Inspection·November 4, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 maintenance services to maintain a clean, orderly, and comfortable environment for two of 28 sampled residents (Resident 50 and Resident 19) when: 1. Resident 50's dresser had no top drawer. 2. Resident 19's floor had multiple scattered black scratches and dimples on the surface of the floor and next to the resident's bed were sticky, brown-colored spots on the floor. This failure had the potential to decrease the comfort and well-being of Resident 50 and Resident 19. Findings: 1. During an observation on 11/1/21, at 11:09 a.m., Resident 50's dresser had an empty area where the top drawer of the dresser should have been located. The contents of the second dresser drawer were visible through the empty area. During a concurrent observation and interview (LVN 1) on 11/2/21, at 8:40 a.m., with Licensed Vocational Nurse 1, in Resident 50's room, LVN 1 stated the top drawer had been missing for quite a while. LVN 1 stated she did not know if anyone had reported that the top drawer was missing. LVN 1 stated staff members usually just made verbal reports to the Maintenance/Housekeeping Supervisor (M/HS). During a concurrent interview and record review on 11/2/21, at 9:50 a.m., with M/HS, the Maintenance Log Binder was reviewed. M/HS stated he did not know exactly when the drawer was reported missing or broken. M/HS stated he had ordered the drawer for Resident 50's dresser a couple months ago. M/HS was unable to provide any written documentation to indicate an order date for the replacement drawer. M/HS stated Stations 1 and 2 each had a Maintenance Log Binder, but staff usually just made verbal reports to him directly regarding maintenance/repair requests. 2. During an observation on 11/1/21, at 11:07 a.m., in Resident 19's room, there were multiple scattered black scratches and dimples on the surface of the floor and sticky, brown-colored spots on the floor next to Resident 19's bed. During a concurrent observation and interview on 11/2/21, at 8:45 a.m., in Resident 19's room, with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the floor had been sticky with stains and dirt when she first came into the room that morning. During a concurrent observation and interview on 11/3/21, at 8:50 a.m., in Resident 19's room, with Housekeeping 1 (HSKP 1), HSKP 1 stated she had tried to clean the floor in Resident 19's room on 10/29/21, and she had not been able to remove the floor's sticky, brown-colored spots. HSKP1 1 stated the scratches/dimples on the surface of the floor were from the repeated movements of the beds. During an observation and interview on 11/3/21, at 10:49 a.m., with HSKP 1 in Resident 19's room, the floor still had scattered black scratches and dimples, but did not have any sticky, brown spots. HSKP 1 stated she had been able to remove the sticky, brown-colored spots from the floor with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 2 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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 cleaning product. 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: 056399 If continuation sheet Page 3 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to act upon an irregularity identified by the Consultant Pharmacist (CP) during the monthly medication regimen review (MRR) for one of 28 sampled residents (Residents 50) when the facility delayed scheduling Resident 50's Abnormal Involuntary Movement Scale test (AIMS, a 12-item clinician rated scale of involuntary movements of various areas of the patient's body) for one month. This failure had the potential to result in Resident 50 having undiagnosed and untreated adverse side effects from prescribed medication use. Findings: A review of Resident 50's admission Record, undated, indicated Resident 50 was admitted to the facility in December 2020, with a diagnosis of dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning) with behavioral disturbance, and a mental condition causing disorientation to reality. A review of Resident 50's Order Summary Report, dated 11/3/21, the Order Summary Report indicated a physician order dated 8/23/21, for quetiapine (An antipsychotic medication used to treat mental processes and behaviors associated with mental conditions causing disorientation to reality), twice a day for, dementia with psychotic features angry outburst. A review of Resident 50's Consultant Pharmacist's Medication Regimen Review (MRR), dated 9/25/21, by Consultant Pharmacist (CP), indicated, Please update the AIMS test for [brand name for quetiapine] use. A review of Resident 50's Consultant Pharmacist's Medication Regimen Review (MRR), dated 10/26/21, by CP, indicated, Please update the AIMS test for [brand name for quetiapine] use. During a concurrent interview and record review on 11/4/21, at 12:41 p.m., with the Director of Nursing (DON), Resident 50's MRR and AIMS evaluations were reviewed. The DON stated CP's recommendations on the MRR dated 9/25/21, had been missed. The DON stated Resident 50 had an AIMS test completed 10/27/21. The DON stated regular completion of the AIMs test was important for the recognition of potential adverse side effects of quetiapine administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 4 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served under sanitary conditions when: Residents Affected - Some 1. Refrigerator 1 had multiple undated food items and repackaged food in plastic bags labeled with use-by dates more than three days in the future. 2. Refrigerator 2 had a cracked pasteurized egg left inside the refrigerator and an open carton of liquid whole eggs without an opened-on date. 3. Refrigerator 3 had a sealed bag of mixed green lettuce that had no label or use-by date. 4. Undated and unlabeled food items were stored in a large clear container. 5. The holder for the can opener in the kitchen work area was covered with brownish-yellow-colored sticky material around the can opener rest. These failures had the potential for residents to develop food-borne illness. Findings: During the initial kitchen tour observation on 11/1/21, at 10:10 a.m., with the Registered Dietitian (RD) and [NAME] 1: 1. Refrigerator 1 had the following items: a. A box of thawed, undated, turkey breakfast sausage links (15 pieces). b. Repackaged food items in a resealable plastic bag labeled 41B lunch, used-by 11/5/21. c. Repackaged in a resealable plastic bag were diced mixed onions and bell peppers labeled used-by 11/6/21. d. Repackaged in a resealable plastic bag were two pieces of thin sliced tomatoes with liquid labeled used-by 11/6/21. e. An opened gallon container of coleslaw dressing, less than a quarter full, with a delivery date of 9/10/21, had no label with date for opened on. During a concurrent interview [NAME] 1 stated he did not know when the thawed sausage links had been placed in the refrigerator to thaw and stated they were very soft now. He stated the turkey sausage was used as an everyday food substitute for residents with no meat preference. [NAME] 1 stated food repackaged in resealable plastic bags should be labeled with use-by dates no more than 3 days in the future. 2. Refrigerator 2 had the following items: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 5 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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 a. An egg carton with one cracked pasteurized egg inside the carton Level of Harm - Minimal harm or potential for actual harm b. A opened 32-ounce container of liquid whole eggs, with a received date of 10/26/21, had no label with date for opened on. Residents Affected - Some 3. Refrigerator 3 had mixed green lettuce repackaged in an unlabeled resealable plastic bag. 4. The kitchen had an unlabeled, undated, clear plastic container with croutons; directly on top of the croutons was an open plastic bag with seven cookies. 5. The kitchen work area had a holder for the can opener which was covered with brownish-yellow, sticky matter where the can opener rested on the holder. During an interview on 11/4/21, at 12:15 p.m., with the RD, the RD stated cracked eggs posed a risk of contamination and should be discarded immediately. A review of the facility's undated policy titled, Food Receiving and Storage, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled, and dated (used-by-date) .Other opened containers must be dated and sealed or covered during storage, with a used-by-date . A review of the facility's undated policy titled, Use By Dates - Refrigerator Items, indicated, .Leftovers (prepared foods), used-by-date is three days once opened . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 6 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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: Residents Affected - Some 1. Clean the area around the enteral feeding pump (a pump used to deliver liquid nutrition directly into the stomach or intestines through a tube inserted into the nose, mouth, or a surgical opening directly into the gastrointestinal tract) for one (Resident 62) of 18 sampled residents. 2. Clean a resident walker stored in a common hallway. 3. Clean a bedside commode stored in a common hallway. These failures had the potential to result in infection and/or the spread of infection for Resident 62, and other residents and visitors in the facility. Findings: 1. A review of Resident 62's admission Record, undated, indicated Resident 62 was admitted in 2019 with a diagnosis of traumatic brain injury and a gastrostomy tube (a tube placed in a surgical opening created through the abdominal wall into the stomach to allow for direct infusion of nutrients and liquids). During an observation on 11/1/21 at 10:38 a.m., in Resident 62's room, an enteral feeding pump was attached to an IV pole (a pole on casters used for hanging solutions for infusion) next to Resident 62's bedside. The tubing for the enteral feeding was disconnected from Resident 62's gastrostomy tube and hung freely from the feeding pump in a downward position with end of the tubing covered. The floor below the feeding pump and tubing had scattered circular, dark brown, sticky substances on the supporting legs of the IV pole and the floor. Adjacent to the IV pole was a bedside commode and a tower-style fan; scattered across the commode and fan was a residue of dust and dark brown, sticky material. Resident 62 lay in the bed, eyes shut. During an interview on 11/1/21 at 10:41 a.m., with Housekeeping 2 (HSKP 2), HSKP 2 stated Resident 19's IV pole, floor, commode, and fan needed to be cleaned. During a concurrent interview and observation on 11/1/21 at 11:48 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was the charge nurse for Resident 62. LVN 1 stated that the room was not clean and should be cleaned on a daily basis. LVN 1 stated it was very important to have the IV pump and floor area clean as bacteria and mold could grow there. During an interview with the Infection Preventionist (IP) on 11/1/21 at 11:55 a.m., the IP stated the residents' room should be cleaned on daily basis because food residue especially can result in bacteria growth, which can cause the spread of infection. 2. During an observation on 11/1/21 at 11:04 a.m., in the common hallway of Wing A, parked against the wall near Resident 19's room, was a walker (an assistive device for walking) with a seat and footrests. The walker had scattered brown and yellow substances on the right handrail and right footrest of the of the walker. During an observation on 11/1/21 at 11:06 a.m., Certified Nursing Assistant 4 (CNA 4) walked down (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 7 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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 - Some the Wing A hallway, touched the walker's right handrail, pushed the walker to one side, and entered a resident room. During an interview with CNA 1 on 11/1/21 at 11:07 a.m., Certified Nursing Assistant 1 (CNA 1) stated the walker in the hallway belonged to Resident 19 and the walker had been placed in the hallway to increase space inside Resident 19's room. CNA 1 also stated the if the walker was not cleaned before being stored in the hallway, the walker could spread bacteria from other residents or staff touching it. 3. During an observation on 11/1/21 at 11:04 a.m., an unlabeled bedside commode, with a brown substance on the commode seat, was against the wall, near the end of the Wing A common hallway (by the emergency exit). During an observation and concurrent interview on 11/1/21 at 11:07 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 examined the commode in the Wing A hallway and stated the brown substance on the seat indicated the commode seat had not been cleaned. CNA 1 was unable to state who the commode belonged to, as there was no label or signage. During an interview and record review on 11/1/21 at 2:47 p.m., with Maintenance/Housekeeping Supervisor (Maint/HSKPS), the Environmental Checklist for Daily Cleaning Monitoring, for Wing A, dated 10/27/2021 and 10/31/2021, was reviewed. The environmental checklist forms had no signed initials under the sections high-touch (surfaces frequently touched) room surfaces: IV pump control, oxygen concentrator, and enteral feeding pump. Maint/HSKPS stated the missing initials on the environmental checklist indicated the housekeepers had either not cleaned those areas or had forgotten to sign the forms to indicate the tasks had been completed. Maint/HSKPS stated the housekeepers were supposed to clean the IV pumps and all high-touch surface areas every day. A review of facility policy and procedure (P & P) titled, Infection Prevention and Control Program, dated 6/2021, indicated, An infection prevention and control (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. A review of facility P & P titled, Cleaning and Disinfection of Surfaces and Equipment, undated, indicated, the following categories are used to distinguish the levels of sterilization/disinfection necessary for items in resident care and those in the resident's environment. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms. Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture, and floors. Most non-critical items can be decontaminated where they are used (as opposed to being transported to a central processing location). Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. During a review of facility P & P, titled Equipment and Supplies, undated, the P & P indicated all such equipment and supplies shall be stored and maintained in accordance with appropriate isolation precautions, consistent with the manufacturer's recommendations. Nursing Services will notify environment services staff regarding equipment that needs sanitizing after use in the care of an individual with isolation precautions. Environmental services staff shall be responsible for cleaning and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 8 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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 sanitizing such equipment before it is returned to Central Supply or to designated storage areas. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 9 of 10 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 056399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 offer and/or provide pneumococcal vaccine (a vaccination to prevent pneumonia, a lung infection which can cause difficulty breathing and death) to one (Resident 3) of five sampled residents. Residents Affected - Few This failure had the potential for Resident 3 to develop and spread pneumonia. Findings: A review of Resident 3's admission Record, undated, indicated Resident 3 was admitted in 2014. During a concurrent interview and record review on 11/3/2021 at 8:35 a.m. with the Infection Preventionist (IP), Resident 3's Immunization record was reviewed. The IP stated Resident 3 last received a pneumococcal vaccine, Pneumovax (generic name of PPSV23) on 9/19/2014. The IP stated Resident 3 had not received another pneumococcal vaccination. The IP stated Resident 3 should have been given the pneumococcal vaccine 5 years after the last dose, unless Resident 3 wanted to refuse the vaccination. The IP stated she had not asked Resident 3 if she wanted a second pneumococcal vaccination. During an interview 11/4/21 at 11:47 a.m. with the IP, the IP stated Resident 3 had not been eligible for the pneumococcal vaccine at the time of admission, as Resident 3 had not yet been [AGE] years old. IP stated Resident 3 was eligible now. A review of the facility policy and procedure titled, Pneumococcal Vaccine, undated, indicated, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. A review of the CDC article titled, Pneumococcal Vaccine Recommendations, dated 8/7/2020, indicated, Anyone who received any doses of PPSV23 before age [AGE] should receive 1 final dose of the vaccine at age [AGE] or older. Administer this last dose at least 5 years after the prior PPSV23 dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 10 of 10