Inspection·November 30, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for three (Residents 14, 67, 36) of eight sampled residents, the minimum data set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) within the deadlines determined by the assessment reference date (ARD, an endpoint for observation periods for MDS assessment data entry) when, Residents Affected - Some 1. Resident 14's quarterly MDS assessment was not completed and transmitted, 2. Resident 67's discharge assessment was not completed and transmitted, and 3. Resident 36's discharge assessment was completed 26 calendar days past the ARD and not transmitted. These failures had the potential to delay Resident 14's individualized care and resulted in Resident 67 and 36's incomplete medical record. Findings: Resident 14 was admitted to the facility in 2023 with diagnoses of right sided hemiplegia (loss of muscle function on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following a cerebral hemorrhage (bleed in the brain). During a concurrent interview and record review on 11/30/23, at 9:16 a.m., with the Director of Nursing (DON), Resident 14's quarterly MDS assessment, with an ARD of 11/10/23, was reviewed. The DON stated Resident 14's MDS assessment was not complete because of an incomplete section on speech and swallow assessment. The DON stated the MDS was not completed on time and should have been completed within 14 days of 11/10/23. A review of Resident 67's admission record indicated Resident 67 was admitted to the facility on [DATE] and discharged on 6/16/23. During a concurrent interview and record review on 11/30/23, at 8:57 a.m., with the DON, Resident 67's MDS assessment record was reviewed. The ARD for the discharge assessment was 6/16/23. The DON stated the record indicated Resident 67 did not have a discharge assessment completed and submitted. The DON stated the discharge assessment was expected to be completed within 14 days of 6/16/23. A review of Resident 36's admission record indicated Resident 36 was admitted to the facility on [DATE] and discharged on 7/12/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 2 of 14 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 11/30/2023 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 0640 Level of Harm - Potential for minimal harm Residents Affected - Some During a concurrent interview and record review on 11/30/23, at 9:06 a.m., with the DON, Resident 36's discharge MDS assessment record was reviewed. The ARD for the discharge assessment was 7/12/23. The DON stated the discharge MDS assessment was completed on 8/7/23 and was not submitted to CMS. The DON stated the discharge MDS assessment was not completed on time and was not submitted to CMS within the deadline set by the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI, a manual for completion of MDS assessments). The DON stated he was unsure of the submission deadline for discharge MDS assessments. The DON stated the facility practice was to submit discharge MDS assessments in batches at least once a month. A review of CMS's RAI manual, dated 10/1/23, indicated discharge assessments were required to be completed 14 calendar days after the date of discharge. The RAI manual indicated quarterly MDS assessments were required to be completed within 14 days of the ARD. The RAI manual also indicated completed assessments were required to be submitted 14 calendar days after the date of completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 3 of 14 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 11/30/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide respiratory care consistent with professional standards of practice for two of 31 sample selected residents (Residents 10 and 11), when: Residents Affected - Some 1. Resident 11 did not receive the oxygen rate based on physician order. 2. Resident 10's oxygen tube was not replaced weekly and the oxygen's humidifier was not replaced when it was empty. These deficient practices had the potential to result in oxygen toxicity for Resident 11 and for Resident 10 to potentially develop respiratory complications. Findings: 1. A review of Resident 11's admission Record indicated, Resident 11 was admitted to the facility with a diagnosis of interstitial pulmonary disease (broad term for a collection of over 150 disorders that inflame or scar the lungs). A review of Resident 11's Minimum Data Set (MDS-an assessment tool used to guide care) section I, indicated Resident 11 was admitted to the facility with a diagnosis of respiratory disease. A review of Resident 11's physician's orders, dated 5/28/23, indicated, O2 2 L/Min (Liter per Minute) via nasal cannula as needed for SOB (Shortness of Breathing) or chest pain . During a concurrent observation, record review, and interview on 11/27/23, at 1:30 p.m., with Registered Nurse (RN) 2, RN 2 checked and confirmed Resident 11 received 3.5 liters per minute O2 via nasal cannula. RN 2 reviewed the physician order and stated that the oxygen was running high for Resident 11 and could have caused hyper-oxygenation and organ damage. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, indicated, . review the physician's order or facility protocol for oxygen administration . 2. A review of Resident 10's admission record indicated Resident 10 was admitted in 2022 with diagnoses including chronic obstructive pulmonary disease (lung disease which reduces lung capacity to exchange oxygen), anemia (low red blood cell count), and hemiplegia affecting her left side (left sided paralysis). A record review of Resident 10's physician orders, dated 11/30/23, indicated Resident 10 had an order for 2L O2 via nasal cannula. A review of Resident 10's MDS, dated [DATE], indicated Resident 10 had severely impaired decision making ability, was unable to communicate and was completely dependent on staff for medical care. During an observation on 11/27/23, at 9:45 a.m., Resident 10 was laying in bed under her covers in her room. Resident 10 was receiving oxygen through a nasal cannula affixed to her nose. The nasal cannula was labeled with a sticker indicating the nasal cannula was used on 11/9/23, at 5:00 a.m. The nasal cannula was attached to a disposable humidifier bottle (a bottle of water used to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 4 of 14 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 11/30/2023 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 0695 humidity to the oxygen) which was empty. The humidifier bottle was marked with a start date of 11/15/23. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/28/23, at 9:59 a.m., with Registered Nurse 3 (RN-3), RN-3 stated oxygen tubing and humidifier was checked every shift and replaced if it was found empty. Residents Affected - Some During an interview on 11/30/23, at 9:45 a.m., with the Director of Nursing (DON), the DON stated the overnight shift was expected to change the oxygen tubing on their shift if a change was due. The DON stated nasal cannula oxygen tubing was expected to be changed weekly. The DON stated nurses on any shift can replace humidifier bottles if found empty. The DON stated humidifier bottles were needed to prevent nose dryness and increase comfort during oxygen treatment. A review of the facility's P&P, titled, Oxygen Equipment, dated 06/2021, indicated, oxygen equipment shall be used according to Center for Disease Control (CDC) guidelines. The P&P indicated nasal cannula oxygen tubing shall be changed weekly. The P&P further indicated humidifier bottles are replaced when empty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 5 of 14 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 11/30/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review, the facility failed to ensure one of four sampled resident (Resident 70) on an antipsychotic (medication that treats several kinds of mental health conditions) was free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of a PRN (as needed) for Seroquel's (antipsychotic) appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 70 to receive unnecessary drugs and suffer adverse medication side effects. Findings: During an observation and interview on 11/27/23 at 11:00 a.m., Resident 70 was sitting up in bed and stated being anxious and gets frustrated because she was helpless. To call for help, Resident 70 stated she screams out for help. Resident 1 stated she wanted someone to get her cell phone to be able to call and speak to her family. Review of the quarterly Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 10/25/23 indicated Resident 70's Basic Interview of mental status (BIMS) score was 3 (meaning severe cognitive impairment). Resident 70 had diagnoses to include stroke (when the blood supply to part of the brain is interrupted or reduced) and brief psychotic disorder manifested by striking out and uncontrollable screaming. Further review indicated Resident 70 was able to make herself understood and required extensive assistance from staff. During an interview and concurrent record review on 11/29/23 at 10:37 a.m., LVN 1 (Licensed Vocational Nurse) stated Resident 70 was on seroquel to relax, keep calm and to manage her outbursts as Resident 70 becomes delirious. LVN 1 further stated Resident 70 had a stroke that affects her left side and had massive striking out. LVN 1 stated non-therapeutic interventions did not help Resident 1. LVN 1 stated resident 70 got angry when she sat in the dining room as she watched others eat while she was NPO (nothing by mouth). Also,when Resident 70 sat in the nursing station, the resident becomes restless and had outbursts. During a review of the physician order, it indicated Resident 70 had a PRN (as needed) order, dated 10/11/23, for Seroquel (antipsychotic) 25 mg every 24 hours for mood stabilization: striking out, uncontrollable screaming. Additionally, Resident 70 had routine seroquel orders: Give 25 mg (milligrams) one time a day for mood stabilization: striking out, uncontrollable screaming and to Give 50 mg two times a day for mood stabilization: striking out, uncontrollable screaming. Review of the Consultant Pharmacist recommendation, dated 10/2023, it indicated that antipsychotic PRN use is not recommended because it takes 3-7 days before the antipsychotic effect begins. Use of PRN antipsychotics could be viewed as a 'chemical restraint'. It indicated PRN orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days and documents this in the clinical record. Furthermore, if the prescriber believes the resident requires an antipsychotic drug on a PRN basis for longer than 14 days, he/she will be required to write a new PRN script every 14 days after the resident has been evaluated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 6 of 14 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 11/30/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/23 at 10:44 a.m., the DON (Director of Nursing) stated Seroquel, for Resident 70 was re-evaluated monthly, quarterly, as needed and during IDT (Interdisciplinary Team) meetings. DON verified the last time the Seroquel PRN was evaluated for Resident 70 was in October 2023. The DON could not provide information that Resident 70 was evaluated after 14 days and that a new script was written by the doctor for seroquel. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 7 of 14 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 11/30/2023 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 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** 2b. A review of the Resident 140's admission record indicated Resident 140 was admitted on [DATE] and included a diagnosis of aftercare following surgical amputation of four left fingers. A review of Resident 140's MDS indicated a BIMS of 14 (cognitively intact) and Resident 140 was able to express wants. A review of Resident 140's diet order, dated 11/16/23, indicated Resident 140 was on a regular diet, double portion protein at breakfast, and a high protein snack two times a day at 0900 and 1900. During an interview on 11/27/23, at 11:38 a.m., Resident 140 indicated the facility did not serve what was indicated on the menu. Resident 140 stated he required a high protein diet. Resident 140 said he received his protein in the mornings, however during lunch and dinner, he received salad and no protein. Resident 140 stated the facility offered him snacks and described it as junk. Based on observation, interview, and record review, the facility failed to follow posted menu when: 1. On 11/28/23, during lunch meal: - Pot stickers were not served as a garnish according to the menu. - Salad plates were provided which was not on the menu. 2. Resident 47 and Resident 140 stated menu was not routinely followed as listed. These failures had the potential for served meals to not meet the nutritional needs of the residents who received food from the kitchen. Findings: 1. During a concurrent interview and record review on 11/28/23, at 9:45 a.m., with the Food Services Director (FSD), facility's undated dietary document Fall Menu Week 3, was reviewed. The menu followed for 11/28/23, Tuesday, lunch meal showed teriyaki chicken, sauteed tofu (instead of vegetable chicken teriyaki), fried rice, garlic broccoli, pot sticker, and mandarin gelatin. During a concurrent observation and interview on 11/28/23, at 12:45 p.m. (after completion of tray line), with [NAME] 2 and FSD, residents were not served pot stickers on their lunch trays. [NAME] 2 stated the tray of cooked pot stickers were left stored inside the oven. [NAME] 2 and FSD stated they failed to include the pot sticker as a garnish on the dinner plates of all the residents not on pureed, renal, or vegetarian diet. During a concurrent follow-up observation, interview, and record review on 11/28/23, at 12:50 p.m., with FSD, the day's lunch menu was reviewed. Residents were served salad greens that was not included in the menu. FSD stated alert residents frequently asked for the green salads. FDS stated if the menu changed, the change was indicated on the menu posted outside the dining room. FSD stated she did not indicate that salad greens were added on the posted menu. During an interview on 11/29/23, at 11:32 a.m., with the Registered Dietitian (RD) 2, RD 2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 8 of 14 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 11/30/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm posted menus should be followed and food item alternates should be posted in advance to meet the nutritional needs of the residents. RD 2 further stated menu changes are subject to RD's approval. A review of the facility's dietary guideline titled, The Meal Manager, dated 8/26/2023, indicated, Pot Stickers .Serve one pot sticker as a garnish according to the menu . Residents Affected - Some A review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2018, indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. The facility will use approved recipes, standardized to meet the resident census . A review of the facility's P&P titled, Menus, undated, indicated, Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed .3. Menus for regular and therapeutic diets are written at least two (2) weeks in advance .4. The Dietitian will review and approve all menus . 2a. A review of Resident 47's admission record indicated Resident 47 was admitted to the facility in 2020, for quadriplegia (loss of muscle function in both arms and legs). A review of Resident 47's minimum data set (MDS-a tool to guide care), dated 10/26/23, indicated Resident 47 had a BIMS score of seven (brief interview for mental status, a tool to determine a resident's cognitive ability to remember and recall information, a score of 13-15 indicates intact cognition, a score of 8-12 indicates moderately impaired cognition and scores 0-7 indicate severely impaired cognition). The MDS assessment indicated Resident 47 usually understood others and others usually understood him. A review of Resident 47's physicians orders, dated 8/31/23, indicated Resident 47 was on a carbohydrate controlled, double protein, mechanical soft diet (one in which the texture of a diet is altered to be soft for easier swallowing). During an interview on 11/27/23, at 09:45 a.m., with Resident 47, Resident 47 stated the facility did not follow the daily menus. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 9 of 14 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 11/30/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to prepare pureed (cooked food that has been ground, pressed, and blended to a consistency of creamy paste) food designed to meet the needs of residents with a specialized diet. This failure had the potential to result in aspiration and choking (inhaling of food and drinks) of medically compromised residents who received pureed food from the kitchen. Findings: During a concurrent observation and interview on 11/28/23, at 12:15 p.m., pureed foods prepared by [NAME] 2 were on the kitchen steam table. [NAME] 2 stated he pureed the chicken teriyaki, broccoli, and rice separately by mixing water and thickener to the foods. During a concurrent observation and interviews on 11/28/23, at 12:45 p.m., with [NAME] 2 and Food Services Director (FSD), in front of the kitchen steam table, pureed chicken teriyaki, pureed broccoli, and pureed rice were scooped to the dinner plate and were observed runny in consistency. FSD checked the pureed food consistency by sticking a spoon upright in the center of each tray with pureed food. All three spoons fell to the side of each tray. FSD stated the pureed foods were not of the correct consistency. During an interview on 11/29/23, at 11:32 a.m., with Registered Dietician (RD) 2 (filling in for RD 1 who was unavailable for interview), RD 2 stated pureed food is comparable to applesauce consistency. A review of the facility's dietary guidelines titled, Glossary of Cooking Terms Related to Texture Modified Diets, dated 10/17, indicated, Anytime food is reduced in size and/or texture dryness may develop. A source of moisture is frequently needed. Broth or light gravy for most meats .are recommended liquids .Puree - to food process or blend food until smooth. Unless ordered differently, pureed food should have form and stand up on a dinner plate like mashed potatoes or pudding-like consistency . Further review of the facility's dietary guidelines titled, The Meal Manager, dated 2023, indicated, Chicken Teriyaki .Pureed .add 1-1/2 tablespoon (tbsp) broth, gravy, or sauce for each portion .add additional liquid 1 tablespoon at a time as needed. Continue blending until pudding-like consistency is reached .Broccoli, Garlic (Frozen) .Pureed and (&) Minced & Moist .gradually add 1 teaspoon (tsp) thickener for each portion .Continue blending until pudding-like consistency is reached .Note: Proportion of liquid to thickener may vary according to manufacturer or type. Follow mixing instructions for brand purchased .Rice, Fried .Pureed, Minced & Moist .Add 2 tbsp broth, gravy or sauce for each portion .Continue blending until pudding-like consistency is reached .Adjust liquid as needed to obtain desired consistency . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 10 of 14 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 11/30/2023 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 store, prepare, and serve food under sanitary conditions when: Residents Affected - Some 1. In the kitchen pantry, multiple opened gallon containers of liquid condiments did not have opened dates. 2. Freezer 1 contained three sealed boxes of meat stored without labels. 3. A dietary staff entered the kitchen without a hairnet. 4. Ice machine interior was unclean. 5. Ice Machine Room door was left open and accessible to unauthorized persons. 6. Resident Food Refrigerator inside Station 1 Medication Room was not cleaned routinely and freezer compartment at Station 1, had ice build-up. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview on 11/27/23, at 9:30 a.m., with the Food Services Director (FSD): Inside the Dry Storage Room, an opened gallon container of light unsulfured molasses had no open date. In the kitchen prep area, there were opened gallon containers of liquid condiments that were used and unlabeled with opened dates: - Two opened containers of Worcestershire sauce - no open dates. - An opened gallon of canola oil & extra virgin olive blend - no open date. - An opened 1.32 gallon of balsamic vinegar - no open date. - An opened gallon of red wine vinegar - no open date. FSD stated the liquid items should have been labeled with opened date. 2. During a concurrent observation and interviews on 11/27/23, at 9:40 a.m., with the FSD and [NAME] 1, Freezer 1 (Meat Freezer) contained three sealed boxes of meat stored without labels. - A box 4/10-pound ground beef, with one sealed pack left inside the box - no label of received date, open date, or used by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 11 of 14 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 11/30/2023 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 - Two sealed boxes with 48/4 ounces chicken breast - no label of received date, open date, or used by date. Level of Harm - Minimal harm or potential for actual harm Cook 1 stated he and another dietary staff received the delivered food items on Friday, 11/24/23, but the dietary staff (unavailable for interview) failed to label the three boxes. FSD stated all delivered and received food items should be dated and labeled when stored. Residents Affected - Some A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, undated, 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 (use by date) .Other opened containers must be dated and sealed or covered during storage . 3. During an observation on 11/28/23, at 11:15 a.m., from the kitchen entrance door, Dietary Aide (DA) 1 entered the kitchen from the back door, walked and passed Refrigerator 1 and Refrigerator 2, then quickly exited from the back door with her hair tied back without a hairnet. During a concurrent observation and interview on 11/28/23, at 11:18 a.m., FSD stated DA 1 entered the kitchen from the back door to check DA 1's work schedule. During the interview with FSD, DA 1 entered the kitchen again, this time with a hairnet on. DA 1 stated she must wear a hairnet when entering the kitchen to prevent food contamination. A review of the facility's P&P titled, Food Preparation and Service, undated, indicated, Food Service Employees shall prepare and serve food in a manner that complies with safe food handling practices .Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food . 4. During an initial tour observation on 11/27/23, at 10:25 a.m., in the hallway between Nursing Station 1 and Nursing Station 2, door to the dedicated Ice Machine Room was left open, visible, and accessible to staff and visitors. The Ice Machine did not have an exterior lock to secure accessibility in getting ice directly from the ice bin. During a second observation and concurrent interview on 11/28/23, at 9:23 a.m., with the Maintenance Supervisor (MS), at the hallway, the Ice Machine Room was once again observed open. The outer side of the door had posted signage that indicated, Staff Only and had a security keypad for the door code. On the inner side of the door were two more posted signages. The first one indicated, Employees Only Ask for Assistance, and the second signage indicated, Leave Fan On! Turn Off Light When Done! Leave Door Cracked/Ajar! MS stated door should be always closed and only kitchen personnel and other staff members should have access to the Ice Machine Room/ice bin to prevent cross contamination. During a concurrent observation and interview on 11/30/23, at 8:56 a.m., with the Clinical Manager (CM), CM stated door to Ice Machine Room should be always shut and was accessible to staff only. When left open, any resident can walk in and get ice and contaminate the ice bin. 5. During a concurrent follow-up observation and interview on 11/28/23, at 9:35 a.m., with MS, inside the Ice Machine Room, the ice machine interior was checked. The edge of the water curtain (where water flows and freezes to make ice) had brownish-orange and pink residue. MS stated the vendor serviced the machine every six months and MS cleaned the machine (no set schedule) in between the vendor's maintenance procedure. MS stated he did not maintain an Ice Machine Cleaning Log other than the vendor visits. MS stated the vendor referred to the residue as permanent stains. When writer wiped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 12 of 14 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 11/30/2023 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 the residue with a clean paper towel, the residue was easily removed. Level of Harm - Minimal harm or potential for actual harm A review of the facility's vendor invoice titled, Description of Work, dated 10/10/23, indicated the vendor conducted ice machine cleaning completed on 10/11/23. Residents Affected - Some Further review of facility's document titled, Logbook Documentation, dated 10/13/23, indicated, .Sanitize interior of ice machine per manufacturer's instructions . A review of the Manufacturer's Manual titled, Vendor Ice Machines, sub-titled, 'Installation, Operation and Maintenance Manual, indicated, Preventative Maintenance Cleaning Procedure - This procedure cleans all components in the water flow path and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure without removing the ice from the bin/dispenser .Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime . 6. During a concurrent observation and interview on 11/30/23, at 9 a.m., with the CM, inside Station 1 Medication Room, the Resident Food Refrigerator was checked. The inside of the refrigerator was unclean with sticky, brown-colored stains. The freezer compartment had thick ice build-up of at least 1 inch all around the freezer section. CM stated she was responsible in making sure refrigerator was cleaned weekly and the freezer defrosted as needed. CM stated she was unsure of when the refrigerator was last cleaned. When asked, CM was unable to provide a Refrigerator Cleaning Log. CM stated uncleaned refrigerator could be a source of infection. A review of the facility's P&P titled, Refrigerators and Freezers, undated, indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 13 of 14 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 11/30/2023 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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident 234) of 31 sample selected residents when Registered Nurse (RN) 1 did not follow infection control standards during wound care for Resident 234. Residents Affected - Some This failure had the potential to result in wound complications and infection for Resident 234. Findings: A review of Resident 234's admission Record indicated Resident 234 was admitted to the facility with a diagnosis of cellulitis (a bacterial infection) of the left lower limb. A review of Resident 234's physician orders for wound care, dated 11/23/23, indicated . R (right) elbow stage III (3) cleanse with NS (Normal Saline), pat dry, apply skin prep . During a concurrent observation and interview on 11/28/23, at 9:15 a.m., RN 1 was observed during the wound treatment for Resident 234 and these following issues were found: 1. RN 1 removed the opened, unsealed package of DermaCol Collagen sheet (DermaCol is an advanced wound care dressing made of collagen, sodium alginate, carboxyl methylcellulose and ethylenediamine-tetraacetic acid and maintains a moist wound environment and creates ideal conditions for healing. May be trimmed and layered for management of deep wounds) from the treatment cart, then removed a piece of the DermaCol sheet from the opened package, and put that piece inside the cup to use on Resident 234's wound. RN 1 confirmed that the package was opened and used for other residents prior to Resident 234, and RN 1 stated that she usually put the DermaCol inside the plastic bag to use for multiple residents. RN 1 stated, using the same dressing package for multiple residents can transfer infection and it is not practical. 2. RN 1 placed the new wound treatment supplies (Gauze, saline, foam dressing, barrier wipe, collagen sheet) on Resident 234's bed side chair without a barrier and while wearing gloves, removed the old dressing, opened a new dressing pad and collagen sheet with the same gloves and applied them on the wound. RN 1 stated she should have used a barrier sheet on which to put her supplies and changed her gloves between the old and new wound dressings for infection control. A review of the facility's policy and procedure (P&P), titled, Wound Care, revised October 2010, indicated, . Use disposable cloth [paper towel is adequate] to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field . put on exam gloves. Loosen tape and remove dressing. Pull gloves over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves During an interview on 11/28/23, at 12:15 p.m., with the Director of Nursing (DON), DON stated the facility did not have any policy and procedure for using the dressing package for multiple residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 14 of 14