Other·September 21, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Annual RE-CERTIFICATION survey. Representing the California Department of Public Health were Health Facilities Evaluator Nurses: 38335,34331,37160,and 39621. The Facility census on the date of entry,6/25/18, was 97 with one bed-hold. There were 20 sampled residents.

F623 SS=F Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 06/25/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 1 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 2 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 3 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their policy and procedure titled "Transfer and Discharge" to notify the Office of the Ombudsman when 3 out of 3 reviewed residents (Resident 93, 56, 41) were transferred to hospitals. This failure had the potential to remove added protection to residents from being discharged or transferred inappropriately. Findings: During a record review on 6/25/18, at 2:31 p.m., Resident 41's Minimum Data Set (MDS, an assessment tool), dated 4/14/18, indicated the facility transferred Resident 41 to the hospital on 4/14/18. During a record review on 6/25/18, at 2:48 p.m., Resident 56's medical record indicated the facility transferred Resident 56 to the hospital on 5/6/18 and 5/31/18. Resident 93's MDS, dated 5/3/18, indicated the facility transferred Resident 93 to an acute care hospital on 5/3/18. During an interview on 6/27/18, at 4:11 p.m., Administrative Staff A stated the facility did not notify the Office of the Ombudsman when a resident was transferred to the hospital. During an interview on 6/27/18, at 4:33 p.m., Administrative Staff B stated the facility did not notify the Office of the Ombudsman when a resident was transferred to the hospital. During an interview on 6/27/18, at 4:36 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 4 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administrative Staff C stated she was not involved in notifying the Ombudsman when the facility sent a resident to the hospital. During an interview on 6/28/18, at 10:18 a.m. the Ombudsman Representative stated the facility did not send copies of notification of discharge and transfer to the office of the Ombudsman. The facility policy and procedure titled "Transfer and Discharge" dated 11/16, indicated, "Notice Before Transfer: Before the facility transfers of discharges a resident, the facility must: Notify the resident and the resident's representative in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 08/01/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 5 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement or develop a comprehensive person-centered care plan for 2 of 20 sampled residents (Resident 41, 51) when: 1. The Certified Nursing Assistant (CNA) did not follow the care plan for transferring Resident 41 from the bed to a wheelchair, which had resulted in Resident 41's skin breakdown on her left leg; and 2. The care plan for fluid restriction was not developed for Resident 51, which had the potential for Resident 51 to develop fluid overload. Findings: 1. During an observation on 6/27/18, at 9:43 a.m., Resident 41 was in bed and wearing a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 6 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE boot on her left leg. During an interview and concurrent record review on 6/28/18, at 8:15 a.m., Licensed Staff F verified Resident 41 was sent to the hospital related to left leg skin breakdown. The Health Status Note dated 4/14/18 at 5:44 p.m., indicated Resident 41 had a black open hematoma (a traumatic injury underneath the skin or the tissues) with black-reddish bleeding with a mild odor on her left lower extremity, and the facility sent Resident 41 to the hospital. Licensed Staff F stated Resident 41 developed the hematoma on her left leg when Resident 41 bumped her leg on a wheelchair on 4/6/18. During an interview on 6/28/18, at 9:20 a.m., Unlicensed Staff D stated Resident 41 hit her leg on the front wheel of the wheelchair when he was transferring Resident 41 from the bed to the wheelchair. Unlicensed Staff D stated, "I was transferring her by myself." Unlicensed Staff D stated he was not sure if Resident 41 needed 1 or 2 person to transfer her. During an observation and concurrent interview 6/29/18, at 9:37 a.m., Unlicensed Staff D demonstrated how Resident 41 hit her leg on the left front wheel of the wheelchair. Unlicensed Staff D demonstrated he was transferring Resident 41 from the bed to the wheelchair when Resident 41 bended her left leg inward underneath the wheelchair seat, and Resident 41 hit the wheel when she moved her leg outward from under the seat. Unlicensed Staff D stated Resident 41 had a two inches skin breakdown that he reported to the nurse right away. During an interview and concurrent record review on 6/29/18, at 10:04 a.m., Licensed Staff E stated the CNAs received report from fellow CNAs and nurses regarding if a resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 7 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE needed 1 or 2- person assist for transfer. Licensed Staff E verified Resident 41's care plan, initiated on 3/21/18, indicated Resident 41 required 2-person assist during transfer. During an interview on 6/29/18, at 10:38 a.m., Unlicensed Staff G stated the CNAs received information on how to transfer a resident from a sheet filled out by the nurse and/or therapist, which was posted on the resident's closet and reviewed by both the incoming and previous CNA during shift change. During a review of the clinical record for Resident 41, the admission Minimum Data Set (an assessment tool) dated 3/21/18, indicated Resident 41 needed extensive assistance (staff provide weight-bearing support) during transfer (how resident moved between surfaces including to and from: bed, chair, wheelchair, standing position) from 2 persons. During a review of the clinical record from the hospital for Resident 41, the Discharge Summary dated 4/17/18, indicated Resident 41 had cellulitis (bacterial infection involving the inner layers of the skin) on her left leg, and it was treated with antibiotics. 2. During an observation and concurrent record review on 6/25/18 at 7:40 a.m., Resident 51 had a sign on the wall above her bed which indicated, "Fluid Restriction" and no water pitcher on the bedside table. Resident 51's medical record indicated she had a history of congestive heart failure (a condition in which the heart doesn't pump blood as effectively as it should and fluids may build up in the body.) During a record review on 6/26/18 at 9:45 a.m., Resident 51's medical record indicated she was placed on a fluid intake restriction of 1500 mL (milliliters) in 24 hours per physician orders dated 3/13/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 8 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 51's care plan on 6/27/18 at 4:00 p.m., it was lacking a plan of care with goals and interventions for fluid restrictions. During a concurrent interview and record review on 06/28/18 09:30 a.m., the DON was asked to locate Resident 51's care plan specific to the order, interventions and goals of the resident's fluid restrictions of 1500 mL in 24 hours. The DON was unable to locate the care plan. When the DON asked Licensed Staff T where Resident 51's care plan for fluid restrictions was located, Licensed Staff T stated it was under the nutritional section, however, when Licensed Staff T reviewed the care plan, she also was unable to locate a plan of care for fluid restrictions. Licensed Staff T stated, "I can't find it." Then Licensed Staff U, an MDS (minimum data set - an comprehensive clinical assessment tool) coordinator, also reviewed Resident 51's medical record but no care plan was located specific to Resident 51's fluid restrictions. The facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated "A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident." Item 7(b) indicated the care planning process will include an assessment of the resident's strengths and needs. Item 8(a) indicated the comprehensive, person-centered care plan will include measurable objectives and timeframe's; 8(b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; 8(g) incorporate identified problem FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 9 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE areas; 8(h) incorporate risk factors associated with identified problems; 8(k) reflect treatment goals, timetables and objectives in measurable outcomes; 8(m) aid in preventing or reducing decline in the resident's functional status and/or functional levels; 8(n) enhance the optimal functioning level of the resident by focusing on a rehabilitative program; and 8(o) reflect currently recognized standards of practice for problem areas and conditions. Item 13 indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 07/17/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide grooming for 1 of 20 sampled resident (Resident 23) when Resident 23 had brown particle covering her left ear canal. This failure might have contributed to Resident 23's difficulty in hearing despite using a hearing aid and had the potential for ear infection. Findings: Resident 23's minimum data set (MDS, an comprehensive clinical assessment tool), dated 2/2/18, indicated Resident 23 had difficulty in hearing. The MDS also indicated Resident 23 was dependent on staff assistance for activity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 10 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of daily living (ADL) care including personal hygiene and bathing. During an observation on 6/26/18, at 11:42 a.m., Resident 23 was in the dining room with her head leaning to the right due to a physical condition. Resident 23 had dark brown particles on the left ear canal entrance. Resident 23 was hard of hearing. During an observation on 6/27/18, at 9:39 a.m., Resident 23 was in bed leaning her head to the right. Resident 23 had dark brown particles on the left ear canal entrance. During an observation on 6/27/18, at 1:50 p.m., Resident 23's left ear had the same dark brown particle. During an observation on 6/28/18, at 8:00 a.m., Resident 23 was sitting in her wheelchair. Resident 23 had a brown particle on her left ear. Resident 23 was hard of hearing. During an interview on 6/28/18, at 10:07 a.m., Unlicensed Staff I stated Resident 23 received shower every Wednesday and Thursday during AM Shift (7 a.m.- 3 p.m.). During an observation on 6/28/18, at 11:40 a.m., Resident 23 was in the dining room with a hearing aid on the left ear. Resident 23 was hard of hearing. During an observation and concurrent interview on 6/28/18, at 11:44 a.m., Licensed Staff J was asked to check Resident 23's left ear. Licensed Staff J removed Resident 23's hearing aid and use a cell phone flashlight to look at Resident 23's left ear. Dark brown particle was blocking the hole of Resident 23's left ear canal. Licensed Staff J stated, "there's a lot of stuff in there, definitely needed some cleaning." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 11 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Staff J stated she would get an order for an eardrop that will help break the particle in the left ear and she would lavage particle out. The facility policy and procedure titled "Bath (Bed)" no date, indicated, "Wash face and ears, rinse well and dry carefully." The facility policy and procedure titled "Bath (Shower)" no date, did not indicate to clean the residents' ears.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 08/01/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 12 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observations, interviews and record review, the facility failed to accurately transcribe admission orders for one out of three sampled residents (Resident 66). This failure resulted in the administration of the wrong medication for thirty days to Resident 66. Findings: During a med pass observation on 6/26/18 at 8:46 a.m., Licensed Staff L was observed administering one tab of Multivitamin with Minerals to Resident 66. During record review on 6/26/18 at 11:13 a.m., it was noted that Resident 66 had been transferred to the facility on 5/27/18, from an acute care facility. The After Visit Summary's medication orders from the acute care facility had been transferred to the nursing facility as admission orders . The acute care facility's After Visit Summary dated 5/27/18 at 2:40 p.m., included the following order, "Administer one tab of multivitamins daily." Licensed Staff M transcribed Resident 66's orders from the acute care facility's After Visit Summary to the facility's medication administration record (MAR). She transcribed the order, "Administer one tab of multivitamins daily" as follows, "Multiple Vitamins-Minerals Tablet, give 1 tablet by mouth one time a day for Supplement." There was no indication that the admitting physician had discontinued the acute care facility's multivitamin order and changed it to multivitamin with minerals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 13 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 6/28/18 at 2:19 a.m., Licensed Staff N, confirmed that there was no evidence suggesting that the facility's admitting physician discontinued the multivitamins from the outside acute care facility and ordered multivitamin with minerals instead. This transcription error led to the wrong administration of 1 tab of multivitamin with minerals for thirty days to Resident 66 (From 5/28/18 to 6/26/18). In addition, all the medication admission orders had not been signed by the admitting physician since admission on 5/27/18. During an interview on 6/26/18 at 11:26 a.m., Administrative Staff O stated that physicians were in the facility Monday through Friday. The physicians had the opportunity to sign the admission orders promptly. Administrative Staff O stated she did not know where the order for multivitamin with minerals came from. Administrative Staff O confirmed that there was no evidence that one of the facility's physician ordered multivitamin with minerals. The facility's procedure titled, "Health Information/Record Manual" revised on 9/18/2012 indicated, "Physician's orders will be entered on admission by the licensed nursing personnel or in some cases by other support staff trained in the regulations and requirements for physician's orders. The licensed nurse must "approve, review, and note the order as stated above." This same facility's procedure also indicated, "Physicians will review the either new orders and/or Monthly Renewal of orders for justification/diagnosis, clinical appropriateness, ordered dosage, time, amount and sign the Monthly Order renewal timely to meet the regulatory requirements."

F802 SS=E Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b) FORM CMS-2567(02-99) Previous Versions Obsolete

F802 Event ID: R1PO11 07/10/2018 Facility ID: CA010000467 If continuation sheet 14 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on dietary staff interview and dietary document review, the facility failed to ensure the Registered Dietitian (R.D.), the position designated to manage the day to day operations of the dietary services, supported dietary personnel competency as evidenced by lack of effective oversight to ensure safe food handling and standards of practice in respect to the cool down process for potentially hazardous foods. Cook V was unable to describe the cool down process for potentially hazardous foods. This failure had the potential to spread foodborne illness when potentially hazardous foods were not cooled using the standard cool-down process. Findings: During an observation and concurrent interview on 6/26/18 at 12 noon, Cook V was chopping FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 15 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE asparagus into bite size pieces and placing in a pot of water. Cook V stated he was preparing asparagus salad for the next day's lunch menu. When asked what he was going to do with the asparagus pieces, Cook V stated, "I have to boil them." During an interview on 6/26/18 at 12:05, Cook V was asked to describe the cool down process for potentially hazardous foods. Cook V asked, "What kind of food?" and was given an example of baked chicken. Cook V stated cooked chicken should reach 140°F (degrees Fahrenheit) in two hours. Cook V then corrected himself and stated, "Well, it's still cooking at 140°F." When asked if there was a chart posted to follow directions for the cool down process, Cook V stated, "No, there isn't." When asked again what temperature cooked meat should reach after two hours, Cook V stated, "Maybe about 60°F." When asked what were a couple of ways to cool down food quicker, Cook V stated, "An ice bath," however he was not able to describe other methods of cooling down cooked meat. Cooked foods must be cooled from 140°F to 70°F within 2 hours and to below 41°F within in an additional 4 hours, for a period of time not to exceed a total of 6 hours. (2013 FDA Food Code) During an interview on 6/26/18 at 12:20 p.m. the RD (Registered Dietitian/Kitchen Supervisor) stated the facility "never uses leftovers" and they "do not use a cool down method ever" because when a roast or other cooked meat is on the menu dietary staff cook and serve it on the same day. The RD stated, "I wouldn't have expected [Cook V] to know [the cool down procedure] because we don't use leftovers ... We cook and use the food the same day." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 16 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 06/26/18 3:48 p.m., when asked, "What did you do with the asparagus you were preparing earlier?" Cook V replied, "I boiled it." When asked, "Where is it now?" Cook V replied, "In the refrigerator." When asked, "Did you have to cool that down?" Cook V replied "Yes, I ran it under cold water a few times until cool then mixed it with the (salad) dressing." When asked if he recorded a temperature of the asparagus before placing in the refrigerator, Cook V replied, "No, because [the RD] said we don't use leftovers." When asked what the PHF (potentially hazardous food) temperature zone is, Cook V stated between 40-140°F. During an interview and concurrent document review on 6/26/18 at 4:05 p.m., the RD stated she realized the staff should be taught about the cool down process "especially like the asparagus." The RD stated a temperature log would be needed. During a review of in-service records for 2017 to 2018 no education was found for the cool down process of potentially hazardous foods. On 6/28/18 at 11:21 a.m., the RD stated she thought about cool down log and stated, "We do have a cool down process, but rarely use it." The RD then provided an old 2008 log with directions printed at the top and another 2017 log used by a former Dietary Service Supervisor. The RD stated she was going to make up a new log. The RD stated she reviewed the cool down process with Cook V because "he doesn't understand this." The facility's policy and procedure titled, "Cooling Monitor for Hazardous Foods," Copyright 2016, revision date not readable, indicated "Food handling rules for cooling hazardous foods should be used by Dietary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 17 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE employees." The procedure section indicated, "Using the Cooling Monitoring Form (Form 406) record temperature of food every hour. The food should be cooled from 140°F to 70°F within 2 hours and cooled from 70°F to 41°F in an additional 4 hours. If a prepared product is initially at [less than or equal to] 41°F there is no need to record this on the Cooling Monitor Form but tightly cover and store in the refrigerator ... If temperature doesn't reach 70°F in 2 hours, reheat to 165°F and try cooling process again.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 08/01/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 18 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 19 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interviews and record review, the facility failed to maintain accurate medical records for two out of four sampled residents (Resident 51 and Resident 72). This failure had the potential for overmedication, and inaccurate medication reconciliation of controlled substances for Resident 51 and Resident 72. Findings: During record review on 6/26/18 at 3:40 p.m., the controlled substances log book/narcotic log indicated Licensed Staff Q signed out the controlled pain medication, hydrocodone acetaminophen 5-325 2 tabs for Resident 51 on 6/15/18 but not entered into her Medication Administration Record (MAR) as administered, on 6/15/18. During an interview with the DON on 6/26/18 at 3:47 p.m., the DON verified that this medication had not been documented in the MAR. The DON stated that she did not know what happened and she would look into it, but presumed the nurse forgot to enter it into the MAR. During record review on 6/26/18 at 3:45 p.m., the narcotic log book indicated Licensed Staff Q signed out the medication hydrocodone acetaminophen 5-325 mg (milligram) two tabs for Resident 72 on 6/9/18 and 6/10/18 at 12:00 a.m., but was not documented in Resident 72's MAR as administered. This was confirmed by the DON on 06/26/18 at 3:47 p.m. The DON looked through the computer system to see if Resident 72 had refused these medications on 6/9/18 and 6/10/18 but could not find any evidence that she refused. During an interview on 6/27/18 at 1:38 p.m., Licensed Staff Q stated that she did not enter the medication hydrocodone acetaminophen 5325 on the computerized MAR, as administered on 6/15/18 for Resident #51, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 20 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/9/18 and 6/10/18 for Resident 72 even though she logged out the medications in the narcotic log book. Licensed Staff Q stated "I got sidetracked..." During an interview on 6/27/18 at 2:07 p.m., the DON was asked if the facility expected nurses to sign or document administered medications right away after giving them, she stated "Yes, that is the standard of practice, to document as soon as possible."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 08/01/2018 §483.80 Infection Control The facility must establish and 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. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 21 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to perform infection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 22 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE control prevention practices for five residents (Resident 41, 43, 51 63, and 66) when: 1. One unlicensed staff did not perform handwashing after providing care to Resident 41, who was on contact isolation for Clostridium difficile, prior to entering another resident's room, which had the potential for spreading diseases; Clostridium difficile (C. diff) is a bacteria that causes inflammation of the colon. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. 2. Staff members did not perform hand hygiene prior to serving lunch trays, in-between preparing and serving lunch trays to residents, or touching food with bare hands for Resident 43, 51, and 63, which had the potential to cause foodborne illness and spread the infections among residents; and 3. The Nurse did not swab medication vial prior to withdrawing medication for Resident 66, which had the potential for cross contamination and cause an infection to Resident 66. Findings: 1. During an observation on 6/25/18, at 10:03 a.m., there was a cart outside Resident 41's room, containing hand sanitizer, gloves, gowns, and mask with a red sign by the door indicating, "See nurse for instructions." During an observation on 6/26/18, at 3:11 p.m., Unlicensed Staff H wore gown and gloves and entered Resident 41's room. Unlicensed Staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 23 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H assisted Resident 41. At 3:13 p.m., Unlicensed Staff H removed her gown and gloves before exiting the room and used hand sanitizer located outside Resident 41's room. Unlicensed Staff H entered room 44 and pulled the privacy curtain for the resident in the third bed to assist another CNA who was already in the room. During an interview on 6/26/18, at 3:23 p.m., Unlicensed Staff H stated Resident 41 was in isolation for contact precautions for C. diff. Unlicensed Staff H stated she took her gown and gloves off and washed her hands after providing care for residents under contact precaution for C. Diff. When pointed out she used hand sanitizer after leaving Resident 41's room before entering Room 44, Unlicensed Staff H stated she washed her hand by the sink inside room 44. During a review of the clinical record for Resident 41, the Progress Note Weekly Summary dated 6/23/18 indicated Resident 41 had loose stool due to C. diff infection. The facility policy and procedure titled "Clostridium Difficile" dated 7/14, indicated, "Glove use when caring for residents with C. difficile infection, washing hands with soap and water upon exiting the room of a resident with C. difficile infection AND strict adherence to hand hygiene in general is considered best practice." The facility policy and procedure titled "Isolation- Categories of Transmission-Based Precautions" dated 1/12, indicated, "In addition to Standard Precautions, implement Contact Precautions for residents know or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 24 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or resident-care items in the resident's environment... Examples of infections requiring Contact Precautions include, but are not limited to: Diarrhea associated with Clostridium Difficile.." During dining observation on 6/25/18 at 12:29 p.m., Unlicensed Staff K was observed assisting Resident 63 with her lunch meal by using a fork to manually feed her. After a few minutes of assisting Resident 63, Unlicensed Staff K got up from her chair and went to assist Resident 51 apply her nasal cannula, without sanitizing her hands in between resident care. Unlicensed Staff K was observed positioning the prongs of the nasal cannula in Resident 51's nose, followed by placing the tubing behind Resident 51's ears. Unlicensed Staff K was observed touching Resident 51's skin and hair. After Unlicensed Staff K had completed the task of applying the nasal cannula to Resident 51, she went back to feed Resident 63 without sanitizing her hands. Unlicensed Staff K was observed picking up the fork and assisting Resident 63 with her meal. Unlicensed Staff K was then observed picking up a cookie with her bare unsanitized right hand, and handing it to Resident 63. Resident 63 ate about three quarters of the cookie. During an interview with the DON on 6/27/18 at 2:01 p.m., she was asked if staff were expected to wash their hands in between resident care. The DON stated that staff were expected to sanitize their hands at least with a hand sanitizer, in between resident care. During an interview on 6/28/18 at 9:49 a.m., Unlicensed Staff K confirmed feeding Resident 63 with a fork, getting up to apply the nasal cannula on Resident 51, touching her hair and skin, and returning to feed Resident 63 without sanitizing her hands. She also confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 25 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE grabbing Resident 63's cookie with her bare unsanitized right hand to give it to Resident 63 to eat. When asked if this was a standard of practice, Unlicensed Staff K stated "No, I should have washed my hands..." Review of the facility's policy titled, "Handwashing/Hand Hygiene," revised on August 2015, item 7 indicates, "Use and alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; i. After contact with a resident's intact skin; o. Before and after eating or handling food; and p. Before and after assisting a resident with meals." 3. During an observation on 6/26/18 at 8:46 a.m., Licensed Staff L did not swab the rubber top of a 1 ml (milliliter) heparin glass vial before withdrawing the medication with a syringe to administer to Resident 66. The vial was still sealed, with a plastic cap covering the rubber top, indicating that it had not previously been used. Licensed Staff L was observed administering the subcutaneous medication to Resident 66 on 6/2/18 at 9:01 a.m. During an interview with the DON on 6/27/18 at 2:05 p.m., she stated that staff were not required to swab the rubber tops of single dose vials, and heparin 1 ml was a single dose vial. During a phone interview on 6/27/18 at 2:52 p.m., with Pharmacy Staff P, he stated that the manufacturer instructions for the 1 ml heparin vials that they provided to the facility indicated that staff were required to check for discoloration of the fluid before administering the medication but did not mention anything about swabbing or not swabbing the rubber top. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 26 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 6/27/18 at 3:10 p.m., the DON was asked to provide evidence that the heparin 1 ml vials did not have to be swabbed prior to withdrawing the medication from the vial, but she did not provide the evidence requested. The facility's policy IIB-16 titled "Subcutaneous Medication Administration," effective on June of 2016, indicated "Prepare medication as follows: 1) calculate correct amount of medication. 2) Shake well if required 3) Prepare syringe and needle a. Swab rubber cap with alcohol sponge." The policy did not indicate that one time sealed doses did not have to be swabbed. On 6/27/18 at 3:10 p.m., the DON confirmed that the policy, "Subcutaneous Medication Administration" did not indicate that one time dose vials were not required to be swabbed prior to withdrawing the medication. During an interview on 6/29/18 at 8:15 a.m., with Licensed Staff L, he was asked if he was required to swab to rubber tops of heparin vials, to which he stated "I did not swab it because it was sealed, when they are sealed they are free of contamination." He was asked what the facility's policy said about that, and he was unable to respond. When asked if the manufacturer approved or did not recommend that the vials be swabbed when sealed and prior to administration, to which he stated that he had not read the manufacturer's instructions. When asked who provided the information that sealed vials did not have to be swabbed, Licensed Staff L indicated, "The facility provided that information." 2. During dining observation on 6/25/18 at 12:11 p.m., a staff member was observed feeding Resident 43 who required assistance when eating. No hand hygiene was observed prior to feeding or when preparing and serving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 27 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 43's tray. No hand hygiene was observed by other staff members in-between trays preparation and serving trays to other residents in the dining room.

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 08/10/2018 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain a clean, sanitary interior to the south station utility room when the linoleum flooring under the ice machine was buckled and in disrepair with black, brown, and yellowish-colored grime and stains. The splash guard surrounding the air gap/drain (the unobstructed vertical space between the water outlet and the flood level of a fixture or the drain) had build-up of black and pink debris and the walls and flashing surrounding the linoleum were peeling and stained yellowish-brown with signs of old water damage. This failure had the potential for staff to track dirt, debris, and germs into resident care areas and cause infections. Findings: During an observation and inspection of the ice machine on 6/28/18 at 11:40 a.m., the ice machine was off the ground and its feet were secured to four 15 inch risers. There was a white drainage tube off the back of the ice machine and it drained into a visible air gap near the front of the ice machine. The air gap was surrounded by a worn splash guard that was stained with black and pink grime. Upon further observation and inspection the linoleum FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 28 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE flooring underneath the ice machine was buckled, had black and yellowish-brown stains, the walls had peeling paint with yellowishbrown stains and there was a black stain on the wall behind a section of peeled linoleum flashing located near the right-front of the ice machine. There was an old, bent straw and rubber band on the floor. During an observation and interview on 6/28/18 at 12:05 p.m., Administrative Staff R concurred the linoleum floor beneath the ice machine was worn and stained. Administrative R stated, "That's probably old water damage," however, he had "not experienced any leaks" with this ice machine since he was hired. Administrative Staff R stated, "It (the floor) was like that when I came on two years ago." When asked who cleaned the floor under the ice machine, Administrative Staff R stated the housekeeping staff did that task. During an observation and interview on 6/28/18 at 2:45 p.m. Administrative Staff S was shown the floor under the ice machine in the south station clean utility room. When asked who cleans the floor, Administrative Staff S stated, "...we mop back there every day." When asked if the floor looked clean, Administrative Staff S stated, "No, we'll get that mopped today." During a follow-up observation and interview on 6/28/18 at 3 p.m., the Administrator was brought to the south station clean utility room to be shown the stained, buckled flooring, the worn and stained splash guard and peeling, stained walls. There were two housekeeping staff in the room, one of which had just mopped the floor underneath the ice machine. The Administrator acknowledged the linoleum flooring was buckled and stained and the splash guard was worn and stained black, and several sections of the surrounding walls were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 29 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555349 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VACAVILLE CONVALESCENT AND REHABILITATION CENTER 585 Nut Tree Ct Vacaville, CA 95687 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE peeling and stained. The Administrator stated the flooring area and damaged walls could be replaced or repaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R1PO11 Facility ID: CA010000467 If continuation sheet 30 of 30