Inspection·June 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interviews and record reviews, the facility did not revise the care plan for two of two sample selected residents (Resident 19 and 52) with new diagnoses, when Residents 19, and 52 were diagnosed with depression and staff did not develop a care plan for depression. This failure in practice had the potential to result in inadequate care and support, potentially worsening their mental health condition, experiencing emotional distress, social withdrawal, and other negative health outcomes, and compromise to their overall well-being and quality of life. Findings: A review of Resident 52's admission Record indicated Resident 52 had a diagnosis of major depression and cognitive decline. A review of Resident 19's admission Record indicated Resident 19 had a diagnosis of depression. During a concurrent interview and record review on 6/4/25 at 1:36 p.m. with Director of Nursing (DON), DON reviewed Resident 52 and 19's diagnoses, MDS, and care plans. DON confirmed Residents 52 and 19 were diagnosed with depression and did not find care plans for their depression. DON stated the nurses should have care planned for the depression because care planning is important for each diagnosis, and staff need to know what care they need to provide for each specific diagnosis to improve the resident's health status. During a concurrent record review and interview on 6/4/25 at 1:40 p.m. with DON, DON reviewed the facility's policy and procedure (P&P) Care Planning-Comprehensive Care Plan, undated, the P&P indicated . Care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident . DON stated that is the only policy and procedure that they have for care planning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 2 of 13 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 06/05/2025 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 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 Based on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming to one of three sampled residents (Resident 50) when she did not receive nail care. Residents Affected - Few This failure had the potential for development of skin injuries and infection for Resident 50. During a review of Resident 50's admission Record, undated, the admission Record indicated Resident 50 was admitted to the facility in March 2025 with diagnoses that included diabetes, dementia, and heart failure. During a review of Resident 50's Minimum Data Set (MDS, , a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/27/25, the MDS indicated Resident 50's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 7, indicating Severe cognitive impairment. The MDS also indicated Resident 50 was dependent on staff for activities of daily living (ADLs, are those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). During a concurrent observation and interview on 6/3/25 at 8:45 a.m. in Resident 50's room, Resident 50 was lying in bed. Resident 50 had long big toenails. Resident 50 stated her toenails are long and needed to be cut. During an interview on 6/3/25 at 11:12 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 acknowledged that she saw that Resident 50's big toenails were long. CNA 6 stated Resident 50's big toenails are crooked looking and on the longer side. She stated the podiatrist comes monthly. She stated she reported it to the nurse yesterday. During an interview on 6/4/25 at 2:35 p.m. with the Social Services Director (SSD), SSD stated nursing should inform him if any resident is required to see the podiatrist who comes in quarterly, and he sends the podiatrist an email and the list. When asked if Resident 50 was on the list, SSD searched for Resident 50's name from the list hanging on the wall and could not find her name. SSD stated Resident 50 was not on the list and no one had told him Resident 50 needed to be added to the list. During an interview on 6/4/25 at 4:15 p.m. with Director of Nursing (DON), DON stated toenails needed to be routinely trimmed and could be done by the CNA. He stated it is important for hygiene. During a follow-up interview on 6/5/25 at 10:40 a.m., DON stated Resident 50 required to be seen by a podiatrist. He stated for residents who do not have complications, the trained staff like the CNA can do that for the residents. During a review of Resident 50's ADL care plan, dated 11/6/23, the care plan indicated, provide assistance with care and ADL. During a review of the facility's policy and procedure (P&P) titled, Foot Care, revised March 2018, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain .foot health .Residents will be assisted to see the specialists (podiatrist .etc.) as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 3 of 13 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 06/05/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 181) was monitored for side effects of divalproex sodium (Depakote -a mood stabilizing medication) which was given to Resident 181 in error. Residents Affected - Few This failure exposed Resident 181 to potentially serious adverse effects. Findings: During a review of Resident 181's admission Record, printed on 6/3/25, the admission Record indicated Resident 181 was admitted to the facility in March 2025. During a review of Resident 181's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/25, indicated Resident 181 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15 indicating moderate cognitive impairment. The MDS also indicated, Resident 181 had multiple diagnoses that included, hip fracture and depression. The MDS revealed Resident 181 did not have symptoms of mood disturbances and/or physical and verbal symptoms directed to self or others. During an interview on 6/2/25 at 12:25 p.m. with Facility Medical Practitioner (FMP), FMP stated, divalproex sodium was indicated for residents with behavioral disturbances. FMP also stated, Residents receiving divalproex sodium should be monitored for sedation/hyperactivity as well as monitored for effectiveness and for side effects especially in the elderly. FMP added Resident 181 received divalproex sodium in error but should have been monitored regardless. During an interview on 6/3/25 at 2:43 p.m., with the Director Of Nursing (DON), DON acknowledged Resident 181 was administered divalproex sodium in error. DON added, it was important to have behavioral and side effects monitoring on Residents receiving psychotropic medication to ensure effectiveness and monitor for side effects. DON confirmed, there was no monitoring for Resident 181's divalproex sodium use. During a telephone interview on 6/4/25, at 2:05 p.m., with the Facility Pharmacy Consultant (FPC), FPC stated, she wrote a report to the prescribing physician with recommendation to clarify Resident 181's diagnosis. FPC added, the physician's order for divalproex sodium did not include behavioral and side effects monitoring. During a review of Resident 181's Order Summary Report, dated 6/4/25, the Order Summary Report indicated a physician order for Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for mood instability with start date 4/8/25. During a review of Resident 181's Medication Administration Record (MAR) for April 2025, the MAR revealed, Resident 181 was administered divalproex sodium 125mg from 4/8/25 until 4/23/25. There was no documented evidence the facility had monitored for the side effects of divalproex sodium on the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 4 of 13 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 06/05/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of a document titled, Consultant Pharmacist's Medication Regiment Review (MRR), dated 4/25/25, the MRR indicated for Resident 181, Please consider adding monitoring related to side effects and targeted behavior of Depakote . During a review of the facility's policy and procedures (P&P) titled, Adverse Consequences and Medication Errors, undated, the P&P indicated .8. Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: f. medication error . During a review of the facility's P&P titled, Psychotherapeutic Drug Management, dated 3/2010, the P&P indicated, This facility shall monitor all psychotherapeutic medications for effectiveness and side effects according to OBRA (Omnibus Budget Reconciliation Act - established federal standards for nursing home care in the United States) guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 5 of 13 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 06/05/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 181) was not given unnecessary psychoactive (controls mood and behavior) medication when Resident 181 was given divalproex sodium (Depakote, a mood stabilizer) without appropriate indications for use. Residents Affected - Few This failure resulted in Resident 181 receiving psychoactive medication without actual psychiatric diagnoses and unnecessarily exposed her to serious adverse side effects. Findings: During a review of Resident 181's admission Record, printed on 6/3/25, the admission Record indicated Resident 181 was admitted to the facility in March 2025. During a review of Resident 181's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/25, indicated Resident 181 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15 indicating moderate cognitive impairment. The MDS also indicated Resident 181 had multiple diagnoses that included, hip fracture and depression. The MDS revealed Resident 181 did not have symptoms of mood disturbances and/or physical and verbal symptoms directed to self or others. During an interview on 6/3/25, at 1:41 p.m., with Registered Nurse (RN) 1, RN 1 stated she made a mistake and transcribed verbal medication order of divalproex sodium in Resident 181's medical record that was intended for Resident 52. RN 1 also stated, she did not read the order back to the ordering physician to ensure the divalproex sodium was for the right resident. During a concurrent interview and review on 6/3/25 at 2:23 p.m., the facility's policy and procedures (P&P) titled Verbal Orders, dated 2/14, was reviewed with the Director of Nursing (DON). The P&P indicated under policy interpretation and implementation .4. The individual receiving the verbal order will: a. read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed. DON stated RN 1 did not read the order back to the doctor to ensure the medication order was for Resident 181. During an interview on 6/3/25 at 2:43 p.m. with DON, DON acknowledged Resident 181 was administered divalproex sodium unnecessarily for two weeks while admitted to the facility. DON also added RN 1 made a mistake and transcribed the divalproex sodium order in Resident 181's medical record instead of Resident 52. DON also stated, Resident 181 or Responsible Party (RP) did not sign a consent for psychotropic medication. During a telephone interview on 6/4/25, at 2:05 p.m., with the Facility Pharmacy Consultant (FPC), FPC stated she wrote a report to the prescribing physician with recommendations to clarify Resident 181's diagnosis. FPC added the physician's order for divalproex sodium indicated it was for mood instability. FPC further added mood instability was not a diagnosis and was not appropriate indication for use of psychotropic medication. During a review of Resident 181's Order Summary Report, dated 6/4/25, the Order Summary Report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 6 of 13 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 06/05/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm indicated a physician order for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for mood instability with start date 4/8/25. During a review of Resident 181's Medication Administration Record (MAR) for April 2025, the MAR revealed Resident 181 was administered divalproex sodium 125mg from 4/8/25 until 4/23/25. Residents Affected - Few During a review of document titled Note To Attending Physician/Prescriber, dated 4/8/25, the note revealed a recommendation from FPC which indicated please clarify diagnosis more specific than 'mood instability' for divalproex sodium order. During a review of Resident 181's Physician Note, dated 4/23/25, the Physician Note indicated under description: Due to a communication error between, a verbal order for divalproex sodium intended for another resident was mistakenly entered under this resident's chart. During a review of the facility's P&P titled, Psychotherapeutic Drug Management, dated 3/2010, the P&P indicated under Procedure A.2. Informed consent shall be obtained from the resident and/or responsible party prior to the administration of psychotherapeutic medication and for each increase in dosage. 3. The psychotherapeutic medication order shall include the following information: Diagnosis for the medication. Behavior manifestations of the disorder treated i.e. auditory hallucinations, hitting others, refusing to eat etc. During a review of the facility's P&P titled, Adverse Consequences and Medication Errors, undated, the P&P indicated under policy interpretation and implementation .4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; b. Defining appropriate indications for use; .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles for the professional(s) providing services. 6. Examples of medication errors include: .b. Unauthorized drug - a drug that is administered without a physician's order. According to the National Library of Medicine, last updated on September 4, 2023, the nurses have a unique role and responsibility in medication administration. Furthermore, it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration which included, 'Right patient' ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. https://www.ncbi.nlm.nih.gov/ FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 7 of 13 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 06/05/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 181) was free from significant medication error when Resident 181 was administered divalproex sodium (Depakote, a psychoactive medication that controls mood and behavior) in error 30 times. Residents Affected - Few This failure resulted in Resident 181 to receive psychoactive medication in error. This failure also exposed Resident 181 to serious health complications and/or jeopardized her safety. Findings: During a review of Resident 181's admission Record, printed on 6/3/25, the admission Record indicated Resident 181 was admitted to the facility in March 2025. During a review of Resident 181's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/25, indicated Resident 181 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15 indicating moderate cognitive impairment. The MDS also indicated Resident 181 had multiple diagnoses that included, hip fracture and depression. The MDS revealed Resident 181 did not have symptoms of mood disturbances and/or physical and verbal symptoms directed to self or others. During an interview on 6/3/25, at 1:41 p.m., with Registered Nurse (RN) 1, RN 1 stated she made a mistake and transcribed a verbal medication order of divalproex sodium (medication used as a mood stabilizer) in Resident 181's medical record that was intended for Resident 52. RN 1 added this resulted in Resident 181 to receive divalproex sodium in error. During an interview on 6/3/25 at 2:43 p.m., with the Director Of Nursing (DON), DON acknowledged Resident 181 was administered divalproex sodium unnecessarily for two weeks while admitted to the facility. DON also added RN 1 transcribed the medication order in error which resulted in administration of divalproex sodium to Resident 181. During a review of Resident 181's Order Summary Report, dated 6/4/25, the Order Summary Report indicated a physician order for Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for mood instability with start date 4/8/25. During a review of Resident 181's Medication Administration Record (MAR) for April 2025, the MAR revealed Resident 181 was administered divalproex sodium 125mg once on 4/8/25, twice a day from 4/9/25 thru 4/22/25, and then once on 4/23/25. During a review of Resident 181's Physician Note, dated 4/23/25, the Physician Note indicated under description: Due to a communication error between, a verbal order for Depakote intended for another resident was mistakenly entered under this resident's chart. During a review of the facility's P&P titled, Adverse Consequences and Medication Errors, undated, the P&P indicated under policy interpretation and implementation .4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 8 of 13 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 06/05/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Defining appropriate indications for use; .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles for the professional(s) providing services. 6. Examples of medication errors include: .b. Unauthorized drug - a drug that is administered without a physician's order. Residents Affected - Few According to the National Library of Medicine, last updated on September 4, 2023, the nurses have unique role and responsibility in medication administration. Furthermore, it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration which included, 'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. https://www.ncbi.nlm.nih.gov/ FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 9 of 13 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 06/05/2025 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 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 proper labeling and storage of medication when the following was noted: 1. Two multi-dose insulin pens for Residents 228 and 40 had no open and beyond use date (BUD-the date after which a medication should not be used) label. 2. Thirteen expired nasal swabs were kept with ready to use medications in medication storage area. This failure had the potential to result in the Residents 228 and 40 receiving ineffective medication doses and Residents receiving abnormal nasal swab test results which could lead to more health issues. Findings: 1. During a concurrent observation and interview on [DATE] at 11:54 a.m., outside Resident 228 room on medication cart, with Registered Nurse (RN) 2, a Novolog FlexPen Subcutaneous Solution Pen Injector 100 unit/milliliter (ml) (Insulin Aspart-fast-acting insulin used to treat high blood sugar/diabetes) had a label with Resident 228's name but no open or BUD label on the pen. Resident 228 had a blood sugar reading of 148. RN 2 stated that per the sliding scale insulin (amount of insulin you take based on your current blood sugar readings), Resident 228 is going to get 1 unit. RN 2 also stated, I could see the problem not knowing when it was opened because don't know how long it's been there. During a review of Resident 228's admission Record, dated [DATE], the admission Record indicated Resident 228 was admitted in [DATE] with a diagnosis of Type 2 Diabetes Mellitus (chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels) with Diabetic Neuropathy. During a review of Resident 228's Active Orders, dated [DATE], the Active Orders indicated that Novolog FlexPen Subcutaneous Solution Pen Injector 100 unit/ml (Insulin Aspart); Inject per sliding scale was ordered on [DATE] by the provider. During a concurrent observation and interview on [DATE] at 12:07 p.m., outside Resident 40 room, on medication cart, with Registered Nurse (RN) 2, an Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro-fast-acting insulin used to treat high blood sugar/diabetes) had a label with Resident 40's name but no open or BUD label on the pen. Resident 40 had a blood sugar reading of 187. RN 2 stated per the sliding scale insulin (amount of insulin you take based on your current blood sugar readings), Resident 40 is going to get 1 unit. RN 2 also stated, again I could see what you are talking about not knowing when it was opened because don't know how long it's been there, and it can get confusing. During a review of Resident 40's admission Record, dated [DATE], the admission Record indicated Resident 40 was admitted [DATE] with a diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 10 of 13 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 06/05/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 40's Active Orders, dated [DATE], the Active Orders indicated that Insulin Lispro Injection Solution 100 unit/ml; Inject per sliding scale was ordered on [DATE] by the provider. During an interview on [DATE] at 12:53 p.m. with Director of Nursing (DON), DON stated that DON stated we just got those Resident's meds delivered, but I understand the need to write opened date so can know and not get confused. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, undated, the P&P indicated, .3. Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing. During a review of the following website https://www.novo-pi.com/novolog.pdf titled, Novolog Insulin Aspart Injection 100 units/ml: Highlights of Prescribing Information, undated, the prescribing information indicated, .16.2 Recommended Storage: 3 mL single-patient-use FlexPen® in use (opened): 28 days discard During a review of the following website https://prescriberpoint.com/therapies/humalog-c8ecbd7#drug_label titled, Humalog (insulin lispro): Instructions for Use, [DATE], the storage information indicated, .In-use Pen Throw away the HUMALOG Pen you are using after 28 days, even if it still has insulin left in it. During a review of the following website https://www.jointcommission.org/standards/standard-faqs/home-care/medication-management-mm/000001529/ titled, Multi-dose Vials - Managing Multi-dose Vials of Injectable Medication, [DATE], the article indicated If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated with the last date that the product should be used (expiration date) and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial .Labeling the vial with the 'date opened' does not meet the intent of this requirement. 2. During a concurrent observation and interview on [DATE] in medication storage room with DON the following was found with ready to use supplies: -3 nasal swabs with expiration dates [DATE] -6 nasal swabs with expiration dates [DATE] -3 nasal swabs with expiration dates [DATE] -1 viral swab with expiration date 6/2021 DON stated, we don't use these anymore, I don't know why they are here, we will throw them out, I will order more if we need it. During a review of the facility's P&P titled, Storage of Medications, undated, the P&P indicated, 4. The facility shall not use discontinued or deteriorated drugs. All such drug shall be destroyed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 11 of 13 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 06/05/2025 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 one of one ice machines was clean. Residents Affected - Many This failure practice could be result in illnesses and infections. Findings: During a concurrent observation and interview on 6/2/25 at 12:10 p.m., with the Maintenance Supervisor (MS) and Dietary Supervisor (DS), who were present in the ice machine room, inside the ice machine tray was wiped with a clean, white wipe. There was black residue on the wipe after wiping the inside of the ice machine. The black residue was confirmed by MS and DS. DS stated he checks and cleans the machine every month for maintenance, and cleans the machine as needed, DS stated he is not cleaning the machine every day or every week routinely. The DS was able to show the monthly maintenance log only and stated that is the only log that he had. During an interview on 6/2/25 at 3:00 p.m. with DS, DS stated the ice machine needed to be checked and cleaned every day for the safety of the residents and staff. Review of the facility's policy and procedure Ice Machines and Ice Storage Chests, dated 2001, indicated . f. Clean and sanitize the tray and ice scoop daily . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 12 of 13 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 06/05/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, facility did not ensure sanitary and comfortable rooms for two of two sample selected residents (Resident 61 and 52), when Resident 61 and 52's rooms (Room numbers 36 and 38) were not clean with brown spots on various surfaces, and the floors were sticky and had food particles scattered around. This failure in practice could have potentially resulted an environment conducive to the growth of bacteria, mold, and other harmful microorganisms resulting in infections and other health issues for residents, and emotional distress and discomfort, leading to a decline in mental health and overall satisfaction with the facility. Findings: A review of Resident 52's admission Record indicated Resident 52 was diagnosed with major depression and heart failure. A review of Resident 61's admission Record indicated Resident 61 was diagnosed with multiple sclerosis (chronic auto immune disease that affects the central nervous system, disrupting communication between the brain and the body, and leading to symptoms such as muscle weakness, coordination issues, and cognitive problems). During an interview on 6/2/25 at 11:00 a.m. with Resident 61, Resident 61 stated his room's floor is always dirty and sticky and he did not feel comfortable in his room. He stated he was very much concerned about infection control and cleanliness in his room. During a concurrent observation and interview on 06/02/25 at 11:14 a.m., in Room numbers 36 and 38 with the Maintenance Supervisor (MS) and Administrator (ADM), there were noticeable brown spots on various surfaces. The floors were sticky and had food particles scattered around. both MS and ADM confirmed, and ADM stated the resident's rooms must stay clean. During a review of the facility's policy and procedure Cleaning and Disinfecting Resident's Rooms, undated, indicated . 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 the facility's policy and procedure Resident Rights, undated, indicated . Have a clean, safe, comfortable, home-like environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056399 If continuation sheet Page 13 of 13