Health inspection·January 14, 2022

F 0558 -At 12:33 p.m. the Director of Nursing (DON) answered Resident 35's call light. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/12/22, at 12:42 p.m. the DON stated call lights should be answered right away. The DON explained the expectation is for staff to answer a call light within 5 minutes. The DON stated if staff were in the hallway, she would expect them to answer the call light. Residents Affected - Few Review of an undated facility policy and procedure titled CALL SYSTEM, indicated, .Answer call bells promptly .Routine calls: Routine calls will be accompanied by an audible signal and a light above the resident's room door will go on. Routine calls should be answered within three minutes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 2 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to give one of three closed record sample residents (Resident 205) the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN/CMS 10055) (a form which gave the choice to continue services under private pay if Medicare did not provide payment), with the appeal contact information. Residents Affected - Few As a result, Resident 205 did not have the choice to appeal the decision or have knowledge of the costs to continue treatment in the facility. Findings: Review of admission record indicated Resident 205 was admitted to the facility in March 2021 and was her own responsible party. Resident 205 was given a Notice of Medicare Non-Coverage (NOMNC) letter on 4/13/21 and was signed by Resident 205 on 4/13/21. The last covered date of Medicare Part A service designated in the letter was 4/15/21. Review of the facility record titled, 2022 BENEFICIARY LIST_ RESIDENTS discharged WITHIN THE LAST SIX MONTHS/MEDICARE PART A, indicated Resident 205 remained at the facility for 4 months and 11 days after the last covered day of Medicare part A service. The SNF ABN form was not given to Resident 205. During an interview on 1/13/22, at 2:10 p.m., the Business Office Manager (BOM) stated Resident 205 had 65 remaining skilled days after last Medicare Part A service covered date 4/15/21. The BOM stated the Minimum Data Set (MDS) nurse was responsible to issue the NOMNC and SNF ABN notices to the residents. During an interview on 1/13/22, at 2:15 p.m., the MDS nurse stated she was only giving NOMNC notice to the residents. She added she did not know when to give the SNF ABN notice to the residents and who was responsible to give the SNF ABN notice. During an interview on 1/13/22, at 2:17 p.m., the Director of Nursing (DON) was not aware of the SNF ABN form. She did not know who was responsible to issue the SNF ABN form to the residents and when. During an interview on 1/13/22, at 2:24 p.m., the BOM stated as per their facility consultant the SNF ABN form needed to be issued to the residents when they had remaining skilled days and they stayed in the facility after last Medicare part A covered day. The BOM verified the SNF ABN form was not given to Resident 205. She stated the SNF ABN notice should have been provided to Resident 205. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 3 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the admission MDS (Minimum Data Set: a standardized assessment and care screening tool) assessment within 14 calendar days after admission for one of fifteen sampled residents (Resident 204). This deficient practice had the potential to delay care planning and delivery for Resident 204's care areas that would have been identified in the admission MDS assessment. Findings: Review of admission record indicated Resident 204 was admitted to the facility on [DATE]. Review of Resident 204's MDS assessments indicated admission MDS assessment was incomplete and was eight days overdue. During a concurrent interview and record review on 1/13/22 at 09:44 a.m., the MDS nurse verified Resident 204's admission MDS assessment was incomplete and eight days overdue. The MDS nurse stated the admission MDS assessment should have been completed within 14 days from admission date by 1/5/22. During an interview on 1/13/22 at 10:25 a.m., the Director of Nursing stated the MDS assessments should be completed timely. Review of the facility policy titled, MDS Completion and Submission Timeframes revised July 2017 indicated, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . According to the RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, .The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .admission assessment (required by day 14) . https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 4 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to conduct an MDS (Minimum Data Set: a standardized assessment and care screening tool) significant change in status assessment (SCSA- an assessment that indicates a major decline or improvement in the resident's status) for one of fifteen sampled residents (Resident 7), when Resident 7 elected hospice services. This failure had the potential of not providing the appropriate care and services to Resident 7 based on Resident 7's current medical status. Residents Affected - Few Findings: Review of admission record indicated Resident 7 was admitted to the facility in early September 2021. Review of Resident 7's physician orders indicated Resident 7 start receiving hospice services on 10/19/21. Review of Resident 7's MDS assessments failed to show an MDS significant change in status assessment was conducted after hospice services were initiated. During a concurrent interview and record review on 1/12/22 at 11:12 a.m., the MDS nurse verified Resident 7 was receiving hospice services since 10/19/21 and an MDS significant change in status assessment was not conducted. She stated the facility must complete a significant change of condition status assessment for a resident who transitions to hospice within 14 days. The MDS nurse further stated the MDS significant change in status assessment should have been completed by 11/2/21 after Resident 7 elected hospice services on 10/19/21. During an interview on 1/13/22 at 10:14 a.m., the Director of Nursing (DON) stated an MDS significant change in status assessment should have been done when Resident 7 elected hospice services. The DON stated MDS assessments should be done timely as per CMS (Centers for Medicare and Medicaid Services) guidelines. Review of the facility policy titled Electronic Transmission of the MDS revised September 2010, indicated, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed . Review of the facility policy titled MDS Completion and Submission Timeframes revised July 2017 indicated, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . According to the CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, .Significant Change in Status Assessment .Must be completed .within 14 days after the determination that the criteria are met for a Significant Change in Status assessment .If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA) .It is a CMS requirement to have an SCSA completed EVERY time the hospice benefit has been elected, even if a recent MDS was done and the only change is the election of the hospice benefit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 5 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0637 https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 6 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the quarterly MDS (Minimum Data Set: a standardized assessment and care screening tool) assessment was completed for one of fifteen sampled residents (Resident 7). This failure had the potential risk of Resident 7 not receiving adequate or appropriate care and services for her specific needs. Residents Affected - Few Findings: Review of admission record indicated Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS assessments indicated the admission MDS assessment was completed on 9/14/21. The quarterly MDS assessment was not conducted by 12/14/21, and was overdue. During a concurrent interview and record review on 1/12/22, at 11:12 a.m., the MDS nurse stated quarterly MDS assessments needed to be done every 3 months. She verified Resident 7's quarterly MDS assessment was missing and should have been completed by 12/14/21. During an interview on 1/13/22 at 10:14 a.m., the Director of Nursing stated MDS assessments should be done timely as per CMS (Centers for Medicare and Medicaid Services) guidelines. Review of the facility policy titled Electronic Transmission of the MDS revised September 2010, indicated, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 7 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. During a concurrent interview and record review on 1/13/22, at 9:56 a.m., with the DON, Resident 14's Weights and Vitals Summary and most current MDS were reviewed. The DON confirmed Resident 14's weight record showed a 20.9 percent weight loss over 6 months on 10/3/21. A review of Resident 14's quarterly MDS, dated [DATE], section Weight Loss, was marked as 0 which indicated Resident 14 did not have a significant weight loss in the last 6 months. The DON confirmed the quarterly MDS was not accurate and should have reflected Resident 14's significant weight loss. Residents Affected - Some Review of the Centers for Medicare and Medicaid Services document titled, Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/19, indicated, .The RAI process has multiple regulatory requirements. Federal regulations .require that (1) the assessment accurately reflects the resident's status . (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf) Based on interview and record review, the facility failed to ensure resident assessments accurately reflected a resident status for two out of fifteen sampled residents (Resident 4 and Resident 14) when the quarterly Minimum Data Set (MDS - an assessment tool) were not accurate for Resident 4 and Resident 14. These failures had the potential to negatively affect the care and services provided to Resident 4 and Resident 14, due to the inaccurate assessment of their strengths, needs, and health status. Findings: 1a. During a concurrent interview and record review, on 1/12/22, at 11:59 a.m., with the Director of Nursing (DON), Resident 4's Weights and Vitals Summary was reviewed. The DON confirmed Resident 4's weight record showed a 10.7 percent weight loss over 6 months on 11/7/21 and a 12.6 percent weight loss over 6 months on 12/5/21. During a concurrent interview and record review on, 1/13/22, at 10:46 a.m., with the DON, Resident 4's quarterly MDS section Swallowing/Nutritional Status, dated 12/19/21 was reviewed. The DON confirmed the section Weight Loss was marked as 0 which indicated No . Loss of 5% or more in the last month or loss of 10% or more in last 6 months . The DON stated the no answer was not accurate because Resident 4 had more than a 10 percent weight loss in the last 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 8 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0642 Ensure a qualified health professional conducts resident assessments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete MDS (Minimum Data Set: a standardized assessment and care screening tool) discharge-return anticipated and reentry tracking assessments for one of fifteen sampled residents (Resident 7), when Resident 7 was discharged to the acute care hospital and was readmitted to the facility in October 2021. This deficient practice placed Resident 7 at risk of not receiving accurate care driven by her individualized assessment and care plans. Residents Affected - Few Findings: Review of admission record indicated Resident 7 was admitted to the facility in early September 2021. Review of nurses' progress notes dated 10/13/21, indicated Resident 7 was sent out to the acute care hospital. Review of nurses' progress notes dated 10/15/21, indicated Resident 7 was readmitted from the acute care hospital. Review of Resident 7's MDS assessments did not show a discharge-return anticipated assessment was completed when Resident 7 was transferred to the acute care hospital on [DATE]. A reentry assessment was not completed for Resident 7 when the resident was readmitted to the facility on [DATE]. During a concurrent interview and record review on 1/12/22 at 11:12 a.m., the MDS nurse stated when a resident was sent to the hospital, they have to complete MDS discharge-return anticipated interrupted-stay assessment within 14 days from the day the resident was sent to the hospital. She further stated a reentry assessment needed to be completed within 14 days from the day the resident was readmitted from the hospital. The MDS nurse verified Resident 7 was discharged to the hospital on [DATE] and was readmitted on [DATE]. She verified discharge-return anticipated and reentry assessments were not completed for Resident 7. She stated a discharge return anticipated assessment should have been initiated on 10/13/21 and completed by 10/27/21 for Resident 7. She further stated a reentry assessment should have been initiated on 10/15/21 and completed by 10/29/21 for Resident 7. During an interview on 1/13/22 at 10:25 a.m., the Director of Nursing stated MDS assessments should be completed timely. Review of the facility policy titled Electronic Transmission of the MDS revised September 2010, indicated, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed . Review of the facility policy titled MDS Completion and Submission Timeframes revised July 2017 indicated, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . According to the RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, .Reentry .Entry tracking record is coded Reentry every time a person: - is readmitted to this facility, and was discharged return anticipated from this facility, and returned within 30 days of discharge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 9 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0642 Level of Harm - Minimal harm or potential for actual harm .Must be completed every time a resident is admitted (admission) or readmitted (reentry) into a nursing home .Must be completed within 7 days after the admission/reentry .Must be submitted no later than the 14th calendar day after the entry . Discharge Assessment-Return Anticipated .Must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days .Must be completed .within 14 days after the discharge date . Residents Affected - Few https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 10 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop and implement a care plan for use of a high-risk psychotropic medication (mind altering drug) for one of 15 sampled residents (Resident 48). Residents Affected - Few This failure had the potential for Resident 48's needs to be unmet for safe and effective monitoring and prevention of recurrent falls and injury. Findings: Review of the clinical record indicated Resident 48 was admitted to the facility in late 2021 with diagnosis of fall with fracture of left radius (large bone in the forearm), weakness, and major depressive disorder. A record review of Resident 48's physician order dated 12/28/21, indicated .Diazepam (mind altering sedative drug) Tablet 5 MG (milligram-unit of measure) Give 1 tablet by mouth as needed for MUSCLE SPASPMS [sic] TWICE DAILY . Review of Resident 48's medical record titled Medication Administration Record (or MAR where doctor's orders were tabulated electronically as a drug chart and serves as a legal record of the drugs administered), with date range of 1/1/2022 to 1/31/22, the MAR indicated Diazepam was administered three times on 1/2/22, twice on 1/3/22, once on 1/4/22, once on 1/5/22, once on 1/8/22, twice on 1/9/22, once on 1/10/22, and once on 1/12/22. The MAR further indicated no monitoring of side effect or behavior monitoring for the medication Diazepam. A subsequent record review of Resident 48's care plan (provides direction on the type of nursing care the resident may need based on their health and medication needs), with date range of 12/29/21 to 12/31/21, the care plan did not indicate any nursing guidelines to monitor for safety precautions and adverse effects of the diazepam, a high-risk psychotropic medication. During an interview with the Director of Nursing (DON) on 1/12/22, at 4:12 p.m., in the DON's office, the DON acknowledge a care plan should have been initiated because diazepam could contribute to risks of fall due to its effect on causing unsteady gait and mental confusion. During an interview with Resident 48 on 1/13/22, at 8:44 a.m., Resident 48 stated she was taking diazepam at home for relief of anxiety [not for muscle spasms]. Review of the facility's policy and procedure titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated October 2019, the policy indicated, Monitoring of side effects or medication-related problems occurs continually, but particularly after medication administration. Review of the facility's policy and procedure titled, MEDICATION MONITORING AND MANAGEMENT, dated October 2019, the policy indicated, Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness. Review of the undated facility's policy and procedure titled, PSYCHOTROPIC DRUG USE POLICY, the policy indicated, Monitoring of side effects and Black Box Warning (the highest warning for drugs to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 11 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0656 alert the public and health care providers of serious side effects) of Psychotropic medication should be done. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 12 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to develop and revise a comprehensive nutrition care plan which included measureable goals and interventions related to weight loss for one of fifteen sampled residents (Resident 14). This failure had the potential to result in Resident 14's nutritional needs not being met. Findings: A review of Resident 14's nutrition assessment, dated 4/5/21, indicated Resident 14 was admitted to the facility with a feeding tube (a tube placed in the stomach to deliver nutrition and hydration) and weighed 163 pounds. The Registered Dietician (RD) documented the goal for Resident 14 was to maintain a consistent weight of plus or minus five pounds (158-168 pounds). During an interview on 1/11/22, at 2:58 p.m., the RD confirmed Resident 14 was admitted with a feeding tube but was upgraded to a pureed, low sugar, oral diet with nectar thick liquids on 4/26/21. On 7/4/21, Resident 14 weighed 150 pounds which was a thirteen-pound weight loss in two months, and a 7.98 percent overall significant weight loss in two months. A review of Resident 14's nutrition comprehensive care plan, not implemented until 7/25/21, indicated Resident 14 was at risk for alteration in nutrition and hydration due to a Recent weight loss of 5 LBS [pounds] in a week. A review of an Interdisciplinary Team (IDT, a group of healthcare professionals) weight change review, dated 7/28/21, indicated Resident 14 now weighed 141 pounds and had a five-pound weight loss in one week, and had lost a total of 22 pounds since admission. Resident 14 remained on a pureed, low sugar diet with nectar thick liquids and received a high calorie drink three times per day. The new recommended interventions for the significant weight loss included to fortify (adding extra fats/calories) the current diet and serve Resident 14 larger portions at mealtimes. A review of Resident 14's comprehensive nutrition care plan revealed the new recommendations implemented on 7/28/21, were never added to the care plan and the overall weight loss of 22 pounds was not mentioned. A review of an IDT weight change review, dated 8/6/21, indicated Resident 14 now weighed 137 pounds and had a four-pound weight loss in one week. Resident 14 lost a total of 26 pounds since admission and a 16 percent significant weight loss since admission. The form indicated Resident 14 consumed 79 percent of her meals on average, and 0-100 percent of her high calorie drink daily. The IDT did not recommend any new interventions for Resident 14 and the comprehensive nutrition care plan was not revised. On 9/5/21, Resident 14 weighed 133 pounds which was now a thirty-pound weight loss since admission, and an 18 percent significant weight loss since admission. On 9/19/21, Resident 14 was sent to the hospital and returned to the facility on 9/24/21, with a diagnosis of COVID-19 and pneumonia. When weighed upon return to the facility Resident 14 weighed 131 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 13 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0657 Level of Harm - Minimal harm or potential for actual harm A review of a nutrition assessment, dated 9/24/21, indicated Resident 14's diet had returned to a pureed, low sugar diet with nectar thick liquids without the large portions. The form indicated Resident 14's appetite was fair eating less than 50 percent of her meals on average and no longer had the high calorie drink ordered. The RD recommended to resume the high calorie drink and to fortify the diet for Resident 14. The RD's documented goal for Resident 14 was to maintain a consistent weight of plus or minus five pounds. Residents Affected - Few Resident 14 weighed 129 pounds on 10/3/21, 127 pounds on 11/7/21, and 126 pounds on 1/2/22. This was a cumulative weight loss of 37 pounds in nine months, and a 22.7 percent significant weight loss in nine months. A review of Resident 14's clinical record revealed the comprehensive nutrition care plan initiated on 7/25/21, was cancelled on 9/20/21, and was never implemented or revised when Resident 14 returned from the hospital. During an interview on 1/11/22, at 2:58 p.m., the DON stated her expectation was for nursing to initiate resident care plans when a change in condition happened which included weight loss. During an interview on 1/12/22, at 4:00 p.m., the DON confirmed the RD was responsible for updating the nutrition care plan with any new recommendations and interventions. During an interview on 1/13/22, at 9:57 a.m., the DON confirmed a resident care plan was important because it outlined the current plan of care for each resident. A review of the facility's policy and procedure titled Care Plans-Comprehensive Person Centered, revised 2016, indicated, .A comprehensive, person-centered care plan .is developed and implemented for each resident .the Interdisciplinary Team must review and update the care plan .when there has been a significant change in the residents condition .when the desired outcome is not met .when the resident has been readmitted from a hosptital stay . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 14 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of fifteen sampled residents (Resident 7) who entered the facility with a urinary catheter (a tube inserted into the bladder to drain or collect urine) received an assessment for the removal of the catheter as soon as possible unless the resident's clinical condition indicated that catheterization was necessary. This failure had the potential for Resident 7 to develop urinary tract infections. Findings: Review of Resident 7's admission record indicated Resident 7 was admitted to the facility in early September 2021 with diagnoses including encounter for palliative care (specialized care focused on providing relief from the symptoms and stress of serious illness to improve quality of life), urinary tract infection, acute kidney failure (when kidneys suddenly become unable to filter waste products from the blood) and overactive bladder (a frequent and sudden urge to urinate that may be difficult to control). admission record indicated Resident 7 had a family member as her designated representative. During an observation on 1/10/22, at 9:28 a.m., Resident 7 had a urinary catheter. During an interview on 1/10/22, at 2:34 p.m., the Resident Representative (RR) stated he did not know why Resident 7 had the urinary catheter. The RR stated Resident 7 got the urinary catheter at the hospital when she went there in October 2021 from the facility. Review of Resident 7's records indicated there was no physician order for the urinary catheter, no catheter care plan and no record of indication for catheter use. Review of nurses' progress notes dated 10/15/21, indicated, .Resident came from the hospital .16 FR [French: unit of tube measurement] Foley [urinary] catheter is in place . During an interview on 1/12/22, at 10:21 a.m., Licensed Nurse (LN) 1 verified Resident 7 had urinary catheter. LN 1 stated she needed to review Resident 7's record to check the medical indication for catheter use. After concurrent review of Resident 7's physical and electronic records, LN 1 verified Resident 7 did not have a physician order for urinary catheter and record of clinical indication for catheter use. LN 1 stated she did not know what was the indication for Resident 7's catheter use. LN 1 stated she believed Resident 7 came back with urinary catheter when she went to hospital in October 2021. During a concurrent interview and record review on 1/12/22, at 10:42 a.m., the Assistant Director of Nursing (ADON) verified Resident 7 came back from the hospital with urinary catheter on 10/15/21. The ADON stated the facility protocol was to evaluate the resident for the need of catheter use when the resident came with a urinary catheter from the hospital, if there was no valid medical indication then catheter was to be discontinued. The ADON verified Resident 7 was not evaluated when she came back from hospital with the urinary catheter on 10/15/21 for a medical indication for catheter use or removal of catheter in the absence of appropriate medical indication. The ADON stated Resident 7 should have been assessed for removal of the urinary catheter unless there was a medical condition that required catheterization. She verified Resident 7 did not have a physician order for catheter and catheter care plan. She stated based on Resident 7's records she did not need a urinary catheter, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 15 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it should have been discontinued. The ADON further stated Resident 7 was placed at risk of infections due to unnecessary catheterization. During an interview on 1/13/22, at 10:02 a.m., the Director of Nursing (DON) stated if a resident came with a urinary catheter from the hospital, the resident needed to be assessed for the necessity of catheter use. She stated, A lot of times when residents come from the hospital they come with foley [urinary catheter], hospital puts everyone on foley who does not even need it. The DON stated the resident will be at increased risk for urinary infection if the catheter is placed unnecessarily, especially elderly resident. Review of the facility policy titled, Orders for Indwelling urinary catheters and Catheter Care revised September 2017, indicated, .Physicians shall order indwelling urinary catheters only for appropriate indications .Staff shall limit the use of indwelling catheters and try to discontinue them whenever possible .Residents/patients will not have an indwelling urinary catheter unless medically necessary .Assess to Identify Indications .The physician will document a valid medical reason for initiating or continuing an indwelling catheter .Periodically, the physician and staff will reassess the need to continue an indwelling catheter and discontinue it when no longer indicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 16 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3b. A review of Resident 14's clinical record revealed an admission weight of 163 pounds on [DATE]. Residents Affected - Some On [DATE], Resident 14 weighed 150 pounds which was a thirteen-pound weight loss in two months, and a 7.98 percent overall significant weight loss in two months. A review of a weight variance report sent to Resident 14's physician on [DATE], indicated Resident 14 had a five-pound weight loss in one week. The report did not address the cumulative weight loss for Resident 14. On [DATE], Resident 14 weighed 137 pounds which was a thirteen-pound weight loss in one month, and an 8.67 percent significant weight loss in one month. A review of a subsequent weight variance report sent to Resident 14's physician on [DATE], indicated Resident 14 had a four-pound weight loss in one week. The report did not address the cumulative weight loss for Resident 14. Resident 14 weighed 133 pounds on [DATE], 129 pounds on [DATE], 127 pounds on [DATE], and 126 pounds on [DATE]. This was a cumulative weight loss of 37 pounds in nine months, and a 22.7 percent significant weight loss in nine months. A review of Resident 14's clinical record revealed no other weight variance reports had been sent to Resident 14's physician after [DATE]. During an interview on [DATE], at 4 p.m., the DON stated Restorative Nurse Assistants (RNA) weigh residents every Sunday and if there is a three-pound weight loss or gain nurses notify the residents physician of the change. The DON went on to say the RD should have notified Resident 14's physician of the cumulative significant weight changes as they occurred but did not. A review of the facility's policy and procedure titled Change In Resident Condition, not dated, indicated, .It is the policy of this facility .all changes in resident condition will be communicated to the physician .Routine medical change .weight loss or gain. 4. A review of Resident 14's clinical record revealed an admission weight of 163 pounds on [DATE]. On [DATE], Resident 14 weighed 141 pounds which was a 22-pound weight loss in three months. A review of a weight variance report sent to Resident 14's physician on [DATE], indicated Resident 14 had lost five pounds in one week. A review of a physician's progress note, dated [DATE], indicated Resident 14 lost over 20 pounds in three months. The physician ordered Remeron (a medication which can help stimulate the appetite) every evening. A review of Resident 14's current and past physician's orders did not reveal Remeron had ever been started by nursing staff at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 17 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE], at 9:52 a.m., the DON confirmed Remeron had never been started for Resident 14. When asked if there was documentation which explained why Remeron was never started, the DON stated no. The DON confirmed Remeron could have helped boost Resident 14's appetite. Resident 14 weighed 133 pounds on [DATE], 129 pounds on [DATE], 127 pounds on [DATE], and 126 pounds on [DATE]. This was a cumulative weight loss of 37 pounds in nine months, and a 22.7 percent significant weight loss in nine months. 5. A review of Resident 14's nutrition assessment, dated [DATE], indicated Resident 14 was admitted to the facility with a feeding tube (a tube placed in the stomach to deliver nutrition and hydration) and weighed 163 pounds. The RD documented the goal for Resident 14 was to maintain a consistent weight of plus or minus five pounds. During an interview on [DATE], at 2:58 p.m., the RD confirmed Resident 14 was admitted with a feeding tube but was upgraded to a pureed, low sugar, oral diet with nectar thick liquids on [DATE]. On [DATE], Resident 14 weighed 150 pounds which was a thirteen-pound weight loss in two months, and a 7.98 percent overall significant weight loss in two months. A review of an IDT weight change review, dated [DATE], indicated Resident 14 now weighed 141 pounds and had a five-pound weight loss in one week, and had lost a total of 22 pounds since admission. Resident 14 remained on a pureed, low sugar diet with nectar thick liquids and received a high calorie drink three times per day. The form indicated Resident 14 consumed 95 percent of her meals and approximately one third of her high calorie drink on average. The new recommended interventions for the significant weight loss included to fortify (adding extra fats/calories) the current diet and serve Resident 14 larger portions at mealtimes. A review of a physician's progress note, dated [DATE], indicated Resident 14 lost over 20 pounds in three months. The physician ordered Remeron (a medication which can help stimulate the appetite) every evening. A review of Resident 14's current and past physician's orders did not reveal Remeron had ever been started. During an interview on [DATE], at 9:52 a.m., the DON confirmed Remeron had never been started for Resident 14. When asked if there was documentation which explained why Remeron was never started, the DON stated no. The DON confirmed Remeron could have helped boost Resident 14's appetite. A review of an IDT weight change review, dated [DATE], indicated Resident 14 now weighed 137 pounds and had a four-pound weight loss in one week. Resident 14 lost a total of 26 pounds since admission and a 16 percent significant weight loss since admission. Resident 14 remained on a large portioned, fortified, pureed, low sugar diet with nectar thick liquids and received a high calorie drink three times per day. The form indicated Resident 14 consumed 79 percent of her meals on average, and 0-100 percent of her high calorie drink daily. The IDT did not recommend any new interventions for Resident 14. On [DATE], Resident 14 weighed 133 pounds which was now a thirty-pound weight loss since admission, and an 18 percent significant weight loss since admission. On [DATE], Resident 14 was sent to the hospital and returned to the facility on [DATE], with a diagnosis of COVID-19 and pneumonia. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 18 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0692 weighed upon return to the facility Resident 14 weighed 131 pounds. Level of Harm - Minimal harm or potential for actual harm A review of a nutrition assessment, dated [DATE], indicated Resident 14's diet had returned to a pureed, low sugar diet with nectar thick liquids without the large portions. The form indicated Resident 14's appetite was fair, eating less than 50 percent of her meals on average and no longer had the high calorie drink ordered. The RD recommended to resume the high calorie drink and to fortify the diet for Resident 14 but did not recommend large portions. The RD documented goal for Resident 14 was to maintain a consistent weight of plus or minus five pounds. Residents Affected - Some Resident 14 weighed 129 pounds on [DATE], 127 pounds on [DATE], and 126 pounds on [DATE]. This was a cumulative weight loss of 37 pounds in nine months, and a 22.7 percent significant weight loss in nine months. A review of Resident 14's clinical record revealed no new dietary recommendations were recommended or implemented after [DATE], even though Resident 14 continued to lose weight. There were also no other IDT weight change reviews done. During an interview on [DATE], at 12:55 p.m., the RD stated she was in the facility three days per week. Each week the RD received a printout from the facility with resident weights and stated herself and the DON would have IDT weight change review meetings based on a three-pound weight loss or gain or a significant weight change of five percent or more in a month, or ten percent or more in six months. A review of Resident 14's Physician Orders for Life-Sustaining Treatment (POLST, used to determine resident wishes in case of an emergency) indicated Resident 14 wished to have full treatment which included cardiopulmonary resuscitation (CPR), and a feeding tube. During a concurrent interview with the RD and DON on [DATE], at 2:58 p.m., the RD was asked if reintroducing the feeding tube or an appetite stimulant medication was ever discussed with Resident 14's family, or with the IDT. The RD stated, It's not like [Resident 14] wasn't eating and would not say more. The DON reviewed Resident 14's clinical record and confirmed there was not a documented discussion with the family, or among the IDT, regarding a feeding tube or an appetite stimulant medication. During an interview on [DATE], at 4:00 p.m., the DON was asked if snacks or any other dietary interventions were offered to Resident 14. The DON stated at one point a high calorie ice cream might have been offered but was unable to find documentation to confirm. When asked if snacks, extra desserts, or a high calorie ice cream could have been an option for extra calories, the DON stated yes. The DON confirmed Resident 14's physician never addressed the weight loss again after [DATE], but should have. A review of the facility's procedure titled, Weight Variance Program, not dated, indicated, .To ensure .on-going monitoring of resident weights and any needed adjustments in diet in accordance with weight variance issues .Weight variance committee .meetings are held weekly .residents with significant weight variance issues for 30, 90, or 180 days .can be discussed . Based on interview, record review, and facility policy review, the facility failed to ensure two of fifteen sampled residents (Resident 4 and Resident 14) nutritional status was maintained when: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 19 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0692 1. Resident 4 was not weighed weekly as ordered; Level of Harm - Minimal harm or potential for actual harm 2. Resident 4 did not receive a supplement at the frequency recommended; Residents Affected - Some 3. Resident 4 and Resident 14's physician was not notified of a significant weight loss (greater than a 5 percent weight loss over 1 month, greater than a 7.5 percent weight loss over 3 months, greater than 10 percent weight loss over a 6 months); 4. Resident 14's physician ordered a medication which may have helped stimulate the appetite but was never started by nursing staff at the facility; and, 5. Resident 14's nutritional status was not consistently monitored, and interventions for weight loss were not revised or monitored for effectiveness. These failures resulted in a significant weight loss for Resident 4 and Resident 14 which they have not recovered from, and had the potential to result in hospitalization and death. Findings: 1. Review of Resident 4's IDT [Interdisciplinary Team - a group of healthcare professionals]- WEIGHT CHANGE REVIEW V 2, dated [DATE], indicated, .[Resident 4] lost 6 lbs. [pounds] x 1 month .Recommend weekly weights . During a concurrent interview and record review, on [DATE], at 11:59 a.m., with the Director of Nursing (DON), Resident 4's Weights and Vitals Summary, and physician orders were reviewed. The DON confirmed an order for weekly weeks started on [DATE]. The DON reviewed the Weights and Vitals Summary and confirmed Resident 4 had only monthly weights completed since [DATE] (no weekly weights occurred). 2. During a concurrent interview and record review on [DATE], at 11:19 a.m., with the Registered Dietician (RD), Resident 4's IDT - WEIGHT CHANGE REVIEW - V 2, dated [DATE] and physician orders were reviewed. The RD confirmed the weight change review indicated .Recommendation: MedPass [a fortified nutritional shake that provided extra calories and protein] 90 ml [milliliters] TID [three times a day] w/[with]medications . The RD confirmed Resident 4's orders indicated, .Order Date: [DATE] .Order Summary: Medpass two times a day for SUPPLEMENT 90 ML **GIVE WITH MEDICATION** . The RD explained, to determine the frequency of the medpass supplement she would speak to staff to see how much a resident was eating and drinking. The RD stated Resident 4 liked to drink more fluids then he ate and because of the consistent weight loss she had suggested the supplement to be given 3 times a day (as opposed to two times per day as ordered). Review of Resident 4's IDT - WEIGHT CHANGE REVIEW V 2, dated [DATE] and signed by the RD, indicated, .Offered supplements .sample was given. Resident willing to try w/medication. Continue to monitor 3a. During an interview on [DATE], at 11:19 a.m., the RD stated Resident 4 weighed 214 pounds on [DATE] and 183 pounds on [DATE]. The RD stated this was a weight loss of 14.5 percent over a 6 month period and was a total weight loss of 31 pounds. The RD stated the nursing staff was responsible for notification to the physician when there was a significant weight change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 20 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review, on [DATE], at 11:59 a.m., with the Director of Nursing (DON), Resident 4's Weights and Vitals Summary, WEIGHT VARIANCE REPORT TO PHYSICIANS, and care plans were reviewed. The DON confirmed Resident 4's weight record showed a 10.7 percent weight loss over 6 months on [DATE], a 12.6 percent weight loss over 6 months on [DATE], and a 13.7 percent weight loss over 6 months on [DATE]. The DON confirmed Resident 4's care plan indicated to notify the physician when there was a weight loss of greater than 10 percent in 6 months. The DON confirmed there was no WEIGHT VARIANCE REPORT TO PHYSICIAN reported for the greater than 10 percent weight loss which occurred on [DATE], [DATE], and [DATE]. The DON stated, in January of 2022 a weight loss of 4 pounds in a month was reported to the physician. The DON explained the physician would not have the full picture (admission weight not recorded on the form), would just see the 4 pound weight loss over 1 month and maybe would not seem like that big of a deal. The DON explained, the licensed nurses get a report that only show 1 month weight loss, not 3 months or 6 months. The licensed nurses are responsible for faxing the WEIGHT VARIANCE REPORT TO PHYSICIANS, but the RD should also be responsible for notifying the physician with a weight change. Event ID: Facility ID: 555186 If continuation sheet Page 21 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for one of fifteen sampled residents (Resident 204) when, Resident 204's physician orders of Oxygen (O2) flow rate and to use O2 humidification (provides moisture to prevent drying out of the airways) were not followed. These deficient practices had the potential to cause health decline and respiratory distress for Resident 204. Residents Affected - Few Findings: Review of Resident 204's admission record indicated Resident 204 was admitted to the facility in late December 2021 with diagnoses including chronic respiratory failure with hypercapnia (a medical condition in which body has low oxygen and too much carbon dioxide), chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), emphysema (a lung condition that causes shortness of breath), and dependence on supplemental oxygen. On 1/10/22 at 11:03 a.m., Resident 204 was observed in bed with oxygen via O2 face mask (used when patients require a high percentage of O2) at O2 flow rate 9 liters per minute. The O2 humidification container was observed on top of the bedside drawer and was not connected to the O2 concentrator (oxygen delivery device). Review of Resident 204's physician orders dated 12/23/21, indicated, CHANGE HUMIDIFIER. every night shift every Sun [Sunday] .OXYGEN VIA SIMPLE MASK AT 8LPM [Liters per minute] CONTINUOUSLY . During a concurrent observation and interview on 1/10/22, at 12:58 p.m., Licensed Nurse (LN) 1 verified Resident 204 was receiving O2 at flow rate of 9 liters per minute and O2 humidification container was not connected to the O2 concentrator. During a concurrent interview and record review on 1/10/22, at 1:00 p.m., LN 1 verified Resident 204's physician orders were to administer O2 at 8 liters per minute and to use O2 humidification. LN 1 stated, It [Resident 204's oxygen rate] supposed to be at 8 liters. LN 1 stated O2 humidification container should have been connected to the O2 concentrator. LN 1 stated giving oxygen at higher rate than ordered can cause O2 poisoning and can affect resident's brain negatively. LN 1 stated O2 from concentrator was dry and can cause nose bleeding when O2 humidification was not used. During an interview on 1/13/22, 10:36 a.m., the Director of Nursing (DON) stated O2 should be administered at the rate physician prescribed. The DON stated O2 humidification should be used if O2 is administered at greater rate than 4 liters per minute. She stated giving O2 at higher rate than prescribed can cause higher carbon dioxide levels especially in COPD residents. She stated it was important to use O2 humidification because it can cause nose dryness and bleeding. Review of the undated facility policy titled, OXYGEN THERAPY indicated, .It is the policy of this facility that oxygen therapy is administered as ordered by the physician .Humidifier (for O2 flow>4 liters/min.) .Connect humidifier to outlet of flowmeter, if oxygen liter flow> 4 l/min [liters per minute] . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 22 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview, and record review, the facility failed to ensure Drug Regimen Reviews (or DRR- review of all medications the residents were using in order to optimized therapy, identify any potential drug reactions, ineffective drug therapy or duplicate drug therapy) by the Consultant Pharmacist ( or CP, a pharmacist with specialized training to review safety aspects of medication use) were acted upon on monthly basis with census of 50 residents. This failure could results in not addressing medication safety irregularities in a timely manner and/or help optimize the drug therapy. Findings: During a review of the facility's document titled Drug Regimen Review (DRR) dated with monthly sections for the year 2021, the document included a printout of recommendations by Consultant Pharmacist (CP) with no follow-through markings. Further review of the DRR documents in a binder for the date range from 4/8/21 to 12/15/21, indicated the following number of recommendations to Medical Doctors (MD) and nursing staff by CP: 12/15/21: 26 notes to MD; 41 notes to nursing 11/11/21: 13 notes to MD; 31 notes to nursing 10/14/21: 9 notes to MD; 39 notes to nursing 09/12/21: 6 notes to MD; 41 notes to nursing 8/17/21: 11 notes to MD; 50 notes to nursing 7/12/21: 11 notes to MD; 54 notes to nursing 6/2021: Empty slot in the DRR binder 5/9/21: 10 notes to MD; 43 notes to nursing 4/8/21: 22 notes to MD; 43 notes to nursing In an interview with Director Of Nursing (DON) on 1/11/22 at 4:51 PM, the DON stated Consultant Pharmacist's notes to Medical Doctors (MD) were placed in the chart and/or faxed to doctor's office for their review. The DON stated that she or her staff did not routinely go through the DRR packet to address nursing recommendations. In a telephone interview with the Consultant Pharmacist (CP) on 1/12/22 at 5:15 PM, the CP stated DRR document were emailed to DON on a monthly basis. CP stated the notes to the MD's were printed on a separate single sheet for MD to review or address. CP added, the majority of the notes to the nursing staff were medication administration recommendations and were formatted as a list of individual residents for nursing to address with follow-through comments section. CP stated, that he had noticed that some recommendations were not addressed and he had to keep repeating them for consideration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 23 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CP stated if a safety issue not addressed within a reasonable timeframe, he would call the facility. CP stated during the pandemic the access to paper chart was limited and if no adjustment to medications were noted in the Electronic Medical Records (EMR- means electronic availability of information about a resident's health history, medicines and notes), the CP had assumed the recommendations were denied. A record review of the DRR for the months of November 2021 and December 2021, indicated nursing recommendation for two sampled residents ( Resident 2 and Resident 12) were not addressed as follows: 1. DRR on December 2021 for Resident 2, indicated Suggest adding GIVE WITH 8 Oz of Water to the cholestyramine (cholesterol lowering drug) . packets order on the recaps (means medication summary) and med sheet ( means MAR or Medication Administration Record or a drug chart) per manufacturers recommendation for administration. Review of Resident 2's MAR on 12/12/2022, indicated the order for cholestyramine as follows: Cholestyramine Light Packet 4 gm (gm is unit of measure); Give 1 packet by mouth two times a day for HYPERLIPIDEMIA;Follow Manufacturer Instruction. Start date 11/30/2020 During a medication administration observation on 1/10/22 at 5:22 PM, Licensed Nurse 2 (LN 2) administered cholestyramine powder packet in less than half of a small cup of water to Resident 2. LN 2 did not look up the manufacturer instruction as noted in the MAR. 2. DRR on November 2021 for Resident 12, indicated Please add take with Food to the following order: Glipizide ER (Diabetes medication that lower blood sugar). Review of the Resident 12's MAR for January 2022, indicated the order for glipizide as follows: glipiZIDE ER tablet Extended Release-24 hour 2.5 mg; Give 1 tablet by mouth one time a day for DM (means diabetes) . Start date 8/6/2021 Review of the drug information on glipizide ER ( ER means Extended Release or long acting medicine) via Lexicomp ( a drug database information for health care staff) last accessed on 1/19/22, indicated the glipizide Extended release: Administer with breakfast or the first meal of the day; swallow tablets whole, do not chew, divide or crush. Review of the facility's policy titled Medication Regimen Review (Monthly Report) last updated on 8/2019, the policy indicated The Consultant Pharmacist performs a comprehensive medication regimen review (MRR) at least monthly . Findings and recommendations are reported to the director of nursing and the attending physician . The policy on section F indicated Recommendations are acted upon and documented by facility staff and or the prescriber . The director of nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 24 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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: Residents Affected - Some 1. High risk anticoagulant medications (or blood thinners) were monitored for side effects (adverse effect of medication) on a regular basis for two out of 15 sampled residents (Resident 34 and Resident 48). 2. The medication side effects were effectively monitored and addressed by medical provider for one out of 15 sampled residents (Resident 11). These failures could result in unsafe medication use for Residents 34, 48 and 11. Findings: 1a. During a review of Resident 34's medical record titled Medication Administration Record (or MAR, a legal drug chart where nurse documented medications administration), dated January 2022, the MAR indicated a doctor's medication order for Eliquis (or apixaban, a blood thinner) as follow: Eliquis Tablet 5 mg (Apixaban) ( mg is unit of measure); Give 1 tablet by mouth two times a day for PULMONARY EMBOLISM (means blood clot in the lung) .- start Date:12/12/2021 Review of the Resident 34's nursing Care Plan (Care Plan correctly identified resident's needs and potential risks related to medication and other health issues) with initiation date of 12/5/21, the care plan document for anticoagulant (blood thinner) medication called Eliquis, indicated a goal of Resident will have no S/SX (means sign and symptoms) of bleeding daily though next review; Date initiated: 12/13/21 and Target Date: 3/12/22. Further review of the Care Plan document under Interventions/Tasks indicated, Check skin Q shift (every shift), Hold the dose (drug dose) and notify MD if any of the following are observed: Blood in urine, Blood in stool, unusual bleeding after shaving, bleeding from gums, bleeding from nose, excessive wound bleeding, large hemorrhagic (refers to excessive bleeding) areas, petechiae (tiny spots of bleeding under the skin) . ; Monitor for bleeding: Gums, stool, skin(bruising), urine . Review of the Resident 34's MAR where the nursing staff were guided to monitors resident's response to medication or adverse effects, the MAR did not show daily monitoring for bleeding or brusing from use of a high risk blood thinner based on the Care Plan. 1b. During a review of Resident 48's medical record titled MAR, dated January 2022, the MAR indicated a doctor's medication order for apixaban as follows: Eliquis Tablet 5 mg (Apixaban); Give 1 tablet by mouth two times a day for HX OF LE STENT VASCULAR ( means for blood flow or clotting issues in the legs)-Start Date 12/31/2021 Review of the Resident 48's nursing Care Plan (Care Plan correctly identified resident's needs and potential risks related to medication and other health issues) with initiation date of 12/29/21, the care plan document for anticoagulant (blood thinner) medication called Eliquis, indicated a goal of Resident will have no S/SX ( means sign and symptoms) of bleeding daily though next review; Date initiated: 01/03/22 and Target Date: 3/29/22. Further review of the Care Plan document under Interventions/Tasks indicated, Check skin Q shift ( every shift), Hold the dose ( drug dose) and notify MD if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 25 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 Residents Affected - Some any of the following are observed: Blood in urine, Blood in stool, unusual bleeding after shaving, bleeding from gums, bleeding from nose, excessive wound bleeding, large hemorrhagic (refers to excessive bleeding) areas, petechiae (tiny spots of bleeding under the skin) . ; Monitor for bleeding: Gums, stool, skin(bruising), urine . Review of the Resident 48's MAR where the nursing staff were guided to monitors resident's response to medication or adverse effects, the MAR did not show daily monitoring for bleeding or brusing from use of a high risk blood thinner based on the Care Plan. In an interview with Director of Nursing (DON) on 1/12/22 at 4:51 PM, the DON stated if the medication care plan required any type of nursing monitoring, it should be forwarded into the MAR for nurses to document it in each shift. The DON stated the night shift nurses performed skin assessment every day and this information was shared with other shifts. If a nurse administered a high risk blood thinner medication they should have looked at the skin assessment sheet. DON acknowledged with nursing workload during medication administration, it was a safer approach to have a specific monitoring line in the MAR to document the serious side effects. Review of the facility's policy titled Medication Monitoring and Management, last updated on 10/2019, the policy indicated The facility employs a system to assure that medication usage is evaluated .when a resident has a change in condition, medication-related problem are considered. The policy further indicated, Facility staff monitor the resident for possible medication-related adverse consequences . 2. During a review of Resident 11's medical record titled Order Summary Report (means doctors order for medicationn and therapy), the document indicated the following doctor's medication orders: Benzotropine ( drug helps with side effects of some mind altering drugs) .Tablet 1 mg (mg is unit of measure); Give 1 tablet by mouth two times a day for EPS( Extra Pyramidal Side effect-- a type of uncontrolled movement of body from medication side effect); Start Date: 10/29/2021 Cyclobenaprine ( medication help with muscle relaxation) Tablet 5 mg; Give 1 tablet by mouth every 8 hour for MUSCLE SPASM ( means body stiffness); Start Date: 10/29/2021 Oxybutynin (medication help with bladder control) Tablet 5 mg; Give 1 tablet by mouth every 8 hours as needed for urinary discomfort; Start Date: 10/29/2021 Review of the product labeling via Food and Drug Administration's approved drug information page called Daily Med which was accessed on 1/13/22, indicated blurred vision was one of the adverse effects related to the anticholinergic (anticholinergic is a group of side effects on the brain and body where nerves in the brain controled the body's response to medication) property of the three medications such as benztropine, Cyclobenzaprine and Oxybutynine. The product labeling for oxybutynine indicated If a patient experiences anticholinergic CNS (means Central Nervous System- or brain/nerve issues) effects, dose reduction or drug discontinuation should be considered. Review of Resident 11's medical record titled Nursing Notes dated 1/2/22, the note indicated Resident 11 C/O (Complaining Of) blurred vision; Resident 11 told the nurse I've not been able to see or read much. In an interview with Resident 11 on 1/13/22 at 2:45 PM, in her room, Resident 11 stated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 26 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 Residents Affected - Some trouble with reading including reading her bible and stated I think its the medicine causing this. Resident 11 stated, she saw an eye doctor and was given new glasses, but still had problem with her eyes and blurriness comes and goes. In an Interview with Resident 11's Medical Doctor (MD 1) on 1/13/22 at 9:52 AM, the MD 1 stated that he will look into the resident's medical record to assess if multiple medications with anticholinergic effects were contributing to resident's vision issue. The MD 1 stated, he often continued the prior to admission medications and at times, the full history of medication use were not communicated to the facility. Review of facility's policy titled Medication Administration General Guidelines, last updated 10/2019, the policy on section 16, indicated Monitoring of side effects or medication-related problems occurs continually, but particularly after medication administration . Review of facility's policy titled Medication Monitoring and management: Preventing and Detecting Adverse Consequences ., last updated 10/2019, the policy indicated The facility employs a system to assure that medication usage is evaluated on an ongoing basis. The policy indicated Facility staff monitor the resident for possible medication related adverse consequences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 27 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, and record review, the facility failed to ensure psychotropic medications (mind altering medication) were effectively monitored, had a specific documented diagnosis, dosage adjustments or a signed consent when perscribed for two out of 15 sampled residents (Resident 2 and Resident 11). This failure could result in unsafe medication use in the facility. Findings: 1. During a review of the Resident 2's medical record titled Order Summary Report (means a list of doctor's orders for medication and therapy), dated 1/6/22, the report indicated a doctor's order for Zyprexa, a mind altering medication as follows: Zyprexa (or Olanzapine, a mind altering medication) Tablet 5 mg (mg a unit of measure) (OLANZapine-generic name for Zyprexa); Give 1 tablet by mouth one time a day for PSYCHOTIC DISORDER ( Psychotic disorders were a group of illnesses that affect the mind) M/B (Manifested By) HALLUCINATIONS.- start date 11/24/20. Further Review of Resident 2's medical record titled Medication Administration Record (or MAR- a drug chart for nursing staff to document and monitor medications), with date range of 1/1/2022 to 1/31/22, the MAR indicated Monitor and record # (number of) psychotic behavior manifested by hallucinations (an experience involving the apparent perception of something not present; like seeing or hearing things) every shift- Start date 11/23/20. Review of the Resident 2s MAR documents for Zyprexa behavior monitoring indicated the following information: January 1- 12th, 2022: Zero behavior disturbances documented by nursing staff December 2021: Zero behavior disturbances documented by nursing staff November 2021: Zero behavior disturbances documented by nursing staff October 2021: Zero behavior disturbances documented by nursing staff September 2021: Zero behavior disturbances documented by nursing staff August 2021: Zero behavior disturbances documented by nursing staff July 2021: Zero behavior disturbances documented by nursing staff June 2021: Zero behavior disturbances documented by nursing staff Review of Resident 2s medical record for nursing plan of care (or nursing care plan contained all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 28 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders including what observations are needed and what actions must be performed), dated 11/25/20, the document indicated the nursing staff's goal on monitoring was as follows: Behavior will be reduced from 5 to 1 monthly though next review; Date initiated: 11/25/20; Revision on 1/12/22 In an interview with Resident 2 on 1/10/22 at 4:29 PM, Resident 2 was not fully aware of why she was taking Zyprexa. Resident 2 stated perhaps it helped her with digestion and stomach. Resident 2 denied ever having hallucinations, having memory issues or getting upset with anyone. In an interview with Director of Nursing (DON) on 1/11/22 at 4:15 PM, the DON stated the quarterly (four times per year) Interdisciplinary Care Conference (a Meeting that reviewed Resident's plan of care for optimization) was attended by the Resident 2 and the overall plan of care including mind altering drug use were discussed. Review of Resident 2's Interdisciplinary Care Conference document, dated 9/9/21 and 3/26/21, the document indicated on both dates under Psychotropic Medication (mind altering drug)/Behavior Manifestations/Risks: On Trazodone (sleep and depression medication) and Zyprexa . The document did not address the number of behavioral issues with use of mind altering drugs and if per plan of care the behaviors issues were reduced. The document further indicated Resident 2, the DON and Social Services were in attendance for care conference meeting. Review of Resident 2's medical record titled History and Physical Examination (or H&P, where the Medical Doctor provided a concise information about a patient's medical history and outlined a plan for addressing the health issues), dated 11/25/21 and 11/24/20, the MD 2 did not provide a diagnosis or an explanation for the use of psychotropic medications. Review of the Resident 2's medical record titled Physician's Progress Notes (means doctor's monthly note in the health record), dated 12/18/21, 10/24/21, 9/18/21, 8/9/21, 6/14/21, 7/10/21, 5/13/21, 4/14/21, 3/13/21, 2/14/21, and 1/23/21, the progress notes written by MD 2 did not address psychotropic medication indication, use or benefits. Review of Resident 2's medical record titled Informed Consent for Psychotherapeutic Drugs (means resident accepted to receive mind altering medication once its effects were explained by a medical doctor), dated 11/23/20, the record included the names of two perscribed mind altering medications including Zyprexa for psychotic disorder, without a medical doctor signature. In an interview with Director of Nursing (DON) on 1/12/22 at 4:30 PM, the DON stated the medical doctors signed the required documents when they visited the facility or, if needed, it was faxed to their office for signature. The DON acknowledged the informed consent was not signed by a medical doctor. In a telephone interview with Medical Doctor 2 (MD 2) who was the primary doctor for Resident 2, on 1/13/22 at 9:31 AM, MD 2 stated resident entered the facility with these medications and he was not the one that initiated the Zyprexa. MD 2 stated that he did not assesse the number of behavior issues recorded by nursing staff in the past year and did not see a need for dose reduction because the resident was doing well. MD 2 stated that he will ask for Psych Consult (means have a mental health specialist ) to see the resident. MD 2 agreed that the diagnosis psychotic disorder listed in the MAR was not specific for a mental health disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 29 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During a review of the Resident 11's medical record titled Order Summary Report (means a list of all doctor's orders for medication and therapy) dated 1/6/22, the report indicated a doctor's order for risperidone, a mind altering medication as follow: risperiDONE tablet 3 mg; Give 1 tablet by mouth two times a day for PSYCHOSIS (A conditions that affected the mind and loss of contact with reality) M/B (manifested By) Auditory Hallucinations ( when one hears voices in the head); Start Date 10/28/21. Further Review of Resident 11's medical record titled MAR, with date range of 1/1/2022 to 1/31/22, the MAR indicated Monitor and record # (number of) psychosis manifested by auditory hallucinations (an experience involving the apparent perception of hearing voices) every shift- Start date 10/28/21. Review of the Resident 11's MAR documents for risperidone behavior monitoring indicated the following information: January 1- 12th, 2022: Zero behavior disturbances documented by nursing staff December 2021: one behavior disturbances documented by nursing staff November 2021: Zero behavior disturbances documented by nursing staff Review of Resident 11's medical record titled History and Physical Examination, written by Medical Doctor 1 (MD 1), dated 10/31/21, the MD 1 indicated mood disorder as a diagnosis. Review of the Resident 11's medical record titled Physician's Progress Notes, dated 11/24/21, the progress notes written by MD 1 indicated Anxiety/ Depression as a diagnosis. Review of Resident 11's undated medical record titled Informed Consent for Psychotherapeutic Drugs, the record included the names of three perscribed mind altering medications including risperidone for psychosis, without a medical doctor signature. In an interview with Director of Nursing (DON) on 1/12/22 at 4:30 PM, the DON stated the medical doctors signed the required documents when they visited the facility or if needed it was faxed to their office for signature. The DON acknowledged the informed consent was not signed by medical doctor. Review of Resident 11's discharge document from hospital, dated 10/28/21, the document included a list of transfer medications with no diagnosis for use of the perscribed drugs. In an interview with Resident 11 on 1/13/22, at 2:45 PM, in her room, Resident 11 stated she had problems with blurred vision and she could not read her bible or books anymore. Resident 11 stated that her medication could be contributing to the blurred vision. In an interview with Resident 11's Medical Doctor 1 (MD 1) who was the facility's medical director, on 1/13/22 at 9:52 AM, the MD 1 stated when a resident was admitted to the facility, the nursing staff were the ones that compiled the medications orders and put it together for behavior and diagnosis based on transfer documents. MD 1 added, he signed the orders at the earliest time when he made rounds at the facility. MD 1 stated he tried to stabilized the resident medically for a safe dischage to home or next level of care and would not want to change anything if no problem was noted. MD 1 acknowledged psychosis diagnosis for risperidone was not in the hospital transfer documents. MD 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 30 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the psychosis diagnosis was not specific enough to describe the use of a mind altering drug and this could impact the care residents received. MD 1 stated there should be a psych Consult to address this type of diagnosis. MD 1 was aware of Resident 11's problem with blurred vision and stated he will be looking to see if it was related to psychotropic medications use. Review of the facility's undated policy titled Psychotropic Drug Use Policy, the policy indicated 'The residents has the right to be free from chemical restraint . The policy further indicated Gradual dose reduction should be done unless clinically contraindicated, in an effort to reach the lowest possible dose and/or discontinue psychotropic medication if there is no manifested behavior. The policy on Procedure section indicated, there Must be an appropriate specific diagnosis and behavior or manifestation documented for the drug being perscribed . Monthly behavior episodes will be tallied and compared to the previous months . unless clinically contraindicated, the facility may request the attending physician to attempt a gradual dose reduction. Review of the facility's undated policy number 4030, titled Informed Consent , the policy indicated The resident has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to use of . psychotherapeutic drugs; attending physician shall be responsible for informing the resident prior to the first use of . psychotherapeutic drugs . for the verification of informed consent to the facility . The facility shall be responsible for documenting verification of informed consent on the Physician's Order with provided stamp. The policy further indicated, A physician order . shall not be considered valid and shall not be carried out until the facility has received verification from the physician that the resident . has given informed consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 31 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure medication error rate was less than 5% during medication administration. The facility had a total of two errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.7%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The two medication errors identified were as follows: Residents Affected - Some 1. Licensed Nurse 3 (LN 3) opened sealed phenytoin capsules (or Dilantin - a medication used to prevent or treat seizure) for oral (by mouth) administration for one resident ( Resident 3) out of 15 sampled residents. This practice could have resulted in lower than expected medication level to protect against seizure. 2. LN 2 administered Metformin pill (a Medication used to treat blood sugar in diabetes) belong to another resident (Resident 13) when the medication supply could not be located for one (Resident 12) out of 15 sampled residents. This practice could pose medication safety risk for residents. Findings: 1. During a medication pass observation on 1/10/22 at 10:43 AM with LN 3 in the Central unit, LN 3 opened up two sealed capsules of phenytoin for Resident 3 and mixed them up with apple sauce for oral administration. Review of Resident 3's medical record titled Medication Administration Record (or MAR where doctor's orders were tabulated electronically as a drug chart and serves as a legal record of the drugs administered), with date range of 1/1/2022 to 1/31/22, the MAR indicated the following doctor's order for phenytoin: Dilantin (phenytoin sodium extended) Capsule 100 mg ( mg is a unit of measure); Give 2 capsule by mouth three times a day for seizures; Do Not Crush or Chew; Start Date: 5/31/2021 In an interview with licensed Nurse 3 (LN 3) on 1/12/22 at 2:01 PM at the [NAME] side nursing station, LN 3 stated she did not know not to open the sealed capsule for oral (by mouth) administration. LN 3 stated that Resident 3 was unable to swallow the capsules and was not aware if other forms of phenytoin could have been ordered for oral administration. In an interview with Director Of Nursing (DON) on 1/12/22 at 4:30 PM in her office, DON stated the phenytoin extended capsule for Resident 3 should have been changed to other forms that was appropriate for oral administration by a phone call to the medical doctor. Review of a document kept in a binder on top of the medication cart, titled Medications Not to Be Crushed dated 12/2010, the list included phenytoin (extended release- means slowly released into the body) with an explanation that the medication was a time release formulation and should not be crushed. Review of the facility's policy titled Medication Administration: General Guidelines, last updated on 10/2019, the policy indicated Medications are administered as prescribed in accordance with good nursing principles and practices . Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy on section 6 indicated If it is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 32 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some safe to do so, medication tablet may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed. The Policy on section 7 indicated liquid dosage forms may be a practical alternative in place of solid tablets . The nurse checks with . Pharmacy . to determine if a liquid form is available . The physician is contacted for a new order before changing the dosage form. 2. During a medication pass observation on 1/10/22 at 5:04 PM with LN 2 in the [NAME] unit, LN 2 was not able to locate a medication called Metformin (medication used to treat diabetes) for Resident 12 in the medication cart. Subsequently, LN 2 found a packet of Metformin medication belonging to another resident (Resident 13). LN 2 decided to use Resident 13's Metformin and administered an equivalent dose to Resident 12. Review of Resident 12's medical record titled Medication Administration Record (or MAR where doctor's orders were tabulated electronically as a drug chart and serves as a legal record of the drugs administered), with date range of 1/1/2022 to 1/31/22, the MAR indicated the following doctor's order for Metformin: metFormin HCL Tablet 500 mg ('mg' is unit of measure); Give 1 tablet by mouth two times a day for DM-2 (means diabetes); Take with food; Start Date:08/19/2021 Review of Resident 13's medical record titled Medication Administration Record with date range of 1/1/2022 to 1/31/22, the MAR indicated the following doctor's order for Metformin: metFormin HCL Tablet 500 mg; Give 0.5 tablet by mouth two times a day for DM=250 mg; Start Date:09/20/2020 In an interview with LN 2 on 1/10/22 at 5:11 PM, LN 2 stated, she was not sure why Metformin was not re-ordered from the provider pharmacy. LN 2 stated it was better to give the same medication from another resident rather than not giving it at all during her shift. In an interview with Director Of Nursing (DON) on 1/12/22 at 4:35 PM in her office, DON stated it was the policy and standard of practice not to borrow medication from another resident. DON added, nursing staff should ask for refill by ordering the product in a timely manner to prevent running out of medication. DON added the provider pharmacy made medication delivery twice per day and if needed, they could facilitate the medication delivery through a local pharmacy for urgent needs. Review of facility's policy titled Unavailable Medications last updated on 8/2019, the policy indicated The facility must make every effort to ensure that medications are available to meet the needs of each resident. Review of the facility's policy titled Medication Administration: General Guidelines, last updated on 10/2019, the policy on section 12 indicated, Medications supplies for one resident are never administered to another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 33 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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, record review, and inspection of medication rooms, medication cart, and treatment carts (medication and treatment carts used for easy transport and storage of drugs or treatment supplies) the facility failed to ensure safe storage and labeling of the medications to meet the needs of residents when: 1. Unlabeled and /or expired (means no longer should be used) medications and supplies were stored in three out of five active medication storage areas including medication room [ROOM NUMBER], medication cart #2 and the treatment cart. 2. The temperature monitoring documentation was not consistently documented and/or monitored in two out of two medication refrigerators. These failures had the potential for residents to receive medication with reduced effect due to unsafe storage. Findings: 1a. During an inspection of the medication room and medication cart #2 on the facility's East Side, on 1/10/22, at 11:18 a.m., accompanied by Licensed Nurse (LN) 1, the following medications were found to be expired, undated and/or unlabeled: I. Trelegy Ellipta (Asthma medication) for Resident 255 had no open date marking. The instruction on the box noted to discard after 6 weeks after opening. II. A box of Novolog FlexPen (Insulin medication in pen shape used for diabetes) in the medication cart, for Resident 21, had date open of 12/1/21 on the outer box, with an unopened and unrefrigerated insulin pen inside. III. A bottle of Nitroglycerin (medication used to treat chest pain) 0.4 mg/tablet (milligram-unit of measure) in the medication cart with no prescription label. IV. A bottle of Lactulose (medication used to treat constipation and liver disease) 10 gm/15 mL (gram and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 34 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 milliliter-unit of measure) for Resident 6 had no prescription labeled. Level of Harm - Minimal harm or potential for actual harm V. Two unlabeled Novolog FlexPens (Insulin medication in pen shape used for diabetes) were in the East side Residents Affected - Few medication refrigerator with no prescription label. VI. One vial of a Tuberculin Purified Protein Derivative or Mantoux (a medication used to test for a disease called tuberculosis) was found opened with no open date marking. The information on the Mantoux box, indicated to Discard opened product after 30 days. 1b. During an inspection of the treatment cart on facility's [NAME] side, accompanied by the Director of Nursing (DON) on 1/10/22 at 11:30 a.m., the following supplies were found to be expired or unlabeled: I. Sani-cloth bleach wipes (disinfectant wipes that cleans and disinfects germs) had an expiration date of 12/21. II. Dakin's solution half strength (topical antiseptic solution used to clean infected wounds, ulcers, and burns) had expiration date of 11/21. III. Lidocaine (an anesthetic medication to relieve pain and numb the skin) 2% Jelly noted as Rx only (a symbol for a medical prescription) had a handwritten mark noted House Supply with no prescription labeled. During an interview on 1/10/22, at 11:45 a.m., the DON confirmed and was aware of the unlabeled and expired medications. 2. During an inspection of the [NAME] Side medication room and review of the MEDICATION ROOM & REFRIGERATOR TEMPERATURE LOG (record of the daily temperature readings) with Infection Preventionist (IP) on 1/10/22 at 9:42 a.m., the IP confirmed missing refrigerator temperatures for the morning and evening shifts of 1/8/22 to 1/10/22 and the medication room temperatures for the morning shifts of 1/8/22 to 1/10/22, the evening shifts of 1/2/22-1/10/22. During an inspection of the East Side medication room and review of the MEDICATION ROOM & REFRIGERATOR TEMPERATURE LOG with LN 1 on 1/10/22, at 10:50 a.m., LN 1 confirmed missing temperatures for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 35 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 morning shift on the following dates of: 1/2/22, 1/4/22-1/6/22, 1/8/22, 1/9/22; and missing temperature for the evening shift for 1/2/22. During an interview on 1/12/22, at 4:12 p.m., the DON confirmed the inconsistent temperature monitoring and documentations. Residents Affected - Few Review of the facility's policy titled Storage of Medications, last revised on 4/2007, the policy indicated Drug containers that have missing, incomplete, improper, or incorrect label shall be returned to the pharmacy for proper labeling before storing. The policy on section 4 indicated, The facility shall not use discontinued, outdated, or deteriorated drugs . All such drug shall be returned . or destroyed. The policy on section 9 further indicated, Medications requiring refrigeration must be stored in a refrigerator located in the drug room . Review of the facility's policy titled Refrigerator under section for infection Control, with revision date of 11/7/2011, the policy indicated Medication refrigerators shall be: Temperature shall be documented on the [Refrigerator Daily Temperature Log] form twice daily [e.g. PM and Noc (night) shift]. Review of the facility's policy titled Vials and Ampules of Injectable Medications, last updated on 10/2019, the policy indicated The date opened and the initials of the first person to use the vial are recorded on multidose vials. The policy on section F indicated, Medication in multidose vials may be used (until the manufacturer's expiration date/for the length of time allowed by state law/according to facility policy/for 30 days) if inspection reveals no problem during that time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 36 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 professional standards were maintained for food service safety and storage for a facility census of 50 when; Residents Affected - Many 1. A bag of frozen chicken breasts were not dated, or labeled as to the contents of the bag in the freezer; 2. Frozen turkey and peeled bananas were freezer burned and available for use in the freezer; 3. Two large serving trays and a twelve-quart clear container used for food preparation and serving were stacked and put away wet; and, 4. Hand hygiene was not performed after using sanitizer to clean a food preparation area and before preparing pureed food in a blender for residents. These failures had the potential to result in chemical food contamination, reduced food quality and taste, and an environment where bacteria can begin to grow in prepared food and on kitchen food preparation and serving equipment. Findings: 1. During the initial tour of the kitchen with [NAME] 1 on 1/10/22, at 8:30 a.m., a clear, sealed plastic bag was observed out of the original shipping container and contained approximately fifteen of the same frozen food products. The plastic bag was not labeled with a date, or a description of the bag's contents. When asked, [NAME] 1 explained the frozen food items were chicken breasts and confirmed they were out of their original shipping container, and were not labeled with a description or a date. A review of the facility's procedure titled Procedure For Freezer Storage, dated 2018, indicated, .All frozen food should be labeled and dated . 2. During the initial tour of the kitchen with [NAME] 1 on 1/10/22, at 8:30 a.m., an opened, resealable plastic bag was observed in the reach in freezer and was labeled Turkey and dated 1/6/22. The large, single piece of turkey had a thick layer of ice over most of the surface area as well as ice flakes coating the inside of the bag. Further observation revealed a resealable plastic bag labeled Bananas, and dated 12/21/21, with approximately eight peeled bananas inside. The bananas had a thick layer of ice covering all visible surface areas as well as ice flakes coating the inside of the bag. When asked, [NAME] 1 stated all stored food in the freezer should be in a sealed bag and should not be freezer burned. [NAME] 1 removed the items and stated they would be discarded. A review of the facility's procedure titled Procedure For Freezer Storage, dated 2018, indicated, .Store frozen foods in an airtight moisure-resistant wrapper .to prevent freezer burn . An article published by the United States Department of Agriculture (USDA) titled Freezing and Food Safety, dated 6/15/13, indicated, .Freezer Burn .Heavily freezer-burned foods may have to be discarded for quality reasons . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 37 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 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 3. During a concurrent observation and interview on 1/12/22, at 10:36 a.m., the Dietetic Services Supervisor (DSS) was observed removing a clear plastic 12-quart (a unit of measure) food container and the lid from the drying rack still wet. The DSS proceeded to take the wet container and lid and stack them on top of dry 12-quart containers and lids. When asked, the DSS confirmed dishes should not be put away wet and placed the two items back on the drying rack. Residents Affected - Many During a concurrent observation and interview on 1/12/22, at 11:04 a.m., Dietary Aide (DA) 2 was observed removing two large serving trays from the drying rack still wet. DA 2 proceeded to stack the two wet serving trays on top of dry serving trays. When asked, the DSS confirmed the trays should not have been put away wet and placed the trays back on the drying rack. A review of the facility's policy and procedure titled, Dishwashing, dated 2018, indicated, .Dishes are to be air dried in racks before stacking and storing . 4. During a concurrent observation and interview in the kitchen on 1/12/22, at 10:43 a.m., DA 1 was observed removing a cleaning cloth from the sanitation bucket and proceeded to wipe off the stainless-steel food preparation area with gloved hands. DA 1 then dropped the cleaning cloth back in the sanitation bucket and walked over to the blender where peaches were being pureed for residents. With the same gloves on, DA 1 turned off the blender, opened the lid, and used a spatula to scrape down the pureed peaches. When asked, DA 1 confirmed hand hygiene was not performed after using the sanitizer solution but should have been and stated, I forgot. During an interview on 1/12/22, at 10:55 a.m., the DSS confirmed without performing hand hygiene between tasks food for the residents could become contaminated. A review of the facility's procedure titled, Hand Washing Procedure, dated 2018, indicated, .When hands need to be washed .before and after doing housekeeping procedures .before and after handling food with the hands ( .mixing, etc.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 38 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe infection control practices to prevent the spread of infection when: Residents Affected - Few 1. The glucometer (device used to measure the blood sugar level) was not sanitized per manufacturer specifications in-between resident care use on two residents (Resident 8 and Resident 12) who required blood sugar monitoring. 2. The Blood Pressure device (or BP device, included a cuff that wraps around the arm, a rubber squeeze bulb, and a gauge that measured the blood pressure flow in the body) was not sanitized in-between resident care use on two residents (Resident 5 and Resident 12) out of a census of 50. These failures could result in the spread of infection among residents in the facility. Findings: 1. During a medication administration observation with Licensed Nurse 2 (LN 2) on 1/10/22 at 4:45 PM in the [NAME] unit, LN 2 went into the Resident 8's room holding the glucometer device, and a bottle of test strips (the strips used with glucometer to help measure blood sugar) to measure Resident 8's blood sugar. LN 2 placed the test strip bottle and one extra lancet needle (its a sharp needle used to puncture finger to get small blood specimen) on Resident 8s side table. LN 2 measured the blood sugar, exited the room and placed the glucometer device, test strip bottle and one lancet needle on the top of the medication cart. LN 2 did not sanitized the glucometer proir to returning it to the medication cart. During a medication administration observation with LN 2 on 1/10/22 at 5:04 PM in the [NAME] unit, LN 2 entered Resident 12s room holding the same unsanitized glucometer with a new test strips on the device to measure Resident 12's blood sugar. In an interview with LN 2 on 1/10/22 at 5:18 PM, LN 2 acknowledged that she did not sanitized the glucometer device in-between resident care and was aware of the risks involved with transmission of infection. In an interview with the Director Of Nursing (DON) on 1/12/22 at 4:12 PM in her office, the DON stated the policy on shared devices was to sanitized the device appropriately in between resident use. Review of the undated facility's policy titled Shared Glucometer Cleaning Protocol, the policy indicated Glucometer shared by multiple patients will be thoroughly wiped with PDI Sani-Cloth Bleach Germicidal Disposable and allowed to air dry for after every use and between every patient . Note: the contact time recommended .is 4 minutes. Review of the facility's policy titled Infection Prevention and Control Program, dated 2021, the policy indicated The elements of infection prevention and control program consist of coordination/oversight, . Prevention of infection . The policy on section 11 further indicated educating staff and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 39 of 40 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 555186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 ensuring that they adhere to proper techniques and procedures. Level of Harm - Minimal harm or potential for actual harm 2. During a medication administration observation with LN 2 on 1/10/22 at 5 PM in the [NAME] unit, LN 2 went into the Resident 5's room holding the Blood Pressure device (BP device) to measure the blood pressure. LN 2 placed the BP cuff on Resident 5's upper arm and measured the blood pressure. LN 2 then exited the room and placed the blood pressure device on the top of the medication cart. LN 2 did not sanitized the BP device proir to returning it to the medication cart. Residents Affected - Few During a medication administration observation with LN 2 on 1/10/22 at 5:11 PM in the [NAME] unit, LN 2 entered Resident 12s room holding the same unsanitized BP device to measure the blood pressure. In an interview with LN 2 on 1/10/22 at 5:18 PM, LN 2 acknowledged that she did not sanitized the BP device in-between resident care and was aware of the risks involved with transmission of infection. In an interview with the Director Of Nursing (DON) on 1/2/22 at 4:12 PM in her office, the DON stated the policy on shared devices was to sanitized the device appropriately in between resident use. Review of the undated facility's policy titled Share Blood Pressure Cuff Cleaning Protocol, the policy indicated Blood pressure cuffs shared by multiple patients will be thoroughly wiped with Super Sani-Cloth Germicidal Disposable Wipe (cleaning wipe) and allowed to air dry for after every use and between every patient . Note: the contact time recommended . is 2 minutes. Review of the facility's policy titled Infection Prevention and Control Program, dated 2021, the policy indicated The elements of infection prevention and control program consist of coordination/oversight, . Prevention of infection . The policy on section 11 further indicated educating staff and ensuring that they adhere to proper techniques and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 40 of 40