Health inspection·March 28, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evaluation of care and functional needs) dated 2/25/19, indicated Resident 71 needed extensive assistance (weight bearing support) and assistance of one-person for eating. During a review of the clinical record for Resident 83, the MDS assessment dated [DATE], indicated Resident 83 needed limited assistance (guided maneuvering of limbs) of one-person physical assist for eating. The facility document titled, MEAL TIME PROCEDURE undated, indicated . ALL NURSING ASSISTANTS NEED TO REPORT TO THE DINING ROOM TO ASSIST WITH PASSING TRAYS AND ASSISTING DINERS IN THE DINING ROOM ON TIME. RESIDENTS NEED SHOULD BE MET PRIOR TO MEALTIME, INCLUDING SET UP FOR MEAL . The facility policy and procedure titled Patients' Rights and Responsibilities dated 5/2003, indicated . Patients have the right to: 1. Considerate and respectful care . 13. Receive care in a safe setting, free from . neglect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 2 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the residents right to privacy during care for two of two sampled residents (Resident 39 and 65) when: Resident 39 and 65 were provided with care by two Registered Nurses (RN 1 and RN 5) without privacy. Residents Affected - Few This practice violated Resident 39's and 65's right to privacy during the delivery of care. Findings: During a medication administration observation on 3/26/19, at 7:35 a.m., RN 5 entered Resident 65's room and took the resident's blood pressure (measures how hard the blood is pushing against the walls of the arteries) while the maintenance man worked on Resident 65's neighbors bed. RN 5 did not pull the privacy curtain to offer Resident 5 privacy and allowed the maintenance man to see. During an interview with RN 5, on 3/26/19, at 8:15 a.m., she stated she should have pulled the privacy curtain around Resident 65's bed to ensure her privacy was protected from others not involved in her care. During a medication administration observation on 3/26/17, at 12:03 p.m., RN 1 entered Resident 39's room to administer an insulin (medication used to treat high blood sugar) injection. Resident 39's sat in front of the sliding door which overlooked to an outside patio. Resident 39 pointed to her abdomen as her preferred site for insulin injection and lifted her blouse to expose the area. RN 1 proceeded to administer Resident 39's insulin without closing the curtain on the sliding door. During an interview with RN 1, on 3/26/19, at 5:20 p.m., he stated he should have closed the curtain on the glass sliding door to provide the resident privacy during medication administration. During an interview with the director of nursing (DON) on 3/27/19, at 9:55 a.m., she stated the resident's right to privacy should have always been maintained while performing care and procedures. The facility policy and procedure titled, Registered Nurse's Job Description & Competency Evaluation dated 1/16/19 indicated, General Accountabilities: . 3. Assures that the rights of the patients are respected and maintained by allowing for privacy, confidentiality, and dignity in the provision of service . The facility's policy and procedure titled, Patients' Rights and Responsibilities dated 5/2003 indicated, POLICY . Patients have the right to . 11. Have personal privacy respected .examination and treatment are confidential and should be conducted discreetly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 3 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to provide a safe and homelike environment for residents when: loud alarms and overhead paging was frequently used in the facility and Resident 4's restroom floor was in disrepair. These failures created an environment that was not homelike for residents. Findings: During an observation on 3/25/19, at 8:50 a.m., in the kitchen, the Dietary [NAME] (DC) 2 overhead paged the Maintenance Engineer (ME). During a concurrent observation and interview with Assistant Director of Nursing (ADON), on 3/26/19, at 9:32 a.m., at the nurses' station, a very loud alarm turned on with a light by a wall at the nurses' station. The alarm was heard in the whole facility. The ADON stated, [The alarm turns on] when the residents push on the exit doors [when they are] trying to go out. The ADON stated some residents with wander guard wrist bands (a system to alert staff when a resident is exit seeking or exits a building) triggered alarms to alert staff when they got close to exit doors. During an observation on 3/26/19, at 10:17 a.m., at the nurses' station, Licensed Vocational Nurse (LVN) 4 was paged overhead to report to the nurses' station. During an observation on 3/26/19, at 10:21 a.m., at the nurses' station, LVN 4 was paged overhead to report to the nurses' station. During an observation on 3/26/19, at 11:33 a.m., at the nurses' station, overhead paging was done from the dining room for Certified Nursing Assistants (CNAs) to assist for lunch. During an observation on 3/26/19, at 11:51 a.m., overhead paging was used for CNA's to assist in the dining room. During an observation on 3/26/19, at 12:09 p.m., overhead paging was used for CNA's to assist in the dining room. During an observation on 3/26/19, at 4:28 p.m., at the nurses' station, overhead paging was done from the dining room for CNAs to assist residents for dinner. During an observation on 3/26/19, at 4:47 p.m., overhead paging was done for CNAs to assist with dinner being served in the dining room. During an observation on 3/26/19, at 4:50 p.m., overhead page was done for a staff to call the nurses' station. During an interview with Resident 30, on 3/27/19, at 8:50 a.m., he stated the noise form the excess alarms and overhead paging bothered him. Resident 30 stated it was a part of living in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 4 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with Registered Nurse (RN) 4, on 3/27/19, at 8:55 a.m., at the nurses' station, a loud beeping occurred every second and continued to beep loudly for two minutes. RN 4 stated. It is not super loud . the door alarm is louder. RN 4 stated the loud alarms and beeping was normal in the facility. During an observation on 3/27/19, at 9:00 a.m., at the nurses' station, overhead paging was done for a nurse to report to the station. A loud beeping started which happened every 4 seconds and continued for 10 minutes. During an observation on 3/27/19, at 9:27 a.m., overhead paging was done to announce the start of group exercise. During an observation on 3/27/19 at 9:31 a.m., overhead paging was done to announce the start of a group activity. During an interview with the Administrator (ADM), on 3/27/19 at 12 p.m., the ADM stated the facility did not have a policy and procedure to control noise levels or loud overhead paging in the facility. During a concurrent observation and interview with Resident 4, on 3/28/19, at 11:23 a.m., in Resident 4's room, a portion of the linoleum floor on the doorway entrance to the bathroom was peeling. Resident 4 stated, In July of last year, I fell going in the bathroom . There is a lip [peeling linoleum] on the floor. My feet frequently get caught on it . See how you get your toes under there . During a concurrent observation and interview with LVN 3, on 3/28/19, at 1:56 p.m., in Resident 4's room, LVN 3 looked at the peeling linoleum floor to the bathroom entrance. LVN 3 used her foot to gauge the extent of the peeling linoleum. LVN 3 stated, It [peeling linoleum flooring] catches my foot. The floor shouldn't be like that . It is not homelike LVN 3 stated it was the resident's home. During a concurrent observation and interview with DON, on 3/28/19, at 2:25 p.m., in Resident 4's room, DON looked at the peeling linoleum floor to the bathroom entrance. The DON used her foot to gauge the extent of the peeling linoleum. The DON stated, There is a lip [peeling linoleum flooring]. The DON stated it was an accident hazard and it was not homelike. During an interview with Administrator, on 3/28/19, at 2:36 p.m., he stated, The floor should be fixed. The facility policy and procedure titled In-Room Furniture Furnishings dated 1/24/18, indicated . Safety Management Program provides our residents . and visitors a physical environment free of hazards our goal top manages activities proactively to reduce the risk of injuries .to promote a home-like environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 5 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to ensure services provided meet professional standard of quality for 18 of 18 sampled residents (Resident 17, 25, 42, 64 ,74, 89, 90, 1, 7, 10, 20, 31, 41, 76, 74, 5, 89 and 64) when: Residents Affected - Few 1. Registered nurse (RN) 5 did not follow the manufacturer's specifications on an inhaler (inhalers - a portable device for administering a drug which is to be breathed in) inhalation administration use for one of 18 sampled residents (Resident 17). This failure had the potential to place Resident 17's at risk for developing infections in her mouth. 2. RN 2 signed the medication administration record (MAR) prior to the administration of medications to one of 18 sampled residents (Resident 25). This failure had the potential to place Resident 25 at risk for medication errors. 3. The facility failed to follow the physician ordered diet for one of 28 sampled residents in the dining room when Resident 5 was served a regular diet instead of a clear liquids diet (water, broth and plain gelatin diet that are easily digested and leave no undigested residue in your intestinal tract). This failure resulted in Resident 5 being given the wrong diet which placed Resident 5 at risk of compromising his scheduled medical procedure. 4. The facility failed to implement their policy in signing physician's telephone orders. This failure resulted in an unsigned telephone order for residents (Resident 42, 64, 74, 89, 90) for more than 5 days. This failure placed residents at risk for medication errors. 5. The facility failed to follow the facility policy and procedure on elopement risk assessment and security monitoring system for eight of eight residents (Residents' 1,7, 10, 20, 31, 41, 76, 74) who had been using wander alarm (a type of security monitoring) were not assessed prior to its use. This failure had the potential for these resident's freedom to move around various places in the facility to be restricted when these resident's elopement risk were not assessed. Findings: 1. During a concurrent medication administration observation and interview with Registered Nurse (RN) 5, on 3/26/19 at 8:15 a.m., in Station 2, RN 5 proceeded to Resident 17's room to administer scheduled oral and inhalation medications. Resident 17 requested her inhalation (inhaler) medication first. RN 5 shook and handed the inhaler to the resident without any instruction. Resident 17 self- administered the inhalation therapy, then grabbed her glass of water with straw, sipped some water and swallowed it. RN 5 instructed resident to rinse her mouth and spit the water out on an empty glass. Residents 17 stated she had swallowed the water. Resident 17 stated she did not know why she needed to rinse her mouth with water and spit the water out into an empty glass. Resident 17's physician's order dated 2/26/19 indicated, [Name brand inhaler] Aerosol Powder Breath activated 1 puff inhale orally . RINSE MOUTH AND SPIT AFTER USE The inhaler patient information insert instruction dated 12/2017, indicated, .Step 6. Rinse your mouth . Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 6 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy and procedure titled, Medication Administration dated 12/12 indicated, . Medication Administration .13. Explain to resident the type of medication being administered and the procedure . During an interview with RN 5, on 3/26/19, at 8:15 a.m., RN 5 stated the correct process was for the nurse to first explained the medication procedure and reason why the resident needed to rinse her mouth out after each inhalation administration. RN 5 stated the risk of resident drinking the water and not rinsing her mouth after the inhaler medication could place Resident at risk of getting oral thrush (a painful yeast infection that affects the inside of the mouth). RN 5 stated continuously educating the resident to rinse her mouth out, not swallow the water and spit the water in the empty glass would ensure the manufacturer's specification were followed. During an interview with the director of nursing (DON), on 3/27/19, at 10 a.m., she stated the expectation would be for the nurse to educate Resident 5 regarding the medications and treatments prior to the administration of the medication to ensure the manufacturer's specifications would be followed. During a review of the clinical records for Resident 17, Minimum Data Set, dated [DATE] Section C0500 BIMS (Brief Interview for Mental Status) indicated 15 - cognitively intact. 2. During a medication administration observation on 3/27/19, at 8 a.m., in Station 2, RN 2 prepared the scheduled morning medications for Resident 25 then, signed the medication administration record (MAR) after all the pills were in the medicine cup and prior to the actual administration of medications to Resident 25. During an interview with RN 2, on 3/27/19, at 8:25 a.m., RN 2 stated the correct medication documentation process was for her to sign the resident's MAR after she had actually administered Resident 25's medications. During an interview with the DON, on 3/27/19, at 10:05 a.m., she stated the expectation would be for the nurse to sign the MAR after the medication was administered to the resident. The facility's policy and procedure titled Medication Administration . Documentation: 1. The individual who administered the medication dose, records the administration on the resident's MAR immediately following the medication being given . Review of the professional reference titled Fundamentals of Nursing-[NAME]-Perry dated 2005, page 847 indicated, Recording Medication administration. After administering a medication, the nurse records it immediately on the appropriate record form . The nurse never charts a medication before administering it. Recording immediately after administration prevents errors . Review of the professional reference titled, Clinical Procedures for Safer Patient Care dated 4/4/19 indicated,6.2 Safe Medication Administration . Medication errors are the number -one error in health care (Center for Disease Control [CDC], 2013) . NEVER document that you have given a medication until you have actually administered it . 3. During an observation on 3/25/19, at 11:48 a.m., in the dining room, Resident 5 was given his lunch tray. Resident 5's lunch tray contained roast turkey with alfredo sauce, pasta and green beans. Resident 5 stated he was on clear liquids (diet). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 7 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Registered Nurse (RN) 1, on 3/25/19, at 12:05 p.m., he stated, For Resident 5, clear liquids was ordered starting today. He is scheduled for a procedure . All meals ordered is clear liquids. RN 1 stated Resident 5 was served the wrong diet. RN 1 stated Resident 5's lunch should have been clear liquids. During an interview with RN 1, on 3/26/19, at 4:11 p.m., he stated the physician ordered diet was not followed for Resident 5's lunch on 3/25/19. RN 1 stated, Doctor's orders should be followed. During an interview with Director of Staff Development (DSD) 2, on 3/27/19, at 2:49 p.m., she stated, When the CNAs and RNA's hand the trays in the dining room, they will not know the diet order changed. They just go by the meal ticket [slip]. DSD 3 stated physician ordered diets should be followed. During an interview with Nutritional Services Supervisor (NSS), on 3/28/19, at 9:10 a.m., she stated the physician ordered diet should be followed. NSS stated, The ordered diet [Resident 5] was not followed . We [Dietary] made a mistake. My staff did not pay attention. NSS stated Resident 5's scheduled medical procedure would have been cancelled if he ate the regular diet served. NSS stated residents could have a bad outcome if the ordered diet was not followed. During an interview with the Registered Dietitian, on 3/28/19, at 11:42 a.m., she stated, We should follow doctor's ordered diet . We [facility] can have a negative [resident] outcome if we don't follow it. During a review of the clinical record for Resident 5, the Order Summary Report dated 3/15/19, indicated Clear Liquid Diet on 03/25/19, 03/26/19, 03/27/19 unless otherwise noted by MD [Doctor] . The facility policy and procedure titled Therapeutic Diets dated 2/22/17, indicated . Therapeutic diets are prepared and served as prescribed by the attending physician . The professional reference titled California Nursing Practice Act dated 1/1/13, indicated . The practice of nursing . means those functions . including all of the following . (2) Direct and indirect patient care services . necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician . 4. During a review of the clinical record for Resident 89, the Physician's Telephone Orders dated 10/31/18 indicated, Transport to ER [Emergency Room] for treatment and evaluation after an unwitnessed fall. The Telephone order document indicated, Physician please sign and return within 72 hours. The telephone order was signed by the physician on 11/19/18 (19 days after the order). During a concurrent interview and record review with the DON and Assistant Director of Nursing (ADON), on 3/26/19 at 9:00 a.m., the DON and ADON reviewed Resident 89's clinical record and stated the physician's verbal/telephone order dated 10/31/19 was not timed, dated or signed by the physician. The ADON stated the telephone order document should be signed within five days from the date of the order. The ADON stated the physician only makes rounds in the facility once a month. During a concurrent interview and record review with the ADON on 3/26/19 at 3:48 p.m., the ADON reviewed the policy titled Verbal or Telephone Orders physician's orders had to be signed within five days of obtaining the verbal/telephone order. The ADON stated, we are not following our policy for verbal/telephone orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 8 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review with the DON and DSD 2, on 3/26/19, at 5:20 p.m., the DON and DSD 2, stated Resident 74's telephone order was written on 10/31/18 and was timed, dated and signed by the physician on 11/19/18. The DSD 2 stated the telephone order was signed by the physician 19 days after the order was given which was greater than the required five days. The DON stated an order was written on 3/15/19 at 14:00 and signed 3/26/19 at 5:30 [10 days later] should have been signed on 3/20/19 by 14:00. The DON and DSD 2, reviewed clinical records for Resident 42, 64, 74, 89, 90 and stated these clinical records contained multiple telephone orders that had not been signed by the physician within the five-day time frame. The DON stated verbal/telephone orders should have been signed by the five-day time frame from the date the order was received. During a concurrent interview and record review with the Medical Records Clerk (MRC), on 3/27/19, at 9:17 a.m., the MRC verified verbal orders for Resident 64 were signed but not dated and times. The MRC reviewed clinical records for Resident 42, 74, 89, 90 and stated the records contained multiple telephone orders that had not been signed by the physician within the five days from the date the order was received. The MRC stated, We call the Doctor's office if we notice it had been a while, like a month or so. The MRC stated the facility policy required a physician signature within five days of obtaining the verbal/telephone order. The MRC stated, I know they are late a lot. The facility policy titled Verbal or Telephone Orders dated 5/2016 indicated, .Procedure .10. Verbal/Telephone orders obtained at [facility name] must be signed within five days. (authentication must include the date and time of countersignature so that compliance can be verified). 5. During a concurrent observation, interview and record review with Rehabilitative Nursing Assistant (RNA)/CNA 9, on 3/26/19, at 10 a.m., CNA 9 demonstrated how sensor alarms (a device that emits sound to alarm staff) were checked daily to verify they were in proper working order. RNA/CNA 9 reviewed the sensor check log for the month of March and stated RNAs were responsible to checked the sensor alarms daily. During a concurrent interview and record review with RN 1, on 3/26/19, at 4p.m., RN 1 reviewed clinical records for Residents' 1,7, 10, 20, 31, 41, 76, 74) who had been using wander alarms and were not assessed prior to its use. RN 1 stated the facility did not perform elopement assessment for residents at risk for elopement. The facility process was for the nurse to place a sensor alarm on residents that were seen going outdoors. RN 1 stated, There is no separate assessment for elopement, it is just a box to check if resident has a history of fall. RN 1 stated if a resident was observed to be at risk for elopement or staff reported a resident was trying to go out of the facility, nurse would apply a sensor alarm. RN 1 stated he does not remember documenting residents risk for elopement in the weekly summary form. RN 1 stated the RNAs (CNA's that provide exercises to resident's) are responsible for checking the sensor alarm daily to ensure the devise is functioning properly. During a concurrent interview and record review with RN 3, on 3/27/19, at 3:03p.m., RN 3 stated the facility did not have an assessment tool for elopement. The RN stated, We just start a behavior monitoring and a care plan and both the charge nurse and the RNA [CNA] will decide if a resident needed a wander alarm (sensor alarm). During an interview with RN 4, on 3/27/19, at 3:49 p.m., RN 4 stated residents were assessed for signs of dementia (a medical condition that causes memory loss), ambulation or mood but unsure if the facility had assessment tool for elopement or any criteria for the sensor alarm. RN 4 stated, I did not see it in the admission packet and elopement is not part of the weekly summary documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 9 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0658 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 Director of Nursing (DON), on 3/27/19, at 4:30 p.m., the DON stated the facility did not have an assessment form for elopement, she stated the facility policy mentioned it but there was no assessment form being used at the time of interview. The DON stated it was the responsibility of all the staff in observing the resident's behaviors and notifying the charge nurse. The facility policy and procedure titled Elopement risk and Security Monitoring System dated 1/2018 indicated, .1. Residents are assessed upon admission for individual characteristics that would put them at risk for elopement .2 .Weekly assessment is documented on the weekly summary form by license nurse . After six months of use, the interdisciplinary team (IDT), at a quarterly conference will assess for discontinuance of sensor use . What to do when the alarm sounds .Find the resident and bring him/her inside the facility . Event ID: Facility ID: 056155 If continuation sheet Page 10 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident who were unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition for two of 28 sampled residents (Residents 83 and 71) when Residents 83 and 71 did not have assistance with their meals. Residents Affected - Few This failure resulted in Residents 83 and 71 having to wait for 10 minutes to receive assistance with their meals which could have the potential to cause unplanned weight loss. Findings: During an observation in the dining room, on 3/25/19, at 11:45 a.m., four residents were seated at the same table. Resident 64 was served her lunch meal by Certified Nursing Assistant (CNA) 1. CNA 1 left and did not serve Resident 71, 83 and 57 their lunch meal. During an observation in the dining room, on 3/25/29, at 11:52 a.m., Resident 71 was served her lunch but did not start eating. Resident 71 waited for assistance. Resident 57 was served her lunch and started eating. At 11:55 a.m., Resident 83 was served her lunch meal. Resident 71 and 83 were assisted with their meals by CNA 2 10 minutes after Resident 64 was served her lunch meal. During an interview with Restorative Nursing Assistant (RNA) 1, on 3/27/19, at 3:49 p.m., he stated, There are only 2 RNAs and 1 CNA assigned to the dining room . We get help from CNAs that are done helping the residents on the floor [resident rooms]. RNA 1 stated residents that needed assistance should be assisted once the meal serving was started. RNA 1 stated, Resident 83 needs to be assisted and fed. If she is not helped, she will not be able to eat enough . Resident 71 needs to be assisted in eating. If she is not helped, she will not be able to eat enough . RNA 1 stated there was no assistance provided in the dining room for Resident 83 and Resident 71 at the start of the meal service. RNA 1 stated, Residents should eat at the same time [on the same table] and be provided assistance. During an interview with RNA 2, on 3/28/19, at 8:25 a.m., she stated there were two RNAs and one CNA assigned to the dining room and there were 8 residents that eat in the dining room that need assistance. RNA 2 stated, They [residents] need a staff to sit with them and assist them. RNA 2 stated they had to wait for CNAs to assist with all the residents that need assistance in the dining room. During an interview with Director of Nursing (DON), on 3/28/19, at 2:05 p.m., she stated residents should not be sitting for more than a couple of minutes in the dining room surrounded by people eating without being assisted. DON stated residents that need to be assisted should receive the required assistance. During a review of the clinical record for Resident 71, the Minimum Data Set (MDS- a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) dated 2/25/19, indicated the Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 4 indicating severe cognitive impairment and Resident 71 required extensive assistance and one-person physical assist for eating. The care plan for Nutritional Status For Resident 71 dated 5/31/18 indicated . Assist resident with all meals as follows: Dependent . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 11 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the clinical record for Resident 83, the MDS dated [DATE], indicated a BIMS score of 8 out of 15 indicating moderate cognitive impairment and Resident 83 required limited assistance and one-person physical assist for eating. The care plan for Nutritional Status For Resident 83 dated 3/7/19, indicated . Assist resident with all meals as follows: Set-up . The facility document titled, MEAL TIME PROCEDURE undated, indicated ALL NURSING ASSISTANTS NEED TO REPORT TO THE DINNG ROOM TO ASSIST WITH PASSING TRAYS AND ASSISTING DINERS IN THE DINING ROOM ON TIME . CNAS ASSIGNED TO THE HALL WILL ASSIST THE DEPENDENT AND ASSISTED DINERS . CHECK TO SEE THAT ALL DEPENDETN DINERS ARE ASSISTED . The facility document titled Job Description . Certified Nursing Assistant undated, indicated . Prepares patients/residents for meals . Assist in feeding . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 12 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and record review, the facility failed to implement an ongoing resident centered activities program to support the resident/family's choice of activities to maintaining and/or improve resident's physical, mental and psychological wellbeing for one of four sampled residents (Resident 43). Residents Affected - Few This failure resulted in the activity needs of Resident 43 going unmet. Findings: During a telephone interview with a family member (FM) 1, on 3/25/19, at 9:27 a.m., she stated Resident 43 loves music, like western and pop music and enjoyed being around people. FM 1 stated she had provided the resident with a radio and wanted the radio to be on music for the resident to make sure Resident 43 wound not feel alone. FM 1 stated the last time she was at the facility, she noticed the television owned by another resident was not on. FM 1 stated she was informed the television set was broken. FM 12 stated she recently bought a new television set for Resident 43's visual stimulation. FM 1 stated she asked some of the CNAs (certified nursing assistant) who had been caring for of Resident 43 for a long time to turn on the television set on or to make sure the radio was playing. FM 1 stated this was not happening all the time when she was at the facility visiting the resident. FM 1 stated Resident 1 was non-verbal and could not communicate what she wanted but could respond with smiles and eye contacts. During an observation in Resident 43's room, on 3/25/19, at 8:10 a.m., 11: a.m. and 4 p.m. Resident 43 was on bed and the black & white television set was turned on with no sound and the radio was not playing. During an observation of Resident 43 in her room, on 3/26/19, at 10 a.m., with the medical record assistant (MRA), the television set TV was on with sound muted and no music was playing from the radio cassette. During a concurrent interview and record review of Resident 43's clinical record with the activity director (AD), on 3/26/19, at 10:25 a.m., she stated the resident loved to watch cartoons on television. Resident 43's care plan on Activity last revised on 2/2019 indicated, Provide room or 1:1 visits such as - Music, pet visits. The AD stated she did not know the family wanted music to be provided to the resident and she did not know there was a radio cassette provided by the resident's family in Resident 43's room. During an interview with CNA 41, on 3/26/19, at 3 p.m., she stated the residents loves music, especially western and pop music. CNA 41 stated when she and another CNAs were on duty they saw to it the TV was on for Resident 43's visual stimulations and the radio was on for hearing stimulation. CNA 41 stated Resident 41 was unable to speak but was able to responded by smiling and eye contact. CNA stated there were different staff assigned to the resident and it was possible the family's request for Resident 43's music to be turned on was not passed on to every CNA working at the facility. During an interview with CNA 22, on 3/27/19, at 8 a.m., she stated Resident 43 was unable to speak but could understand and respond to simple cues like holding on the rail when staff provided care. CNA 22 stated Resident 43 was unable to move on her own because she had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity of joints of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 13 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete both upper and lower extremities and was unable to walk. CNA 22 stated she was a new care provider for Resident 43 and did not know the television set or the music radio should be turned on for the resident. During a concurrent interview with the AD and review of the clinical record for Resident 43, the Minimum Data Set (MDS) assessment dated 1/2018 indicated under section F, Interview for activity Preferences While you are at the facility .B. how important is it to you to listen to music you like ? . Very important . how important it is to you to do your favorite activities? . Very important. The AD stated Resident 43's activity preferences should have been implemented for resident to have meaningful activity experiences. Event ID: Facility ID: 056155 If continuation sheet Page 14 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure residents environment remained free of accident hazards for one of 59 sampled residents (Resident 4) when the linoleum (hard, washable floor covering) flooring by the door to Resident 4's bathroom was lifted and peeling off the floor base. This failure resulted in a hazardous environment for Resident 4 that could lead to falls. Findings: During a concurrent observation and interview with Resident 4, on 3/28/19, at 11:23 a.m., she stated, In July of last year, I fell going in the bathroom . There is a lip [peeling linoleum] on the floor. My feet get caught on it . See how you get your toes under there? There was peeling of the linoleum flooring going to the bathroom. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 3/28/19, at 1:56 p.m., in Resident 4's room. LVN 3 felt the floor by the bathroom door with her foot. LVN 3 stated, It [peeling linoleum flooring] catches my foot. It is a fall risk. The floor shouldn't be like that. LVN 3 stated the floor was an accident hazard and should not be left like that. During an observation and concurrent interview with Director of Nursing (DON), on 3/28/19, at 2:25 p.m., DON felt the floor by the bathroom door. DON stated, There is a lip [peeling linoleum flooring]. DON stated it was an accident hazard and a fall risk. During an interview with Administrator (ADM), on 3/28/19, at 2:36 p.m., he stated, The floor should be fixed. ADM stated the peeling linoleum flooring was a fall risk for the resident. During a review of the clinical record for Resident 4, the Minimum Data Set (MDS- a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) dated 3/5/19, indicated the Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 12 indicating moderate cognitive impairment. During a review of the clinical record for Resident 4, the Post Fall Summary dated 2/4/19, indicated . Date/Time of fall: 2/1/19 [at] .[1:15 p.m.] Summary of Fall: Res [Resident] found on the floor . resident states that she was walking to the BR [bathroom] . No injuries noted . During a review of the clinical record for Resident 4, the Post Fall Summary dated 11/26/18, indicated . Date/Time of fall: 11/24/18 [at] . [12:35 p.m.] Summary of Fall: Res [Resident] was found sitting on buttock on floor . Res states she was transferring food items from lunch tray to small table . and fell to the floor. No injuries noted . The facility policy and procedure titled Fall Risk Assessment dated 4/2018, indicated . [Facility Name] will ensure the resident environment remains as free of accident hazards as possible while allowing maximum mobility . The facility policy and procedure titled In-Room Furniture Furnishings dated 1/24/18, indicated . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 15 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 Safety Management Program provides our residents . and visitors a physical environment free of hazards our goal top manages activities proactively to reduce the risk of injuries . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 16 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide sufficient staffing to residents when the dining room was left with insufficient staff to meet the needs of the residents requiring assistance for two of three meals on Saturday, March 23, 2019. This failure resulted in residents not having care and socialization needs met. Findings: During a resident council meeting interview, on 3/26/19, at 10:00 a.m., nine residents (Residents 8, 11, 12, 13, 14, 27, 40, 67 and 86) and two family members attended the resident council meeting and 11 out of 11 attendees at the resident council meeting expressed they were not happy with the short staffing situation in the facility dining room. During an interview with Resident 86, on 3/26/19, at 10:01 a.m., he stated staffing was an issue on holidays, weekends and flu season. He stated the facility would close the dining room prior to the weekend because of insufficient staffing. During an interview with Resident 42's wife (RW42), on 3/26/19, at 10:01 a.m., she stated the facility was understaffed and questioned why her husband only gets out of bed twice a week. She stated her husband was not receiving the care he needed. RW42 stated one Certified Nursing Assistant (CNA) was assigned to her husband's hallway with 14 residents on the hall require assistance. During an interview with Resident 40, on 3/26/19, at 10:02 a.m., she stated her call light had been on for 30 minutes before a CNA tended to her needs. During an interview with Staffing Coordinator (SC), on 3/27/19, at 9:45 a.m., SC stated on 3/23/19 Saturday the facility had two day-shift licensed nurse and one CNA who called in sick and the facility did not replace the three staff members. SC stated some of the effects of being short staffed were not providing good patient care, dining room were closed when they did not have enough CNA's and Restorative Nursing Assistant's (RNA's). SC stated the dining room unavailability affected resident rights, they did not get their meals timely. SC stated it was not written anywhere that the facility needed a total of eight RNA's and CNA's to open the dining room, it was just known that if the number dropped below eight the dining room was closed. SC stated, Residents are upset when dining room is closed because they like to socialize and eat with friends. The facility document titled Daily Schedule dated 3/23/19, indicated an LVN, an RN and a CNA called in, did not come to work and were not replaced on the schedule. During an interview with Director Staff Development (DSD) 1, on 3/27/19, at 3:00 p.m., she stated the dining room had been closed depending on how many RNA's are working. DSD 1 stated, The facility need a minimum number of RNA's and CNA's working for the dining room to remain open, when there are sick calls the dining room might be closed. DSD 1 stated there was no policy regarding dining room closing process related to staffing. DSD 1 stated, It is a resident's right to have access to the dining room for all meals. During an interview with Director of Nursing (DON), on 3/27/19, at 3:40 p.m., she stated in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 17 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many staffing plan the facility needed a minimum of eight RNAs/CNAs for the dining room to be open. The DON stated, Less staff makes it hard to deliver trays in a timely manner. The DON stated the plan regarding staffing and the dining room was not written in a policy. The DON stated it was her goal to schedule enough staff so that the dining room was open for breakfast, lunch and dinner 365 days a year. The DON stated, It is not good if we close the dining room related to staffing. The DON stated she was not aware the dining room had closed on 3/23/19 due to staffing. The facility policy and procedure titled Nursing Department, Scope of Service undated, indicated . Staffing, Adjustment to staffing in the Nursing Department . is based upon residents' needs and acuity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 18 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and record review, the facility failed to ensure a performance review of every nurse aide at least once every 12 months was for 17 of 21 Certified Nursing Assistants (CNAs). Residents Affected - Some These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews. Findings: During employee records review with the Director of Staff Development (DSD) 1 and 2, the vice president for human resource (VP/HR) and the VP/HR Assistant on 3/25/19, at 2:50 p.m., the following CAN records indicated: 1. CNA 31 with a hire date (HD) of 3/22/17, was evaluated on 11/19/18, eight months and 18 days late. 2. CNA 32 with a hire date of 7/1/13, was evaluated on 11/20/18, four months and 19 days late. 3. CNA 62 with a hire date of 2/21/17, was evaluated on 3/7/18, 14 days late. 4. CNA 65 with a hire date of 1/26/17, was not evaluated on 1/2018 and 1/2019. 5. CNA 2 with a hire date of 5/26/16, was evaluated on 11/21/18, seven months and 21 days late. 6. CNA 28 with a hire date of 3/28/16 was evaluated on 5/17/18, two months and 19 days late. 7. CNA 17 with a hire date of 1/6/17 was evaluated on 10/22/18, 10 mos. 21 days late. 8. CNA 42 with a hire date of 9/8/16 was evaluated on 11/21/18, two months and 13 days late. 9. CNA 51 with a hire date of 2/21/17 was evaluated on 5/14/18, three months and 23 days late. 10. CNA 41 with a hire date of 1/4/05 was not evaluated on 1/2019. 11.CNA 66 with a hire date of 10/20/16 was evaluated on 11/21/18, one months late. 12. CNA 10 with a hire date of 9/19/16 was evaluated on 11/20/18, two months late. 13. CNA 12 with a hire date of 2/11/17 was evaluated on 11/15/18, nine months and 14 days late. 14. CNA 37 with a hire date of 5/31/17 was evaluated on 11/28/18, five months and 28 days late. 15. CNA 34 with a hire date of 9/25/17, was evaluated on 11/26/18, two months and one day late. 16. CNA 45 with a hire date of 3/22/16 was evaluated on 11/20/18, eight months and 20 dates late. 17. CNA 48 with a hire date of 8/16/10 was evaluated on 11/19/18, four months and 11 days late. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 19 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0730 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the VP for HR, on 3/25/19, at 3:30 p.m., he stated the competency evaluations of the CNAs should have been done every 12 months from the CNA's hire date. The facility's policy and procedure titled Employee performance appraisal dated 11/13 indicated, . It is the policy of [name of facility] to review each employee's performance during the first ninety (90) days of a new position and annually thereafter. PURPOSE: To provide for a comprehensive and systemic review of the employees' performance in order to define expectations and assure competence . PROCEDURE . Annual anniversary Performance Appraisal . Schedule the performance appraisal session before the employee's anniversary review date . RESPONSIBILITY: The manger/supervisor is responsible for conducting performance appraisals on a timely basis, prior to the due date . The Human Resource Department is responsible for monitoring and ensuring compliance of the Performance Appraisal program . Event ID: Facility ID: 056155 If continuation sheet Page 20 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles and ensure all drugs and biologicals were securely stored and permit only authorized personnel to have access to these medications when: 1. An insulin medication vial was not labeled with a change of direction sticker for one of 12 sampled residents (Resident 63). 2. Registered nurse (RN) 5 left an inhaler on top of the med cart unattended. 3. RN 2 left the medication cart unlocked and unattended. These failures placed all residents' health and safety at risk when drugs were inappropriately labels and drugs were left unattended and accessible to unauthorized individuals. Findings: 1. During a concurrent medication administration observation and interview Registered Nurse (RN) 1, on 3/26/19 at 12 p.m., RN 1, held the bottle of the insulin and read the pharmacy label, Humalog [insulin medication to treat diabetes (a medical condition that causes high blood sugars) 100 units/ml (milliliter) vial, inject 10 units every morning and evening daily . RN 1 stated there was a new order for the insulin does. During an interview with RN 1, on 3/26/19, at 12:15 p.m., he stated there should have been a change of direction sticker attached to the Humalog insulin vial and the box. He stated it was the responsibility of a licensed nurse on duty to attach a change of direction sticker on the medication. RN 1 obtained a change of direction sticker which indicated, DIRECTION CHANGED REFER TO CHART [medical record]. During a review of the clinical record for Resident 66, the physician's telephone order dated 3/6/19, indicated, Change insulin with sliding scale medium [refers to the progressive increase in pre-meal or nighttime insulin doses]. The medication administration record dated 3/6/19, indicated, .Medium dose using Humalog insulin, Follow hypoglycemia (deficiency of glucose in the bloodstream) protocol. During an interview with the Director of Nursing (DON), on 3/27/19, at 10;10 a.m., she stated the expectation would be for the nurses to ensure a change of direction sticker be placed on the insulin bottle and containers as soon as the direction change for its use was received by the licensed nurse to ensure safety in the administration of medications. The facility's policy and procedure titled Medication administration dated 12/12 indicated, . PROCEDURES Medication Preparations . 3 .Apply a direction change sticker to label if directions have changed from the current label . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 21 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 The facility's policy and procedure titled MEDICATIONS AND MEDICATION LABELS' dated 12/12 indicated, POLICY . Medications are labeled in accordance with currently accepted professional principles . to promote safe medication use . PROCEDURES . 6. a. If the prescriber's direction for use change or the label is inaccurate, the nurse may place direction change, change of order-check chart or similar label on the container indicating there is a change in direction for use, taking care not to cover label information. b. When such a direction change label appears on the container, the medication nurse checks the resident's medication record (MAR) or the prescriber's order for current information. 2. During a medication administration observation on 3/26/19 at 8:55 a.m. in Station 2. RN 5 left an inhaler (an oral inhalation for asthma) unattended while RN 5 placed a call to the pharmacy to follow up the eye drops supply for another resident. During an interview with RN 5, on 3/26/19, at 9:10 a.m., she stated the inhaler should have been securely stored inside the med cart after use and should not have been left unattended on top of the med cart to avoid the potential risk of residents and others having access to the inhaler. During an interview with the DON, on 3/27/19, at 10:03 a.m., she stated the expectation would be for all nurses to make sure all medications were secured inside the medication cart prior to the nurse leaving the area. The facility's policy and procedure titled Medication Administration dated 12/12 indicated, . PROCEDURES Medication Administration: . During administration of medications medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart 3. During a medication administration observation on 3/27/19, at 8:20 a.m., in Station 2, RN 2 left the medication cart unlocked and unattended in front of room [ROOM NUMBER] while she was in room [ROOM NUMBER] attending to a resident behind a curtain. RN 2 stated she was unable to see the unlocked medication cart from behind the closed privacy curtains. RN 2 stated the medication cart should have been locked. During an interview with the DON, on 3/27/19, at 10:04 a.m., she stated the medication cart should never have been left unlocked and unattended to prevent unauthorized access to the medications. The facility's policy and procedure titled Medication Administration dated 12/12 indicated, . PROCEDURES Medication Administration: 17. During administration of medications medication cart is kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 22 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed when incorrect portions of beef stew were served to 21 of 22 residents receiving small portion diets. This failure resulted in residents receiving incorrect servings and amount of nutrients in their meals which could potentially result to negative outcome to the residents. Findings: During an observation and concurrent interview with Dietary [NAME] (DC) 2, on 3/26/19, at 11:38 a.m., in the kitchen, trayline [meal service on trays] was started. There was a pan of regular beef stew with red and blue ladle. A pan of mechanical beef stew had red and blue ladle. A pan of pureed beef stew had red and blue ladle. DC 2 stated, The blue ladle is 6 oz. [ounce - unit of measure] and red ladle is 8 oz. During an interview with DC 4, on 3/26/19, at 1145 a.m., she stated the regular and mechanical beef stew pan both had blue and red ladles. DC 4 stated, They are 8 oz. [red] and 6 oz. [blue]. During an interview with DC 3, on 3/28/19, at 8:14 a.m., she stated, We have to follow the menu and the recipe . We also follow the right size scoop [measurement]. DC 3 stated if the food amount on the menu was not followed the patient would not get the right amount of nutrients. During an interview with Nutritional Services Supervisor (NSS), on 3/28/19, at 8:34 a.m., she stated there were 22 residents on small meal portions with one resident on clear liquids diet. NSS stated, Menus are supposed to be followed, also food items and measurement. NSS stated there could be negative resident outcomes if the menu was not followed. NSS stated, They [residents] won't get sufficient calories . they can have weight loss, get sick, poor wound healing, weight gain, obesity . If the menu says 5 oz., then we serve 5 oz. During an interview with the NSS, on 3/28/19 at 1048 a.m., she stated there were 21 residents that was served 6 oz. of beef stew. During an interview with Registered Dietitian (RD), on 3/28/19, at 11:42 a.m., she stated menus were used to ensure nutritional adequacy of the meal for the residents. RD stated, Menus should be followed . Also for variation that meets the nutritional requirement. The scoops and measurement should be followed. RD stated residents could have negative outcomes if the menu was not followed. RD stated, You can have malnutrition, skin break down and weight gain. The facility document titled Spring Cycle Menus Week 3 Tuesday dated 3/26/19, indicated . Regular . [NAME] Beef Stew . Small . 5 oz . Mech Soft [mechanical soft- ground] . [same portions as regular diet] . CCHO [Controlled Carbohydrate] . [NAME] Beef Stew . Small . 5 oz . The facility document titled Compact Roster by Room [Diet List] dated 3/26/19, indicated 22 residents on small portions diet. The facility document titled Job Description . Supervisor Nutrition and Food Services undated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 23 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated . Position Accountabilities . 4. Monitor tray-line to ensure the correct foods are served according to menu and diet orders . 8. Supervises food preparation . Ensures that portion control standards are followed . The facility policy and procedure titled Menus dated 2018, indicated . It is the policy of the [facility name] to provide residents with sufficient and adequate nutrition . Menus are provided . to meet all nutritional guidelines and resident need according to the RDA [Recommended Daily Allowance]. The facility policy and procedure titled Food Preparation and Service dated 2018, indicated . If the Dietary Service Manager is not available, the manager's designee assumes the responsibility for dietary activities, to include but not limited to: a . b. Following the written menus . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 24 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to follow the physician ordered diet for one of 28 residents (Resident 5) in the dining room when Resident 5 was served a regular meal instead of a clear liquid. This failure resulted in Resident 5 being given the wrong diet which had the potential to compromise his scheduled medical procedure. Findings: During an observation on 3/25/19, at 11:48 a.m., in the dining room, Resident 5 was given his lunch tray. On Resident 5's tray was roast turkey with alfredo sauce, pasta and green beans. Resident 5 stated he was on a clear liquid diet. During an interview with Registered Nurse (RN) 1, on 3/25/19, at 12:05 p.m., he stated, For Resident 5, clear liquids was ordered for today. He is scheduled for a procedure . All meals ordered today is clear liquids. RN 1 stated Resident 5's lunch should have been clear liquids. During an interview with RN 1, on 3/26/19, at 4:11 p.m., he stated the physician ordered diet was not followed for Resident 5's lunch on 3/25/19. RN 1 stated, Doctor's orders should be followed. During an interview with Director of Staff Development (DSD) 2, on 3/27/19, at 2:49 p.m., she stated, When the CNAs and RNA's hand the trays in the dining room, they will not know the diet order changed. They just go by the meal ticket [slip]. DSD 3 stated physician ordered diets should be followed. During an interview with the Nutritional Services Supervisor (NSS), on 3/28/19, at 9:10 a.m., she stated the physician ordered diet should be followed. The NSS stated, The ordered diet [Resident 5] was not followed . We [Dietary] made a mistake. My staff did not pay attention. The NSS stated Resident 5's scheduled medical procedure would have been canceled if he ate the regular diet served. During an interview with the Registered Dietitian, on 3/28/19, at 11:42 a.m., she stated, We should follow doctor ordered diet . We [facility] can have a negative outcome if we don't follow it. A review of the facility document for Resident 5, the meal ticket dated 3/25/19, indicated, . Lunch . Diet: CCHO [Controlled Carbohydrate] . Consistency: Regular . During a review of the clinical record for Resident 5, the Order Summary Report dated 3/15/19, indicated, Clear Liquid Diet on 03/25/19, 03/26/19, 03/27/19 unless otherwise noted by MD [Doctor] . The facility document titled, . NURSING DEPARTMENT SCOPE OF SERVICE dated 8/3/17, indicated, . All care is provided by licensed professionals under the general direction of a physician . The facility document titled, Job Description . Supervisor Nutrition and Food Services undated, indicated, . Position Accountabilities . 4. Monitor tray-line to ensure the correct foods are served according to menu and diet orders . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 25 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility policy and procedure titled, Therapeutic Diets dated 2/22/17, indicated, . Therapeutic diets are prepared and served as prescribed by the attending physician . The facility policy and procedure titled Food Preparation and Service dated 2018, indicated . If the Dietary Service Manager is not available, the manager's designee assumes the responsibility for dietary activities, to include but not limited to: a . c. Checking of resident's trays . The facility policy and procedure titled Diet Orders/ Changes dated 2/22/17, indicated . The Nutrition and Food Services . are also responsible for accurately completing the change of diet procedure-recording all information in the resident's profile card . and the meal card. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 26 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to store and handle food safely when: Residents Affected - Many 1. There were red bell peppers with a black organic substance and past their storage guidelines. 2. There was black and yellow substance inside the ice machine. 3. Trayline (meal service) food temperatures were taken in an unsanitary way. These failures resulted in unsafe food storage and handling that could lead to contamination and potentially negative outcome to all residents who consumed food from the kitchen. Findings: 1. During an observation and concurrent interview with Dietary [NAME] (DC) 2, on 3/25/19, on 8:22 a.m., there was a bin of red bell pepper that had a black substance in the walk in refrigerator. DC 2 stated the date on the bin was 3/14/19 and there were 10 bell peppers inside. DC 2 stated, It is mold. During an interview with DC 3, on 3/28/19, at 8:16 a.m., she stated, Fresh bell pepper is good for 7 days. DC 3 stated it was not good to use moldy bell pepper. DC 3 stated, Sometimes it [red bell pepper] gets rotten . It has to be fresh to use for the residents. DC 3 stated the patients could get sick if fed with moldy food. DC 3 stated, Expired food have to be thrown away. During an interview with Nutritional Services Supervisor (NSS), on 3/28/19, at 9:02 a.m., she stated, Red bell peppers should be good for 7-10 days. NSS stated it was not good to use a moldy bell pepper. NSS stated, It should be tossed and not served to the residents . They could get sick. The facility policy and procedure titled, Guidelines for Length of Storage of Foods dated 2/22/17, indicated, . It is the policy of [facility name] that food products be stored in a safe manner to prevent food-borne illnesses. PURPOSE . To provide guidelines for food storage in the absence of a manufacturers expiration date . The facility document titled, Produce Storage Guidelines dated 8/15, indicated, . [NAME] or red peppers . 7 to 10 days . 2. During an observation and concurrent interview with the Maintenance Engineer (ME), on 3/25/19, at 8:56 a.m., in the staff breakroom, the ice machine had a black and yellow substance by the bottom part of the evaporator. The ME stated he did not know what it was. The ME stated, It is something. The ME examined the bottom part of the evaporator (the part that cycles water to form ice cubes) with a white paper towel. The ME stated, I got a little something. There was a yellowish-substance on the paper towel from the ice machine evaporator. During an interview with Certified Nursing Assistant (CNA) 2, on 3/28/19, at 8:34 a.m., she stated ice was placed in the water pitchers for the residents. CNA 2 stated, Seven residents don't like ice or can't have ice . The rest like ice in their water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 27 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 - Many During an interview with ME, on 3/28/19, at 1:50 p.m., he stated the ice machine was not clean. ME stated, I don't know what the black and yellow substance is . I would not use the ice and water from it. ME stated the ice machine was not safe for use for the residents. ME stated, The residents could get sick. During an interview with Director of Nursing (DON), on 3/28/19, at 2:16 p.m., she stated she did not consider the ice machine with the black and yellow substance clean and safe for use. The DON stated, I wouldn't want to drink it [water/ice] . I don't know what the black and yellow substance is. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated, . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . Follow the manufacturer's instructions for cleaning and maintaining the equipment . The facility document titled, [Ice machine brand] Installation, Use & Care Manual undated, indicated, . Maintenance . Clean the ice machine every six months for efficient operation. If the ice machine requires more cleaning and sanitizing, consult a qualified service company . CLEANING/ SANITIZING PROCEDURE . The ice machine and bin must be disassembled, cleaned and sanitized . remove mineral deposits from areas or surfaces that are in direct contact with water . 3. During an observation and concurrent interview with DC 1, on 3/26/19, at 11:24 a.m., in the kitchen, DC 1 was taking the temperatures for the food on the steam table. The thermometer handle touched the food when taking of temperatures was done with the mechanical (ground) beef stew, pureed beef stew, pureed corn bread and the white bean soup. DC 1 stated the plastic handle of the thermometer should not touch the food. During an interview with DC 3, on 3/28/19, at 8:18 a.m., she stated, When doing the temp [food temperature], the handle should not touch the food . The handle is not sanitized. DC 3 stated the thermometer handle was not supposed to touch the food. DC 3 stated, If the handle touches the food, the food gets contaminated. During an interview with the Registered Dietitian (RD), on 3/28/19, at 11:42 a.m., she stated the thermometer handle should not touch the food. RD stated, 'I can't say for sure that the handle got sanitized. RD stated the food could potentially get contaminated. The facility document titled, Job Description . Supervisor Nutrition and Food Services undated, indicated, . Position Accountabilities . Ensures food safety guidelines are followed for receiving, storage, preparation and service of foods. Follows established policies and procedures for safe food handling and storage The facility policy and procedure titled Food Storage dated 2/22/17, indicated . Sufficient storage facilities are provided to keep food safe . Food is stored, prepared . by methods designed to prevent contamination . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 28 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a policy regarding the use and storage of foods brought to residents by family and visitors from outside of the facility when there were unlabeled and incorrectly labeled resident food items in the resident refrigerator. Residents Affected - Many This failure had the potential of giving unlabeled or incorrectly labeled food items to the wrong resident which could result in negative outcome to the residents. Findings: During an observation and concurrent interview with Registered Nurse (RN) 1, on 3/25/19, at 4:06 p.m., in the medication room, there was a resident refrigerator with resident food items. RN 1 stated, We just put the room number on the residents' food items. There were three 12 oz. (ounce - a unit of measure) cans of beer labeled 27C, one 8 oz. can of Lime A [NAME] ([NAME] drink) labeled 6A, three unlabeled 8 oz. cans of Lime A [NAME], four 12 oz. can of Keystone Light labeled 32A and five 12 oz. cans of Michelob Ultra labeled 6A. During an interview with RN 1, on 3/25/19 at 5:05 pm, he stated, The Nurses label the food items and put it in the fridge [resident's]. RN 1 stated if the food item was labeled with just room numbers resident food items could get mixed up if the resident changed rooms. RN 1 stated, I couldn't remember if we had any in-service in food handling of resident food . There is a possibility of giving the food item to the wrong resident. During an observation of the resident refrigerator and concurrent interview with the Assistant Director of Nursing (ADON), on 3/27/19, at 9:35 a.m., in the medication room, she stated there were 3 unlabeled beverage drinks (Lime A [NAME]) and there were 3 beer cans labeled 27C. The ADON stated, We don't have a resident in 27C . Resident might have been discharged or moved to another room. The ADON stated she doesn't know how they should label the resident food items. The ADON stated, It is not a good practice to just put the room numbers . There is a chance it will be given to the wrong resident. During an interview with the Director of Nursing (DON), on 3/28/19 at 2:10 p.m., she stated they did not have a policy for food brought in from home by family or visitors. The DON stated, It [resident food items] should labeled with the resident's name. The facility policy and procedure titled, Food from Outside Sources dated 2/22/17, indicated, Food brought in by visitors for residents is discouraged doe to problems of infection control . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 29 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to use staff development resources effectively and efficiently to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual training when 57 of 59 Certified Nursing Assistants (CNAs) did not complete one or more of the annual five required dementia training in-services. Residents Affected - Many This failure had the potential for the residents to be cared for by CNA's inadequately trained. Findings: During a concurrent interview and record review with Director of Staff Development (DSD 2), on 3/28/19 at 11:30 a.m., DSD 2 stated the dementia in-service training sign-in sheets indicated there were missing CNA signatures on all five dementia training in-services. DSD 2 stated the following CNA's did not complete one or more of the required five dementia training modules, CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65. During a concurrent interview and record review with DSD 1, on 3/27/19, at 5:08 pm, she stated four hours of Dementia training were done on the first day of orientation for new hires and one hour of dementia training was completed using the five hand on hand training videos during the year. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 3/28/19, at 11:15 a.m., the ADON stated the facility did not have a policy on dementia training. The ADON stated the in-services for all five modules were incomplete and not all of the CNA's attended the dementia in-service training. During a concurrent interview and record review with DSD 2, on 3/28/19, at 11:30 a.m., DSD 2 stated the dementia in-services sign-in sheets indicated there were missing signatures on all five dementia training in-services. During an interview with the DON on 3/28/19 at 11:45 a.m., the DON stated five dementia training in-services were required annually. Review of the facility record titled, Resident Matrix (a listing of residents by medical conditions) [undated], indicated there were twenty-six residents diagnosed with Alzheimer's/Dementia (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). The professional reference titled, Center for Clinical Standards and Quality/Survey and Certification Group dated 9/14/12, indicated, The Affordable Care Act: Section 6121 requires the Centers for Medicare and Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS created this training program to address the requirement for annual nurse aides training on these important topics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 30 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interviews and record review, the facility failed to assess the demographic composition of its resident population and location as part of the required facility assessment when there was no water management program for the facility. This failure resulted in the facility not having a water management program which could potentially expose the residents to Legionella in an event of an outbreak. Findings: During an interview with Maintenance Engineer (ME), on 3/27/19, at 10:52 a.m., ME stated he was aware of the All Facilities Letter 18-39 that was issued on September 17, 2018 requiring facilities to develop and implement a water management program. ME stated, We do not test for Legionella. ME stated he had not tested for Legionella and the facility did not have any water testing results. ME stated he did not have a map of the water system and do not have a policy regarding testing the water for Legionella or a water management plan. During an interview with Administrator (ADM), on 3/27/19, at 10:55 a.m., ADM stated he had just become aware of the All Facilities Letter 18-39 that was issued on September 17, 2018 requiring facilities to develop and implement a water management program. ADM stated it was a brand new regulation and the facility does not have a contract for water testing. During an interview with ME, on 3/27/19, at 11:50 a.m., ME stated he had not tested the water yet. ME stated someone tested the water in the main facility (hospital) but did not test the Nursing and Rehabilitation building. During an interview with Chief Engineer (CE), on 3/28/19, at 11:10 a.m., CE stated they were using the guidelines from The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) to develop their water management plan. CE stated we have started the water testing procedure without having a full fledged policy or water management plan. During an interview with CE and concurrent record review, on 3/28/19, at 11:10 a.m., the facility document titled, Legionnaires and Other Waterborne Diseases Management Plan for Prevention dated 2/14, CE stated the water management plan was not included in the Legionnaires and Other Waterborne Diseases Management Plan for Prevention and there should be a policy for the facility's water management plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 31 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 effectively implement and maintain an infection prevention and control program for 11 of 59 sampled residents (Resident 46, 63, 39, 11, 238, 63, 32, 36, 43, 14 and 18) when: Residents Affected - Many 1. Registered nurse (RN) 5 and RN 1 failed to perform hand hygiene prior to placing on gloves when care was delivered to residents during a physical assessment and a finger stick procedure to test blood for blood sugar levels for (Resident 46, 63, and 39). 2. Licensed vocational nurse (LVN) 4 and RN 1 used a contaminated pair of gloves in the performance of the finger stick procedure on three residents (Resident 11, 238, and 63), and touched objects in the resident room without changing the gloves LVN 4 wore to perform the finger stick procedure. 3. RN 5 used a contaminated pair of gloves in the provision of care to Resident 43. 4. Resident 14's nasal (nose) cannula (a plastic tubing used for the delivery of oxygen through the nose) was exposed and left hanging low draped over the regulator dial of the oxygen concentrator. 5. The facility did not have a water management program for Legionella (a waterborne bacteria). 6. Resident 18's continuous positive airway pressure (CPAP- therapy is a common treatment for obstructive sleep apnea) tubing was disconnected from the oxygen and the exposed end of tubing was touching the ground. 7. Resident 18's oxygen concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream) filter was covered in a black fluffy substance. These failures placed the residents' health and safety at potential risk for cross-contamination, spread of infections, and water borne bacteria. Findings: 1. During a medication pass observation on 3/26/19 at 10:55 a.m. in Station 2, RN 5 did not sanitize or wash hands before donning gloves in the performance of the skin assessment of Resident 46's buttocks for pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a medication administration observation on 3/26/19 at 11:54 a.m., in Station 2, RN 1 did not sanitize or wash hands before placing on gloves when a finger stick (a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing) was performed on Resident 63. On 3/26/19 at 12:03 p.m., in Station 2, RN 1 did not wash hands before placing on gloves when a finger stick procedure was performed on Resident 39. 2. During a medication administration observation on 3/26/19 at 11:24 a.m., LVN 4 sanitized her hands, donned (placed on) a pair of gloves, opened the medication administration record, used a key to open the medication cart and prepared the materials for a finger stick procedure for Resident 11. LVN 4 then sanitized her hands, donned a pair of gloves and documented the result of Resident 11's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 32 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 Residents Affected - Many finger prick test. LVN 4 then opened the medication administration record, used a key to open the medication cart and prepared the materials for a finger stick procedure for Resident 238. LVN 4 wore the same pair of gloves in performing finger sticks on Resident 11 and Resident 12. During a medication administration observation on 3/26/19 at 11:54 a.m., in Station 2, inside Resident 63's room, RN 1 wore a pair of gloves flipped on the overhead lights in the resident's bed and then performed the finger stick. RN 1 used the same pair of gloves in the performance of the finger stick procedure on Resident 63. RN 1 then, without removing the gloves, turned off the overhead light on the resident's bed, and turned down a t.v. in the room for one of the residents. 3. During a medication administration observation on 3/26/19 at 12:25 p.m. in Station 2, after the skin assessment was done on Resident 43, without removing gloves and sanitizing hands and donning a pair of new clean gloves, RN 5 repositioned the resident with the assistance of a staff, arranged the pillows and bedding and obtained a mouth swab and cleaned the resident's mouth. During an interview with LVN 4 on 3/26/19 at 4:46 p.m., she stated she should have sanitized her hands before and after performing the finger stick on the resident and changed to a clean pair of gloves before doing the finger stick procedure. LVN 4 stated she had thought sanitizing hands should be done in between patient care only. During an interview with RN 5 on 3/26/19 at 5:09 p.m., she stated she should have sanitized her hands before the use of gloves when performing procedures. RN 5 stated she should have changed gloves and sanitized her hands after performing a procedure and going from a dirty part to a clean part in providing care to the resident. During an interview with RN 1 on 3/26/19 at 5:25 p.m., he stated he should have sanitized his hands before the use of gloves when he did the finger stick procedure on the resident. RN 1 stated after the finger stick procedure was done, he should have changed gloves and sanitized his hands before touching objects inside the resident's room to prevent cross contamination of different body sites. During an interview with the director of nursing (DON) on 3/27/19 at 9:40 a.m., she stated the expectation would be to sanitize hands and use the gloves according to the standard precaution policy. The DON stated the licensed nurses (LNs) should have removed gloves, sanitized hands before donning a pair of clean glove for another procedure. The DON stated the LN should have removed the used gloves, sanitized hands before touching objects in the resident's room to prevent the potential of cross contamination (exposing germs from a dirty site to a clean site) and potential spread of infection. The facility policy and procedure titled, Registered Nurse's Job Description & Competency Evaluation dated 1/16/19 indicated, General Accountabilities: . 8. Practice Universal precautions while providing care and performing other hospital services . The facility's policy and procedure titled, Standard Precaution dated 4/5/17 indicated, PROCEDURE 1. Hand Hygiene . b. Wash hands or use alcohol based hand hygiene product: i. Before patient contact ii. After patient contact iii. After contact with items in the patient's environment iv. After removing gloves v. Between glove changes vi. after any procedure. c. Wash hands, or use alcohol based hand hygiene product, between task and procedures on the same patient to prevent cross contamination of different body sites. 2. Gloves . c. Change gloves between task and procedures on the same patient after contact with materials that may contain a high concentration of microorganisms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 33 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 Residents Affected - Many 4. During an observation and concurrent interview with Resident 14, on 3/25/19, at 9:36 a.m., in Resident 14's room, a nasal cannula was hanging by the oxygen concentrator gauge exposed and close to the floor. Resident 14 stated, I am using that. Resident 14 stated there was no storage bag for her nasal cannula. During an observation and concurrent interview with LVN 1, on 3/25/19, at 9:38 a.m., in Resident 14's room, Resident 14's nasal cannula was hanging by the oxygen concentrator gauge exposed and close to the floor. LVN stated, It [nasal cannula] should have been stored in a bag if not being used. During an interview with LVN 1, on 3/25/19, at 5:05 p.m., she stated, I changed the nasal cannula because it is an infection control issue. During an interview with DSD 1, on 3/27/19, at 3:07 p.m., she stated, Nasal cannula should be kept in a ziploc [resealable] bag for storage . If it is on the floor it should be tossed. If left exposed it should be discarded. DSD 1 stated it [nasal cannula] was contaminated. DSD 1 stated, It is an infection control issue. During an interview with the DON on 3/28/19, at 2:01 p.m., she stated there was a risk of contamination when a nasal cannula hung close to the floor. During a review of the clinical record for Resident 14, the Minimum Data Set (MDS- a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) Assessment, dated 12/18/18, indicated the Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 15 indicated no cognitive impairment. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated, . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . use barrier protective coverings (i.e. table paper, probe covers, etc.) as appropriate . 5. During an interview with the Maintenance Engineer (ME), on 3/27/19, at 10:52 a.m., the ME stated he was aware of the All Facilities Letter 18-39 that was issued on September 17, 2018, which required facilities to develop and implement a water management program. The ME stated they had not tested for the presence of Legionella (bacteria). The ME stated, I do not have any water testing results. I do not have a map of our water system. I do not think we have a policy regarding testing the water for Legionella or a water management plan. During an interview with the Administrator (ADM), on 3/27/19, at 10:55 a.m., the ADM stated he had just become aware of the All Facilities Letter 18-39 that was issued on September 17, 2018, which required facilities to develop and implement a water management program. The ADM stated it was a new regulation and facility did not have a contract for water testing. During an interview with the ME, on 3/27/19, at 11:50 a.m., the ME stated they had not tested the water yet. During an interview with the Chief Engineer (CE), on 3/28/19, at 11:10 a.m., he stated they were using the guidelines from The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) to develop their water management plan. CE stated they had started the water testing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 34 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 procedure without having a full-fledged policy or water management plan at this time. Level of Harm - Minimal harm or potential for actual harm During an interview with the CE and concurrent record review, on 3/28/19, at 11:10 a.m., the facility document titled, Legionnaires and Other Waterborne Diseases Management Plan for Prevention dated 08/03/2007, CE stated the water management plan was not included in the Legionnaires and Other Waterborne Diseases Management Plan for Prevention and there should be a policy for the facility's water management plan. Residents Affected - Many 6. During an observation on 3/25/19, at 8:40 a.m., in the resident's room, Resident 18 was sitting in bed with a nasal cannula attached to oxygen. A continuous positive airway pressure(CPAP) machine (used to keep the air sacs of the lung inflated) was located on the bedside stand with one end of the tubing attached to the CPAP machine and the other tubing attached to an oxygen source was in use and had touched the ground. During an interview with Registered Nurse (RN) 1, on 3/25/19, at 9:50 a.m., RN 1 stated the filter of the CPAP machine was dirty and needed to be replaced. RN 2 stated, I got it from the storage room. During an interview with the ME, on 3/25/19, at 2:17 p.m., he stated nursing staff and housekeeping staff were responsible for keeping the concentrator clean. During an interview with ADON, on 3/26/19, at 3:48 p.m., she stated the CPAP tubing came in a plastic bag and should have been stored in a plastic bag. The ADON stated, If it is not stored in a plastic bag it needs to be cleaned and put into a larger plastic bag for storage. During an interview with DSD 1, on 3/27/19 at 3:08 p.m., she stated CPAP and oxygen tubing should be stored in a bag at the bedside when not in use. DSD 1 stated if tubing was exposed and on the floor it should be discarded. DSD 1 stated if the end of the tubing that connected to the oxygen concentrator touched the ground it was contaminated and should not be reused by the resident. DSD 1 stated it was an infection control issue. During an interview with the DON, on 3/27/19 at 3:55 p.m., she stated when the CPAP tubing was not in use, it should be kept neatly rolled around the machine. The DON stated CPAP tubing should not be on the floor. The DON stated, It is an infection control issue. 7. During an observation on 3/25/19, at 8:40 a.m., in a Resident 18's room, Resident 18 was sitting in bed with a nasal cannula attached to an oxygen concentrator. The air filter located on the back of the oxygen concentrator had black particles covering the entire filter surface. During an interview with RN 1) on 3/25/19, at 9:50 a.m., he stated patient equipment tubing needed to be bagged and stored with the machine when not in use. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . use barrier protective coverings (i.e. table paper, probe covers, etc.) as appropriate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 35 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain equipment in safe operating condition when: Residents Affected - Many 1. There was ice build-up on the door frame and on a copper pipe inside the walk-in freezer. 2. There was black and yellow substance in the ice machine at the bottom part of the evaporator. These failures had the potential for the residents to use ice and food that was unsafe for consumption that could lead to negative outcome. Findings: 1. During an observation on 3/25/19, at 8:24 a.m., in the kitchen, there was ice build-up on the top frame of the freezer door and copper pipe by the top, right corner toward the back of the walk-in freezer. During a concurrent observation and interview with the Dietary Aide (DA), on 3/28/19, at 8:09 a.m., in the kitchen, the freezer door was not fully closed. Inside the freezer, there were water drops along a strip of plastic by the side of the freezer door. The DA stated he had noticed the ice buildup in the freezer. The DA stated it water drips happened when the freezer door was not fully closed or left open for a while. During an interview with the Maintenance Engineer (ME), on 3/28/19, at 1:40 p.m., he stated he went inside the walk-in freezer a few times and used a heat gun to thaw the ice build up. The ME stated, I do not do any maintenance check in the freezer, I only regularly check the coil on the roof. The ME stated ice buildup indicated something was not working properly with the freezer. The ME stated, If the freezer temperature goes up, the food could spoil. The ME stated there should be no ice build-up in the freezer. During an interview with Administrator (ADM), on 3/28/19 at 2:35 p.m., he stated the ice buildup was because there was a problem with the gasket which caused the ice build-up. The ADM stated, It brings moisture inside and it freezes . It could ruin food. 2. During a concurrent observation and interview with the ME, on 3/25/19, at 8:56 a.m., in the staff breakroom, the ice machine had black and yellow substance by the bottom part of the evaporator. The ME stated he did not know what the yellow substance was. The ME examined the bottom part of the evaporator with a white paper towel and stated, I got a little something. There was a yellowish-substance on the paper towel from the ice machine evaporator. During an interview with the ME, on 3/28/19, at 1:50 p.m., he stated the ice machine was not clean. The ME stated, I don't know what the black and yellow substance is . I would not use the ice and water from it. The ME stated the ice machine was not safe for use for the residents. During an interview with Director of Nursing (DON), on 3/28/19 at 2:16 p.m., she stated she did not consider the ice machine with the black and yellow substances to be clean and was not safe for use. The DON stated, I wouldn't want to drink it [water/ice] . I don't know what the black and yellow substance is. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 36 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated, . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . Follow the manufacturer's instructions for cleaning and maintaining the equipment . Review of the facility document the, [Ice machine brand] Installation, Use & Care Manual undated, indicated, . Maintenance . Clean the ice machine every six months for efficient operation. If the ice machine requires more cleaning and sanitizing, consult a qualified service company . CLEANING/ SANITIZING PROCEDURE . The ice machine and bin must be disassembled, cleaned and sanitized . remove mineral deposits from areas or surfaces that are in direct contact with water . The facility policy and procedure titled, Inventory and Inspection of New Equipment dated 2/16, indicated, . It shall be the responsibility of the Engineering Department to routinely inspect all . equipment to determine its safe operation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 37 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual mandated training to keep competencies in the delivery of care when: 1. Three of 21 CNAs (CNA 1, 2 and 3) completed less than 12 hours of mandatory training per year. 2. 57 of 59 CNAs (CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65) did not complete the five dementia training modules offered by the facility. This failure resulted in CNA's insufficient training which placed the resident at risk to not have quality of care needs met. Findings: 1. During employee records review with the director of staff development (DSD) 1 and 2, the vice president for human resource (VP/HR) and the VP/HR Assistant on 3/25/19 at 2:50 p.m., stated from 3/16/18 to 3/24/19: 1. CNA 1 was provided in-service training's for five of 12 hours. 2. CNA 2 was provided in-service training's for seven of 12 hours. 3. CNA 3 was provided in-service training's for eight of 12 hours. During a concurrent interview with DSD 1 and DSD 2, on 3/25/19, at 3:40 p.m., both stated, the expectation was for the CNAs to have 12 hours of in-service training to ensure their competency met the need of the residents in the facility. 2. During a concurrent interview and record review with DSD 1, on 3/27/19, at 5:08 pm, she stated four hours of dementia training were done on the first day of orientation for new hires and the remainder of the hours annually for dementia using the five hand-on-hand training videos. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 3/28/19, at 11:15 a.m., the ADON stated the in-services for all five modules were not completed, and not all the CNAs attended the dementia in-service training. During a concurrent interview and record review with DSD 2, on 3/28/19 at 11:30 a.m., DSD 2 stated the dementia in-service training sign-in sheets indicated there were missing CNA signatures on all five dementia training inservices. DSD 2 stated the following CNA's did not complete one or more of the required five dementia training modules, CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65. During an interview with the DON on 3/28/19 at 11:45 a.m., the DON stated five dementia training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 38 of 39 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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 0947 in-services were required annually. Level of Harm - Minimal harm or potential for actual harm Review of the facility record the, Resident Matrix (a listing of residents by medical conditions) [undated], indicated there were twenty-six residents diagnosed with Alzheimer's/Dementia (an irreversible, progressive brain disorder that slowly destroyed memory and thinking skills and eventually the ability to carry out the simplest tasks). Residents Affected - Many Review of the professional reference titled, Center for Clinical Standards and Quality/Survey and Certification Group dated 9/14/12, indicated, The Affordable Care Act: Section 6121 requires the Centers for Medicare and Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia .CMS created this training program to address the requirement for annual nurse aides training on these important topics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056155 If continuation sheet Page 39 of 39