing staff were to alternate use in-between care and clean the glucometer after each use. The IP stated in her training she emphasized the nursing staff to put the glucometer on a tissue to avoid contact with surfaces and use a wipe to clean and keep wet for 2 minutes. The IP stated the facility's approved sanitizing wipe had a two-minute wet time to kill all the germs. The IP stated the sanitizing wipe used for glucometer cleaning had no bleach (a cleaning chemical that kill germs in health care facilities) and they would use bleach if a resident had an infection called C. Diff (or Clostridium Difficile- a germ that causes a severe infection of the stomach and spreads very easily). The IP added there was no need for the nursing staff to use gloves when using the sanitizing wipe to clean and disinfect the glucometer or other shared resident care devices. In an interview with the Director of Nursing (DON) in her office on 12/14/23, at 4:45 PM, the DON stated the nursing staff should sanitize the glucometers before and after use and alternate the two glucometers in the medication cart. The DON stated the facility used the purple top sanitizer wipe to clean and sanitize the glucometer. The DON stated the bleach wipe was only used when there was a C. Diff infection was suspected. During a review of the glucometer manufacturer's instructions with [brand name] Assure Platinum Blood Glucose Monitoring System, with revision date of 9/2019, last accessed on 12/18/23, via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 28 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 https://medaval.ie/docs/manuals/Arkray-Assure-Platinum-Manual.pdf, the section on Cleaning and Disinfecting . indicated, The meter should be cleaned and disinfected after use on each patient .The cleaning procedure is needed to clean dirt, blood, and other body fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens (means germs in the blood). Residents Affected - Few During a review of the facility's policy titled, Glucose Monitor Cleaning/Disinfecting, dated 1/2021, the policy indicated, The glucose meter should be cleaned and disinfected after use on each patient .Open disinfectant package, follow product label instruction to disinfect the meter .Following cleaning, the meter should be disinfected with a .5-6% sodium hypochlorite solution (same as bleach) .unless a cleaning and disinfectant in one are used. 2. During a medication observation with LN 4 on 12/12/23, at 9:05 AM, in the facility's [NAME] hallway, LN 4 entered Resident 57's room without gloves or sanitizing hands to administer the medications including an eye drop. LN 4 after medication administration, exited the room without hand sanitization. LN 4 moved on to the next resident (Resident 82) for medication administration and put on gloves without using the hand sanitizing gel. Once done with the medication administration, LN 4 exited the room, and with the same gloves cleaned the medication tray then removed his gloves without using alcohol gel or washing hands. In another medication administration observation with LN 5 in the East hallway on 12/12/23, at 4:06 PM, LN 5 entered Resident 72's room with a blood pressure device without sanitizing hands with alcohol gel. LN 5 once out of the room, with bare hands, used one germicidal (kills germs) wipe to quickly clean one side of the blood pressure device and returned it to the bottom drawer of medication cart. LN 5 did not wash or sanitize their hands before re-entering the Resident 72's room for medication administration. In an interview with LN 4 on 12/13/23, at 2:29 PM, in the [NAME] hallway, LN 4 stated he may have missed hand sanitization before or after entering the room. LN 4 stated the hand washing was more important than hand sanitization and it should have been done frequently. For the eye drop administration, LN 4 stated the Resident did not like him using gloves during eye drop administration and did not want him to touch his face. In an interview with LN 5 on the East Hallway, on 12/13/23, at 3:55 PM, LN 5 acknowledged that she should have used gloves when using the sanitizing wipe to clean blood pressure device and may have forgotten to use hand gel before and after resident care. In an interview with the facility's Infection preventionist (IP) in her office on 12/13/23, at 2:47 PM, the IP stated she had been doing educational sessions on hand hygiene and had performed audits to give feed back to staff. The IP stated staff should wash their hands when soiled and use alcohol-based hand gel to sanitize their hands before and after entering any resident room. In an interview with the DON in her office on 12/14/23, at 4:45 PM, the DON stated she expected staff to sanitize their hands before any resident contact and wash their hands with soap and water if C. Diff. was suspected. During a review of the facility's approved disinfectant wipe labeled as Super Sani-Cloth Germicidal Disposable Wipe, with a purple color top, the label on Personal Protection indicated, When using this product, wear disposable protective gloves . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 29 of 30 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 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 a review of the facility's policy titled, Hand Washing-Hand Hygiene, dated 8/20, the policy indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .Personnel shall follow hand washing/hand hygiene procedures to help prevent the spread of infection .When indicated, employee must wash their hands .using soap and water .Apply (alcohol based hand rubs) to palm of hand and rub hands together . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 30 of 30