Health inspection·December 1, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm In an interview with the Interim Director of Nursing (IDON) on 11/30/23, at 1:30 PM, the IDON stated the facility was reviewing and trying to clarify the indication for use of the mind-altering medication. The IDON stated she believed the medical doctors had access to hospital records and could extract the diagnosis if needed. The IDON acknowledged that the medical doctors for Resident 3 did not document a schizoaffective disorder diagnosis in their H&P or progress notes. Residents Affected - Few 1b. During review of Resident 17's electronic medical record titled, Order Summary Report, (a document that listed the doctor's orders for medications and nursing care), dated 11/23, the record indicated Resident 17 was receiving two mind-altering medication orders for quetiapine and perphenazine (a mind-altering medication used to treat mental health) for a diagnosis of schizophrenia. During a review of Resident 17's medical record titled, History and Physical, (or H&P) dated 7/26/23, written by MD 1, the record did not show any diagnosis for schizophrenia. The H&P indicated all available hosp. (hospital) records reviewed in detail. During a review of Resident 17's medical record from Hospital A titled, Discharge Summary, dated 7/25/23, the record did not indicate any diagnosis of schizophrenia for mind altering medication use. During review of Resident 17's medical record titled, MDS, dated 11/13/23, the record on section I indicated YES for diagnosis of schizophrenia under Psychiatric/Mood Disorder. In a concurrent record review and interview with the MDS-LN, in her office, on 11/29/23, at 4:02 PM, MDS-LN stated the diagnosis documentation in the MDS was a collaborative effort by nursing, medical records and MDS staff. MDS-LN stated the schizophrenia diagnosis should have been clarified and she was not sure why it was chosen. MDS-LN stated she contacted Resident 17's family doctor that had known the resident for a long time, and he didn't have the indication in his records. In an interview with the IDON on 11/29/23, at 10:15 AM, the IDON stated the facility could not find any documentation in the records and/or from the previous hospitalization for a schizophrenia diagnosis. The IDON stated the facility was looking into how the mental health diagnosis was documented in the records without a clear indication. The IDON stated the medical doctor was asking for a psychiatric consult (a mental health doctor) to assess mental health issues with no prior documentation history. The IDON stated she contacted the family and was told Resident 17 had a history of episodic temper tantrums. In a telephone interview with Resident 17's RP 2 on 11/29/23, at 2:35 PM, RP 2 stated she was never informed or told that Resident 17 had schizophrenia. RP 2 stated the only episodes of outburst for Resident 17 was after having a major seizure due to a having a big cyst (abnormal growth) at the base of her scalp since childhood. In a telephone interview with MD 1 who cared for both Resident 3 and Resident 17, on 11/30/23, at 12:19 PM, MD 1 stated they should have looked at the diagnosis closely for accuracy. Review of the facility's policy titled, Physician Services, revised date of 5/16/19, the policy on section 12 indicated, Orders shall be verified on admission with the attending physician by the designated licensed nursing personnel; Orders for medication .shall state .reason for administration and shall be supported by a diagnosis. Review of the facility's policy titled, Psychotropic Medication Use, dated 7/2022, the policy (continued on next page) 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 12/01/2023 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 indicated, Residents, families and/or the representatives are involved in the medication management process. Psychotropic medication management include; a. indication for use . 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 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 12/01/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure accurate documentation of a mental health diagnosis for 2 of 18 sampled residents (Resident 3 and Resident 17) based on standards of practice when: Residents Affected - Some 1. Resident 3's medical record was marked with schizoaffective disorder (a mental health disorder marked by a combination symptom, such as hallucinations or delusions, and mood disorder symptoms) as a diagnosis for use of quetiapine (or Seroquel, an antipsychotic [mind altering] medication used to treat mental disease) with no prior history of such diagnosis; and, 2. Resident 17's medical record was marked with schizophrenia (a serious mental condition involving a breakdown between thought, emotion, and behavior, leading to faulty perception and withdrawal from reality) as a diagnosis for use of quetiapine and perphenazine (a mind-altering medication used to treat mental disease) with no prior history of such diagnosis. These failures may result in unsafe treatment and care of the residents. Findings: 1. During a record review of Resident 3's medical record titled, Medication Administration Record, (or MARa document that listed the medication use and doctor's orders) dated 11/2023, the record indicated Resident 3 was receiving a mind-altering medication order as follows: Quetiapine .Oral Tablet 25 MG (or Seroquel, MG or milligram, a unit of measure); Give 1 tablet by mouth one time a day for m/b (manifested by) refusal of essential care related to schizoaffective disorder .-Start Date- 2/3/23. During a review of Resident 3's medical record titled, History and Physical, (or H&P, a summary of medical condition upon admission to the facility) dated 10/19/22, the record written by Medical Doctor (MD) 1, did not indicate a diagnosis for schizoaffective disorder. During a review of Resident 3's medical record, from an acute care hospital titled, Final Report, dated 10/17/22, the record did not show a past or current history of schizoaffective disorder. During a review of MD 1's monthly progress note, dated 11/3/23, the progress note for Resident 3 did not indicate a diagnosis for schizoaffective disorder. During a review of Hospice Records (an end-of-life service for comfort care) visit dated 11/11/23, the record did not indicate a diagnosis for schizophrenia for Resident 3 on quetiapine use. During a review of Resident 3's medical record titled, MDS, (or Minimum Data Set, a mandated reporting by federal government on resident's medical diagnosis and care) dated 11/9/22, the record on section I indicated NO for diagnosis of schizophrenia. During a review of Resident 3's medical record titled, MDS, dated 11/9/2023, the record on section I indicated YES for diagnosis of schizophrenia. Review of Resident 3's electronic medical record, under Medical Diagnosis, the record indicated, on (continued on next page) 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 12/01/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1/5/23, the diagnosis of schizoaffective disorder was listed as number 12 under classification of During Stay diagnosis. Review of the Resident 3's electronic record for Psychotherapeutic Drug Summary-Monthly, (a review & summary of behavior monitoring that facility tallying for targets behavior) dated 10/1/23 to 10/31/23, the document indicated the refusal of essential care was noted once during the whole month. In a telephone interview with Resident 3's Responsible Party (RP) 1 on 11/29/23, at 3:15 PM, RP 1 stated Resident 3 never had mental issues and was not aware of a schizoaffective disorder. In a concurrent record review and interview with the facility's Clinical Liaison (CL) on 11/29/23, at 3:36 PM, the CL confirmed the records did not show any prior history of a schizoaffective disorder. The CL stated the behavior monitoring listed as refusal of essential care was not likely to pose harm to anyone and it should be reassessed. In a concurrent record review and interview with the facility's MDS coordinator (MDS-LN), in her office, on 11/29/23, at 4:28 PM, MDS-LN stated the diagnosis for use of Seroquel should have been listed as depression and it was mislabeled in the MDS database and medical chart. MDS-LN stated she could not find any diagnosis for a schizoaffective disorder. In an interview with the Medical Record Director (MR) on 11/30/23, at 12:04 PM, in her office, MR stated she had been looking for Resident 3's source of the diagnosis documented in the medical record and, so far, could not figure out how it was added. MR stated she only entered them in the electronic medical record when the director or nurse manager gave her the diagnosis list. In an interview with the Interim Director of Nursing (IDON) on 11/30/23, at 1:30 PM, the IDON stated the facility was reviewing and trying to clarify the indication for use of the mind-altering medication. The IDON stated, she believed the medical doctors had access to hospital records and could extract the diagnosis if needed. The IDON acknowledged that the medical doctors for Resident 3 did not document a schizoaffective disorder diagnosis in their H&P or progress notes. 2. During a review of Resident 17's electronic medical record titled Order Summary Report, (a document that listed the doctor's orders for medications and nursing care) dated 11/23, the record indicated Resident 17 was receiving two mind-altering medication orders as follows: Quetiapine .Oral Tablet 25 MG .(or Seroquel, MG or milligram, a unit of measure); Give 1 tablet by mouth one time a day for SCHIZOPHRENIA M/B (manifested by) AUDITORY HALLUCINATION (hearing unreal voices); Start Date- 7/27/23. Perphenazine Oral Tablet 2 MG .Give1 tablet by mouth one time a day for SCHIZOPHRENIA M/B AUDITORY HALLUCINATIONS; Start Date- 7/27/23. During a review of Resident 17's medical record titled, History and Physical, (or H&P) dated 7/26/23, written by MD 1, the record did not show any diagnosis for schizophrenia. The H&P indicated all available hosp. (hospital) records reviewed in detail. During a review of Resident 17's medical record from Hospital A, titled, Discharge Summary, dated 7/25/23, the record did not indicate any diagnosis of schizophrenia for mind altering medication use. (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 12/01/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm During a review of MD 1's monthly progress notes, dated 10/6/23 and 11/1/23, the progress note for Resident 17 did not indicate a diagnosis for schizophrenia. During a review of Resident 17's medical record titled, MDS, dated 11/13/23, the record on section I indicated YES for diagnosis of schizophrenia under Psychiatric/Mood Disorder. Residents Affected - Some Review of Resident 17's electronic medical record, under Medical Diagnosis, the record indicated on 7/28/23, the diagnosis of schizophrenia was listed as number 13 under classification of Admission diagnosis. In an interview with the IDON on 11/29/23, at 10:15 AM, the IDON stated the facility could not find any documentation in the records and/or from the previous hospitalization for a schizophrenia diagnosis. The IDON stated the facility was looking into how the mental health diagnosis was documented in the records without a clear indication. The IDON stated the medical doctor was asking for a psychiatric consult (a mental health doctor) to assess mental health issues with no prior documentation history. The IDON stated she contacted the family and was told Resident 17 had a history of episodic temper tantrums. In a telephone interview with Resident 17's RP 2 on 11/29/23, at 2:35 PM, RP 2 stated she was never informed or told that Resident 17 had schizophrenia. RP 2 stated the only episodes of outburst for Resident 17 was after having a major seizure due to having a big cyst (abnormal growth) at the base of her scalp since childhood. In a concurrent record review and interview with MDS-LN, in her office, on 11/29/23, at 4:02 PM, MDS-LN stated the diagnosis documentation in the MDS was a collaborative effort by nursing, medical records and MDS staff. MDS-LN stated the schizophrenia diagnosis should have been clarified and she was not sure why it was chosen. MDS-LN stated she contacted Resident 17's family doctor that had known her for a long time, and he didn't have the indication in his records. In an interview with the MR on 11/30/23, at 12:04 PM, in her office, MR stated she had been looking for Resident 17's source of the diagnosis documented in the medical record and so far, could not figure out how it was added. MR stated she entered the diagnosis in the electronic medical record when the director or nurse manager gave her the list to add in the computer. In a telephone interview with MD 1 who cared for both Resident 3 and Resident 17, on 11/30/23, at 12:19 PM, the MD 1 stated they should have looked at the diagnosis closely for accuracy. In a telephone interview with the facility's Consultant Pharmacist (CP) on 11/30/23, at 11:49 AM, the CP stated he relied on the documented diagnosis in the medical record for accuracy as it must have been reviewed and approved by medical doctors. The CP stated during the IDT (Interdisciplinary team meeting- a team of health care professional caring for residents) meeting, a new diagnosis and/or respond to therapy was discussed and he did not recall questioning the accuracy of the diagnosis or the type of behavior monitored. Review of the facility's policy titled, Psychotropic Medication Use, dated 7/2022, the policy indicated, Residents, families and/or the representatives are involved in the medication management process. Psychotropic medication management includes: a. indication for use . Review of the facility's policy titled, Medication Orders: Non-controlled Medication Order (continued on next page) 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 12/01/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Documentation, dated 8/2019, the policy indicated, Elements of the Medications Order; Medication orders specify the following .Diagnosis or indication for use. The policy on section B indicated, Any dose or order that appears inappropriate considering resident's age, condition .or diagnosis is verified with the attending physician. Review of the facility's policy titled, Consultant Pharmacist Reports: Medication Regimen Review, dated 8/2019, the policy on section D indicated, In performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards. Review of the facility's policy titled, Medication Monitoring and Management, dated 10/2019, the policy indicated, when a resident received a new medication, the medication order is evaluated for the following: 1. The dose, route of administration, duration and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer specification for use. 2. A written diagnosis/indication .support the use of the medication. Review of the facility's policy titled, Physician Services, revised date of 5/16/19, the policy on section 12 indicated, Orders shall be verified on admission with the attending physician by the designated licensed nursing personnel; Orders for medication .shall state .reason for administration and shall be supported by a diagnosis. 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 12/01/2023 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 0685 Assist a resident in gaining access to vision and hearing services. 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 ensure 1 of 18 sampled residents (Resident 26) received proper vision treatment when Resident 26 was not seen by an ophthalmologist (a medical doctor who specializes in eye and vision care) as referred. Residents Affected - Few This failure had the potential to delay care and treatment for Resident 26. Findings: During an interview on 11/28/23, at 12:15 p.m., Resident 26 stated he had an eye problem and he wanted to see a doctor. Resident 26 stated he could not see anything, and he wanted to tell the doctor that his eyes were not the same. Resident 26 stated he did not know what had happened to his eyes and he needed a doctor to help him. Resident 26 further stated the facility staff told him that there was no doctor. Review of Resident 26's nurses progress note, dated 7/9/23, indicated, Resident seen by NP [Nurse Practitioner] [Provider Name] for routine monthly routine visit. Received orders for referral to ophthalmologist. Orders noted and carried out. Review of Social Services note dated 7/17/23, indicated, Resident was referred to specialist for Cornea [the clear, outer part of the eye that help eyes focus] consultation with [Eye Clinic], first available appointment is [DATE]th @ 2:20 Further review of Resident 26's medical record failed to show if Resident 26 was seen by the ophthalmologist. Review of Social Services note dated 11/27/23, indicated, Writer called [Eye Clinic] to schedule appointment the soonest appointment they had available is February 16th at 1pm, for cornea specialist. During an interview on 11/29/23, at 12:10 p.m., the Social Services Director (SSD) stated Resident 26's primary care provider referred him to be seen by an ophthalmologist. The SSD stated she contacted Resident 26's optometrist's (a doctor who performs eye exams to identify any problems in the vision and prescribe many of the most common treatments to correct the vision such as eyeglasses) clinic and they told her that Resident 26 needed to be seen by the specialist, an ophthalmologist. The SSD further stated she called an ophthalmologist's office who scheduled an appointment for Resident 26 to be seen on 9/27/23. The SSD stated the ophthalmologist's office told her to keep the appointment and they would call her once they got the required paperwork from his optometrist. The SSD stated they never called her and she should have followed up with Resident 26's ophthalmologist sooner. The SSD stated she should have followed up before Resident 26's appointment on 9/27/23, to confirm his appointment for a corneal consultation. The SSD stated they had an appointment book for residents, but she did not enter Resident 26's 9/27/23 ophthalmology appointment in the book because she needed to confirm it. The SSD stated Resident 26 missed his ophthalmology appointment on 9/27/23 which delayed his eye care or treatment if needed. During an interview on 11/29/23, at 12:46 p.m., Licensed Nurse (LN) 4 stated Resident 26 could only see shadows. LN 4 stated Resident 26 had been complaining that he could not see. LN 4 added Resident 26 had been asking to see a doctor. LN 4 further stated his primary care provider was aware and (continued on next page) 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 12/01/2023 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few referred him to be seen by an ophthalmologist. LN 4 stated the SSD was aware who scheduled the appointments. During an interview on 11/30/23, at 3:12 p.m., the interim Director of Nursing (IDON) stated when a resident was referred to be seen by a specialist then staff should work on it within 24 hours. The IDON stated if staff did not hear back from the specialist's office, then staff should follow up with the office. The IDON stated she was aware that Resident 26 missed his ophthalmology appointment. The IDON stated Resident 26 was placed at risk to continue to be impaired for his vision. The IDON added Resident 26's ophthalmology appointment and treatment/care was delayed which could result in worsening of Resident 26's eyes condition. Review of Resident 26's care plan dated 5/3/22, indicated, The resident has impaired visual function r/t [related to] Disease Process: DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS [tear glands], UNSPECIFIED VISUAL LOSS .Arrange consultation with eye care practitioner as required Review of a facility policy titled, Social Services, revised 11/29/23, indicated, .Medically-related social services are provided to assist residents to attain/maintain the highest practicable physical, mental and psychosocial well-being and to improve their ability to manage their everyday physical, mental and psychosocial needs .Social services includes items such as .Arranging ancillary services that residents need such as .optometry and ophthalmology routine services or as needed .Social services will be responsible for coordinating resident referrals to outside agencies . 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 12/01/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment and supervision for one of two residents (Resident 2) at risk of elopement (resident leaves the premises without the facility's knowledge and supervision) when: 1. Resident 2 eloped from the facility, falling out of her wheelchair and sustaining a fractured left ankle; and, 2. Resident 2's Elopement/Wandering Risk Assessment was not assessed accurately. These failures resulted in Resident 2 not receiving additional monitoring which allowed Resident 2 to exit the facility unnoticed and sustain an accidental injury while outside the facility's premises without supervision from staff. 1. During a review of Resident 2's clinical record titled, admission RECORD, (a document that contains the resident's demographics) indicated, Resident 2's diagnosis included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a medical illness that negatively affects how one feels or acts), and a history of falling. During an interview on 11/29/23 at 3:52 PM, with the Administrator (ADM), the ADM played the facility's video surveillance (front entrance view from inside and outside) from 8/14/23 (date of accident). The ADM confirmed the contents of the video were as follows: the inside video surveillance depicted Resident 2 in her wheelchair in the front lobby and able to propel (drive, push, or cause to move forward) her wheelchair independently. The video displayed three other residents in the lobby (two resident sitting in a wheelchair, and the other resident sitting in a chair with the walker in front of the resident). There was a staff member walking around the lobby doing various tasks. There was another staff member seen emptying the trash can. When the staff members left the lobby, Resident 2 wheeled herself to the front lobby doors and the two glass sliding doors opened all the way (automatically) and then partially opened and closed two times (possible malfunction) and then remained open. The video then displayed Resident 2 swiftly rolling down the cement slope (in her wheelchair) towards the street. The second video surveillance was captured from outside the facility. Resident 2 was seen swiftly rolling down the sloped cement entry ramp and towards the street. Resident 2's front wheelchair wheels caught on the curb, and she fell out of her wheelchair, front first, into the street (next to the curb). Three bystanders quickly came to Resident 2's aid as cars were driving past her on the street. The ADM stated, Resident 2 was able to leave the facility undetected by staff and the staff were alerted when a bystander notified facility staff. The ADM stated Resident 2 had a pattern of sitting in the lobby. The ADM stated, once exiting the facility doors, a cement slope ramp levels off at the sidewalk and then the street. The ADM stated, he was unsure what to do about the slope, as it could pose as a safety hazard. The ADM stated this was an avoidable accident. During a review of Resident 2's clinical record titled, Situation-Background-Assessment-Recommendation [SBAR] Communication Form and progress note, dated 8/14/23, indicated, Resident 2 had an unwitnessed fall on 8/14/23 at 1:35 PM, on the sidewalk of the facility. Resident 2 was able to verbalize severe pain of 10/10 (numerical pain assessment tool - 0= no pain through 10 being the worst pain) to the left leg. The document further indicated, . Bystander notified staff that resident found on (continued on next page) 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 12/01/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few street near curb by front entrance on the floor with wheelchair nearby. Resident found siting ground [sic] on [sic] with legs bent at 45-degree angle. Tx [treatment] nurse and therapist assessed resident. Resident .able to report pain to L [left] ankle. Upon further assessment to area noted with L ankle bent outward with resident yelling in pain upon palpation [feeling with the fingers or hands during a physical examination] with skin tear to L outer ankle Resident then lifted back into wheelchair .L leg stabilized with splint and PRN [as needed] pain medication administered for c/o [complaints of] severe pain to L leg. 911 contacted and [AMBLANCE NAME] arrived at approximately 1:45 PM, resident transferred to [HOSPITAL NAME]. During a review of Resident 2's clinical record titled, Emergency Documentation, dated 8/14/23, by the Emergency Department Physician (ED Phys.), indicated, Resident 2 was brought into the hospital via ambulance after a fall outside the facility. An x-ray (photographic or digital image of the internal portion of the body) of of the left leg indicated, there was a displaced fracture (break) of the left distal fibula (the outer and usually smaller of the two bones between the knee and the ankle) and a displaced fracture of the left ankle. Resident 2 had a reduction (push or pull the ends of the fractured bone until they line up) of the left ankle and was discharged with a well-padded 3-sided short leg splint (a supportive device that supports a broken bone or injury). During a review of Resident 2's clinical record titled, Care Plan, dated 8/14/23, indicated, Resident 2 had a fall with an injury to the lower left leg as evidenced by Resident 2 verbalizing severe pain to the extremity. During a review of Resident 2's clinical record titled, Care Plan, dated 12/13/22, indicated, Resident 2 had impaired cognitive (mental) function or impaired thought processes related to dementia. During a review of Resident 2's clinical record titled, Care Plan, dated 6/16/21, indicated, Resident 2 had a potential for fall or injury related to impulsive mobility. During a review of Resident 2's clinical record titled, Care Plan, dated 6/8/21, indicated, Resident 2 was at risk for elopement/wandering due to cognitive impairment secondary to dementia and depression. Interventions included, check Wander Guard (electronic monitoring system that alarms when the resident exits a facility door) or safety alarm devices for functioning, keep resident safe by using a Wander Guard on a wheelchair and or upper/lower extremity (arm or leg), monitor residents whereabouts frequently, provide a name band and replace as needed, provide diversional activities tailored towards residents functional and cognitive capabilities. During a concurrent observation and interview on 11/29/23, at 12:37 PM, with Resident 2, Resident 2 was observed in her wheelchair (in the dining room) with a Wander Guard around her right ankle. Resident 2 had a splint around her left leg. Resident 2 stated, she was in pain due to her ankle injury but was unable to identify how the ankle injury occurred. During an observation on 11/30/23, at 4:10 PM, the cement slope ramp was observed, beginning outside the facility's lobby doors then leveling out by the sidewalk to the curb, and finally dipping down from the curb to the street. The cement slope distance was approximately 12.5 feet (unit of measurement) long from the entrance doors and then leveled out onto the sidewalk. The sidewalk was approximately 9 feet to the curb. The curb was approximately a one-foot drop to the street. During an interview on 11/29/23, at 11:07 AM, with Licensed Nurse (LN) 3, LN 3 stated Resident 2 liked to sit in her wheelchair by the front door and watch people outside the glass doors. LN 3 (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 12/01/2023 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 0689 stated, she was unsure if Resident 2 had a Wander Guard in place at the time of the accident on 8/14/23. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/23, at 12:45 PM, with the Clinical Liaison (CL), the CL stated on 8/14/23, Resident 2 was in the front lobby in her wheelchair. The CL further stated Resident 2's normal behavior was to look out the front glass sliding doors. The CL explained on 8/14/23, the receptionist at the front lobby left the area to use the bathroom. The CL stated Resident 2 exited the front lobby doors (unnoticed) in her wheelchair and rolled down a slope that led to the sidewalk, curb, and street. The CL further stated Resident 2 fell out of her wheelchair onto the street (by the curb). The CL explained Resident 2's diagnosis of dementia made her a higher risk for elopement. Residents Affected - Few During an interview on 11/29/23, at 3:24 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 8/14/23, she did not see Resident 2 leave the facility. CNA 1 further stated Resident 2 had wandering behaviors, was confused, needed a Wander Guard, and a bed alarm (an alarm that alerts staff when the resident has gotten out of bed). CNA 1 explained Resident 2 was able to move around the facility independently in her wheelchair. CNA 1 stated, Resident 2 left the facility via the front lobby sliding doors, fell out of her wheelchair, and broke her ankle. CNA 1 further stated she was unsure if the Wander Guard alarm was activated on the day of the accident. During an interview on 11/30/23, at 9:41 AM, with the Minimum Data Set Licensed Nurse (MDS-LN [MDS tool for implementing standardized assessment and for facilitating care management in nursing homes]). MDS-LN stated Resident 2 was able to propel her way around the facility, frequently sat by the front lobby door, and asked to exit the front door (exit seeking behavior). MDS-LN further stated due to the fact Resident 2 fell and broke a bone, the facility did not provide a safe environment which was free from accidents. During an interview on 10/30/23, at 10:53 AM, with the Infection Preventionist (IP), the IP stated Resident 2 was able to move around the facility independently, was very confused, difficult to redirect, and enjoyed sitting by the nurse's station near the front lobby doors. The IP stated, the front lobby doors did not always function properly. During an interview on 11/30/23, at 11:11 AM, with the Maintenance Supervisor (MS), MS stated in the past, the nob at the top of the front entrance doors had been manually changed to a different code setting (automatically open and/or locked function). MS stated, he had been called at least two times at night because the entrance doors were malfunctioning by opening automatically (could not recall dates). During an interview on 11/30/23, at 11:15 AM, with LN 6, LN 6 stated the facility had issues with the front door malfunctioning. LN 6 further stated sometimes the doors wouldn't open and sometimes the doors were stuck in the open position. LN 6 explained the doors had a setting to allow it to automatically open when it sensed a person at the door. LN 6 stated the staff were not supposed to have it on that setting and did not know why it would ever be moved to that setting. LN 6 further stated Resident 2 was able to get around the facility independently in her wheelchair, was confused, and would sometimes sit by the front lobby doors. During an interview on 11/30/23, at 11:28 AM, with LN 4, LN 4 stated on the date of the accident, Resident 2 was supposed to have a Wander Guard on her. LN 4 further stated Resident 2 had intermittent confusion, frequently wandered around the facility, and liked to sit in the lobby. LN 4 explained when residents were at increased risk for elopement, the staff encouraged activities to keep them (continued on next page) 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 12/01/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few occupied. LN 4 stated Resident 2 should not have been permitted to sit by the front door because she was a risk for elopement. LN 4 further stated once in a while the front glass sliding doors did not close and a staff member would have to stand by the door until maintenance fixed the door. During a phone interview on 11/30/23, at 3:09 PM, the Medical Doctor (MD) 1, MD 1 stated Resident 2 was an elopement risk because she was confused. During a concurrent interview and record review on 11/30/23, at 12:07 PM, with the IDON, the P&P titled, Resident Rights, dated December 2022, was reviewed. The P&P indicated, . Policy Interpretation and Implementation - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . e. be free from injury/accident. The IDON stated the front lobby sliding doors were malfunctioning on 8/14/23. The IDON further stated due to the malfunction of the front sliding doors, Resident 2's fall and fracture was preventable if the lobby doors would have been locked. The IDON explained it was the responsibility of the entire staff to keep the residents safe and free from accidents and the P&P was not followed. During a review of the P&P titled, Fall Risk Assessment, dated 3/2018, indicated, Policy Statement - The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors .8. The staff will seek to identify environmental factors that may contribute to falling . 2. During a concurrent interview and record review on 11/30/23, at 9:49 AM, with the Assistant Director of Nursing (ADON), Resident 2's Elopement/Wandering Risk Assessments were reviewed. The Elopement/Wandering Risk Assessments indicated, - 5/28/21 - Elopement/Wandering Risk Assessment - Elopement/Wandering Risk Score = 8 (9 or above indicated a risk for elopement). Due to bouts of forgetfulness & confusion d/t [due to] dementia & depression, resident remains at risk for elopement. Interdisciplinary Team [IDT- group of caretakers and staff who discuss the Resident's treatment and status] recommends to continue use on interventions stated above. Wander Guard monitored daily for function and placement. The assessment further indicated, the interventions included, Wander Guard, frequent monitoring, identification bracelet, recreational activities, personalization of room with facility objects and photos, photo on wander list, and staff aware of resident's wander risk. The ADON stated the assessment should have indicated Resident 2 was slightly limited not very limited (able to independently move around the facility in her wheelchair). The modified score would have increased Resident 2's risk for elopement. - 6/15/21 - Elopement/Wandering Risk Assessment - Elopement/Wandering Risk Score = 8. The assessment indicated, Resident alert and oriented x 2 [knows who they are and where they are, but not what time it is or what is happening to them] with intermittent confusion. Resident had a behavior of wandering the facility. Risk for elopement at this time. Elopement interventions in place. The assessment further indicated, the interventions in place included, Wander guard, frequent monitoring, identification bracelet, recreational activities, personalization of room with facility objects and photos, photo on wander list, and staff aware of resident's wander risk. The ADON stated Resident 2's elopement/wandering score did not match the comments of being high risk for elopement. - 8/14/23 at 1:40 PM (day of elopement)- Elopement/Wandering Risk Assessment - Elopement/Wander Risk Score = 6. The assessment indicated, Resident was at risk for elopement, and the interventions in place were, Wander Guard, frequent monitoring, identification bracelet, recreational activities, personalization of room with facility objects and photos, photo on wander list, and staff aware of (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 12/01/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's wander risk. Comments included: Resident is wheelchair bound and able to propel inside the facility. Has not attempted to leave the facility. The audit report indicated, the assessment was edited on 8/17/23, 8/23/23, and 9/1/23 (unable to see what was edited). The assessment was completed after the elopement. - 11/27/23 - Elopement/Wandering Risk Assessment - Elopement/Wander Risk Score = 8. The assessment indicated, Resident 2 was very limited, and Resident 2 was not an elopement risk (Resident 2 eloped on 8/14/23). The ADON stated she coded the assessment incorrectly and Resident 2 should have been deemed an elopement risk. The ADON further stated it was important to complete the Elopement Wandering Assessments correctly to ensure Resident 2 had the correct amount of supervision. The ADON explained Resident 2 had severe dementia, could propel herself around the facility in her wheelchair, had wandering behaviors, and; therefore, was at risk for elopement. The ADON stated on the day of the accident, Resident 2 did not have a Wander Guard in place. The ADON further stated it was the entire staff's responsibility to ensure the safety of Resident 2. The ADON explained Resident 2 was able to exit the facility through the lobby doors without being detected by the staff, therefore, the accident was preventable. The ADON stated Resident 2 could have been hit by a car. During a concurrent interview and record review on 11/30/23, at 11:50 AM, with the Interim Director of Nursing (IDON), Resident 2's elopement/wandering risk scores, care plans, physician's orders, and admission/discharge history were reviewed. The IDON stated the LVN coded the 11/27/23 elopement/ wandering assessment incorrectly and Resident 2 should have been deemed an elopement risk. The IDON further stated, she was unsure of the reason Resident 2 did not remain a high risk for elopement. During and concurrent interview and record review on 11/30/23, at 12:03 PM, with the IDON, the Policy and Procedure (P&P), titled, Wandering and Elopements, dated March 2019, was reviewed. The P&P indicated, The facility will identify residents who are at risk of unsafe wandering .Policy Interpretation and Implementation 1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident' safety . The IDON stated Resident 2's diagnosis of dementia, intermittent confusion, and ability to propel herself around the facility was an important factor when assessing for elopement risk. The IDON stated, the importance of an accurate wandering assessment was to ensure residents had the appropriate supervision. The IDON stated, Resident 2 was an elopement risk in 2020 and had a Wander Guard in place; however, on the date of the accident, Resident 2 did not have a Wander Guard on her person and was deemed not to be an elopement risk. The IDON stated, she was not sure why Resident 2's elopement risk changed from high risk to not a high risk for elopement. The IDON verified the elopement assessment completed on 11/27/23 was incorrect when it indicated Resident 2 was not at risk for elopement. The IDON stated, interventions that are implemented with high-risk elopement residents are frequent monitoring, Wander Guard, and staff are made aware of the wandering risk. 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 12/01/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the necessary services and assistance were provided to maintain bowel and bladder continence (the ability to control movements of the bowels and bladder) for 1 of 18 sampled residents (Resident 4), when: 1. A bowel and bladder training program (a schedule of urinating and defecating to improve continence) was not developed and initiated for Resident 4 as indicated by her bowel and bladder assessment; and, 2. Resident 4's bowel and bladder assessments were not completed accurately. These failures resulted in Resident 4 using briefs (adult diapers) for urination, had the potential to not provide adequate care and a risk for further decline to Resident 4's bowel and bladder control. Findings: 1. Review of Resident 4's admission record indicated Resident 4 was admitted to the facility in September 2023 with multiple diagnoses including fracture of right femur (leg bone), chronic kidney disease, pain in right hip. Review of Resident 4's bowel & bladder assessments dated 9/13/23, and 9/27/23, indicated, .Candidate for Scheduled toileting (timed voiding) . Review of Resident 4's care plan dated 9/19/23, indicated BOWEL FUNCTION ALTERED MANIFESTED BY .[X] INCONTINENCE .Interventions .PLACEMENT IN THE FOLLOWING: [] BOWEL TRAINING PROGRAM [] SCHEDULED TOILETING [x]INCONTINENCE CARE AND COMFORT .PROVIDE DISPOSABLE BRIEFS FOR DIGNITY . Review of Resident 4's care plan revised 10/16/23, indicated, .PATIENT HAS INCONTINENCE FREQUENTLY INCONTINENT OF: [X] BOWEL [X] BLADDER AT RISK FOR: *SKIN BREAKDOWN *UTI [Urinary Tract Infection] .Interventions .PROVIDE INCONTINENT BRIEFS FOR DIGNITY AND COMFORT . Review of the MDS (Minimum Data Set: a standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE], indicated Resident 4 had intact cognition and needed one-person physical assist for toilet use. Further review of Resident 4's MDS Section H Bladder and Bowel indicated a trial of toileting program had not been attempted. During an interview on 11/27/23, at 11:28 a.m., Resident 4 stated she started using briefs when she came to the facility because the facility staff put a brief on her when she came to the facility. Resident 4 stated she was on a water pill and needed to urinate frequently. Resident 4 stated she assumed she needed to go in the brief because staff put a brief on her, and staff could not be there constantly to help her to the toilet. Resident 4 stated she could not have a bowel movement (BM) in the brief and would hold the BM until staff came to help her to the toilet. Resident 4 stated at home before she came to the facility, she was going in the toilet for both urination and BM even while she was taking the water pill. (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 12/01/2023 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 During a concurrent observation and interview on 11/29/23, at 11:19 a.m., Resident 4 was sitting up in a wheelchair in her room. Resident 4 stated she would be going home soon, and she would be going in the toilet for both urination and BM. Resident 4 stated she did not have a strong urge to urinate when she was sitting up but as soon as she would stand up, she had to go and could not hold/control it. Resident 4 stated she did not have a strong urge to urinate but she could go in the toilet if someone could help her now. Residents Affected - Few During an observation on 11/29/23, at 11:33 a.m., Certified Nursing Assistant (CNA) 2 assisted Resident 4 to the toilet when Resident 4 requested. Resident 4 urinated in the toilet. During an interview on 11/29/23, at 11:43 a.m., after Resident 4 used the bathroom, Resident 4 stated, I feel better. It always feels better to relieve yourself in the toilet. I am so glad to say goodbye to the diapers. I will use the pull-ups just to make sure I make it to the toilet. During an interview on 11/29/23, at 11:44 a.m., CNA 2 stated Resident 4 urinated in the toilet when she assisted her. CNA 2 stated Resident 4 needed assistance to use the bathroom. CNA 2 stated sometimes they had residents on timed voiding where they put them on the toilet before and after meals or so on as per their bowel and bladder training program. CNA 2 stated currently they did not have any residents on bowel and bladder training/timed voiding. During a concurrent interview and record review on 11/29/23 at 3:24 p.m., the Director of Staff Development (DSD) confirmed that she completed Resident 4's bowel and bladder assessment, dated 9/27/23, which indicated Resident 4 was a candidate for scheduled toileting/timed voiding. The DSD stated she was just helping her nurse. The DSD stated she did not know what happened next. The DSD stated they did not do toilet trainings at the facility. During a concurrent interview and record review on 11/29/23, at 3:56 p.m., the Clinical Liaison (CL) stated the bowel and bladder assessment was done upon admission. The CL stated if there was an indication that a resident was a candidate for bowel and bladder training, then they would initiate a scheduled toileting program based on resident needs/assessment for bowel and bladder training. The CL verified Resident 4's bowel & bladder assessment upon admission and on 9/27/23, indicated Resident 4 was a candidate for bowel & bladder training program. The CL verified there was no record indicating a bowel & bladder training program was developed or initiated for Resident 4. The CL stated Resident 4's admission assessment indicated Resident 4 had been incontinent for about a month only, which could be from being sick and in the hospital. The CL stated based on Resident 4's admission assessment and elimination record, Resident 4 was a good candidate for the bowel and bladder training program. The CL stated Resident 4 should have been started on a scheduled toileting program for bowel and bladder training as her assessment indicated. The CL stated Resident 4 was at risk of increased incontinence, brief dependence, skin integrity issues such as rash or redness from brief use, dignity issues. The CL stated incontinence could affect a resident's quality of life. During an interview on 11/30/23, at 3:03 p.m., the Interim Director of Nursing (IDON) stated the bowel and bladder assessment was done upon admission, at 14 days, and quarterly. The IDON stated after completion of a resident's assessment, staff should plan a toileting schedule program and implement as applicable based on a resident centered approach. The IDON stated the risks of not developing and initiating a bowel and bladder training program as indicated were increased incontinence, skin impairment, dignity issues such as wearing a brief could make someone feel embarrassed. 2. During a concurrent interview and record review on 11/29/23, at 3:56 p.m., Resident 4's bowel (continued on next page) 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 12/01/2023 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 and bladder assessments, dated 9/13/23 and 9/27/23, were reviewed with the CL. The CL stated Resident 4's bowel and bladder assessments were completed incorrectly. The CL stated Resident 4's bowel and bladder assessments indicated Resident 4 was always mentally aware of her toileting needs but was never continent. The CL stated if Resident 4 always knew when she needed to go then she could not be always incontinent. The CL stated the first two sections of Resident 4's bowel and bladder assessments were not done correctly. The CL stated Resident 4's assessments should have been done correctly to reflect an accurate resident condition. During a concurrent interview and record review on 11/30/23, at 2:28 p.m., the DSD confirmed she completed Resident 4's bowel and bladder assessment on 9/27/23. The DSD stated she reviewed Resident 4's bowel and bladder elimination task to complete her bowel and bladder assessment. Resident 4's bowel and bladder elimination task for the month of September 2023 were reviewed with the DSD. The DSD verified Resident 4 was not always incontinent of bowel and bladder. The DSD verified Resident 4 had episodes of bowel and bladder continence prior to 9/27/23, when she did the assessment. The DSD stated she should have selected the option of continent 1-2 times per day instead of never continent on Resident 4's bowel and bladder assessment. The DSD stated Resident 4's bowel and bladder assessment was not accurate. The DSD stated Resident 4's bowel and bladder assessment should have been completed accurately. During an interview on 11/30/23 at 3:03 p.m., the IDON stated a bowel and bladder assessment was completed upon admission, at 14 days and quarterly. The IDON stated staff developed a plan of care based on the assessment results. The IDON stated the bowel and bladder assessment should be accurate and reflect the resident's condition accurately. The IDON stated if an assessment was not completed accurately then possibly the resident would not have an appropriate plan of care and would not receive appropriate care. Review of a facility policy titled Bowel and Bladder Program revised May 2023, indicated, .Purpose .To enable the resident to regain bowel/bladder control .To restore the resident to the highest level of independence possible .To improve/restore the resident's dignity, self image and morale .To avoid the possibility of skin breakdown due to incontinency .It is the policy of this facility to assist each resident to achieve and maintain the highest level of independence. To achieve this goal each resident will be assessed within two weeks of admission for the need for bowel/bladder program .When the written assessment indicates the presence of incontinency or there is evidence of a decline in continency, the licensed nurse will initiate the individual bowel and bladder management program .Prepare appropriate training - Enter the individualized program to be followed: toileting method, and times. Instruct resident and staff on procedure and recording result . 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 12/01/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to provide the services of a full time (working 40 or more hours a week) Director of Nursing (DON) onsite to fulfill the job duties of the DON. Residents Affected - Few This failure had the potential to result in the needs of the residents not being adequately assessed and met in a timely manner and could potentially impact the quality of care delivered by licensed and non-licensed nursing staff for a census of 57 residents. Findings: A review of the undated facility's job description titled, JOB DESCRIPTION JOB TITLE: Director of Nursing Services, the job description indicated, .The primary purpose of .[the DON] is to plan, organize, develop and direct the overall operation of .Nursing Service Department .to ensure that the highest degree of quality care is maintained at all times .The Director of Nursing Services reports to the Administrator .DUTIES AND RESPONSIBILITIES .Develop, implement, and maintain an ongoing Quality Assurance and Performance Improvement [QAPI; a data driven and proactive approach to quality improvement] Program for the nursing service department related to Quality of Care, Quality of Life and resident choice .Serve on, participate in, and attend various committees of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Budget, Quality Assurance and Performance Improvement .) as required .EDUCATION REQUIREMENTS .Must be a graduate of an accredited college or university .Must possess a current, unencumbered, active license to practice as a Registered Nurse . During an interview on 11/28/23, at 4:33 p.m., with the Interim Director of Nursing (IDON), the IDON stated she was filling in for the facility to support as the DON and her hours varied as she also went to another facility. The IDON further stated she worked 8 hours a day. The IDON mentioned she came to the facility 2-4 days a week and worked an average of 16-32 hours a week. During an interview on 11/28/23, at 5:17 p.m., with the IDON, the IDON stated she was not full time, and she was not working 40 hours a week since she started in December 2022 as the IDON for the facility. When asked if the IDON was able to fulfill the duties and responsibilities of the DON, the IDON stated there were 2 Assistant Directors of Nursing (ADONs) who she coordinated with to assist in completing the DON's task. A review of the facility's document titled, CONSULTANTS SIGN IN LOG, from June 2023-November 2023, indicated the IDON's hours were less than 40 hours per week. The record indicated: 1. The month of June 2023: a. The days 6/1/23 and 6/2/23 had hours worked, a total of 13.5 hours worked. b. For the week of 6/4/23 (6/8/23, 6/9/23 hours worked), a total of 14 hours worked. c. For the week of 6/11/23 (6/16/23 hours worked), a total of 6.5 hours worked. d. For the week of 6/18/23 (6/19/23- 6/21/23, 6/23/23 hours worked), a total 27 hours worked. (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 (X3) DATE SURVEY COMPLETED A. Building 12/01/2023 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 0727 e. For the week of 6/25/23 (6/30/23 hours worked), a total of 7 hours worked. Level of Harm - Minimal harm or potential for actual harm 2. The month of July 2023: a. For the week of 7/2/23, no hours worked documented. Residents Affected - Few b. For the week of 7/9/23 (7/10/23, 7/11/23 hours worked), a total of 14 hours worked. c. For the week of 7/16/23 (7/21/23 hours worked), a total of 7 hours worked. d. For the week of 7/23/23 (7/24/23 hours worked), a total of 6.5 hours worked. e. For the week of 7/30/23, no hours worked documented for 7/30/23 and 7/31/23. 3. The month of August 2023: Facility did not provide document. 4. The month of September 2023: a. The days 9/1/23 and 9/2/23 no hours worked documented. b. For the week of 9/3/23 (9/5/23, 9/6/23 hours worked), a total of 16 hours worked. c. For the week of 9/10/23, no hours worked documented. d. For the week of 9/17/23 (9/20/23 hours worked), a total of 8 hours worked. e. For the week of 9/24/23 (9/25/23, 9/29/23 hours worked), a total of 16 hours worked. 5. The month of October 2023: a. For the week of 10/1/23 (10/2/23, 10/6/23 hours worked), a total of 16 hours worked. b. For the week of 10/8/23 (10/12/23, 10/13/23 hours worked), a total of 16 hours worked. c. For the week of 10/15/23 (10/19/23, 10/20/23 hours worked), a total of 16 hours worked. d. For the week of 10/22/23 (10/25/23-10/27/23 hours worked), at total of 22 hours worked. e. For the week of 10/29/23 (10/30/23, 11/3/23 hours worked), a total of 16 hours worked. 6. The month of November 2023: a. For the week of 11/5/23, no hours worked documented. b. For the week of 11/12/23 (11/16/23 hours worked), a total of 8 hours worked. c. For the week of 11/19/23 (11/20/23-11/22/23 hours worked) a total of 24 hours worked. (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 12/01/2023 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 0727 d. For the days 11/27/23 and 11/28/23, 12 hours worked per day. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/27/23, at 4:43 p.m., with the Clinical Liaison (CL), the CL stated her job title was the Clinical Liaison and Staffing Coordinator. The CL further mentioned she was a Licensed Vocational Nurse (LVN). Residents Affected - Few During an interview on 11/29/23, at 5:20 p.m., with the Assistant Director of Nursing (ADON) in the [NAME] Nurse Station, the ADON stated she was the only ADON, and she was a LVN. During a concurrent interview on 11/30/23, at 11:11 a.m., with the Administrator (ADM), the facility document titled, CONSULTANTS SIGN IN LOG, for the month of November 2023 was reviewed. The ADM confirmed the IDON was not working 40 hours a week full time, and she should be. During an interview on 11/30/23, at 12:29 p.m., with the ADM, the ADM stated the IDON had not met the 40 hours fulltime since he began his position at the facility in February of 2023. During a concurrent interview and record review on 11/30/23, at 3:49 p.m., the ADM stated the facility's quality assessment and assurance (QAA) committee met monthly for QAPI meetings rather than required quarterly to have closer view of areas needing improvement. The ADM stated the facility's QAA committee members included Medical Director (MD), ADM, DON, Infection Preventionist (IP), Director of Staff Development (DSD), Minimum Data Set (MDS) nurse, Rehabilitation Department, and Dietary Department. The facility's QAPI meetings sign-in sheets were reviewed with the ADM. The ADM verified the IDON did not attend the monthly QAPI meetings on 3/23/23, 5/18/23, 6/15/23, 7/27/23, 8/17/23 and 9/14/23. The ADM stated the expectation was to have the IDON attend the QAPI meetings at least quarterly. The ADM stated the IDON gave input in QAPI meetings, followed through with the nursing plans, and oversaw nurses. During an interview on 11/30/23, at 5:24 p.m., the ADM stated he did not have the QAPI meeting sign in sheet for the month of April 2023. The ADM verified the IDON did not attend the QAPI meetings for the second and third quarter. Review of an undated facility document titled QA & A Committee Information indicated, 1. Administrator .2. Director of Nursing - [name of the IDON] .Meetings are held on a monthly basis for QA . Review of the facility policy titled SNF [Skilled Nursing Facility] Quality Assurance Performance Improvement QAPI Plan, revised 7/31/23, indicated, .our purpose is to provide excellent quality care to the residents we serve .Our QAPI committee consists of a chairperson and seven subcommittees with representation from administration, the medical director, nursing .Our QAPI Program is Chaired by the Administrator Our seven subcommittee's each has a chairperson who leads the committee and assigns indicators to members on a monthly basis. Subcommittees 1. Resident Choice .This subcommittee meets monthly to review the Resident Choice to view potentially deficient practices, identify trends, and develop a plan of correction to be implemented to ensure substantial compliance. Current Resident Choice subcommittee members: Chairperson [name of IDON] DON .2. Quality of Life .This subcommittee meets monthly to review the Quality of Life dashboard to identify potentially deficient practices, identify trends and develop a plan of correction to be implemented to ensure substantial compliance. Current Quality of Life subcommittee members: Chairperson [name of IDON] DON .3. Clinical Care .This subcommittee meets monthly along with the Medical Director to review the Clinical Care dashboard to identify potentially deficient practices and identify trends to develop a plan of correction to be implemented to ensure substantial compliance. Additionally, the subcommittee monitors existing (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 12/01/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few QI[Quality Improvement]/QM[Quality Management] results, internal monitors for falls, medication errors, pressure ulcers, incident reports, infection reports, and any other concerns. Current Clinical Care subcommittee members: Chairperson [name of IDON] DON .5. Facility Standards .This subcommittee meets monthly to review the Facility Standards dashboard .Current Facility Standards subcommittee members: Chairperson [name of IDON] DON .6. Surveys addresses Resident Satisfaction Surveys .This subcommittee meets monthly .Current Surveys Subcommittee members .[name of IDON] DON .7. Audits addresses critical areas of medical records and other documentation .This subcommittee meets monthly to review the audits .Current Audit subcommittee members .[name of IDON] DON .The Administrator, Director of Nursing and Medical Director are responsible and accountable for developing, leading, and closely monitoring the QAPI program . A review of the facility's policy titled, ADMINISTRATIVE MANUAL .Nursing Services, revised dated 9/12/19, the policy indicated, .Director of Nursing Services .Is designated full-time* to carry out the Resident Care Policies under the direction of the Medical Director and Administrator .Qualifications include Registered professional nurse with full time administrative authority, responsibility and accountability for nursing functions, activities, and training of the nursing staff .Serves only one facility as Director of Nursing Services . FORM CMS-2567 (02/99) Previous Versions Obsolete 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 12/01/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure safe and accountable medication use, documentation, and the timely availability of medication with a census of 57 when: Residents Affected - Few 1. There was a discrepancy between the Controlled Drug Record (or CDR, an accountability record for opioid use) removal and the respective Medication Administration Record (or MAR referred to as a drug chart that serves as a legal record of the drugs administered to a resident) documentation for two residents (Resident 163 and Resident 999); and, 2. Diabetic medication (medication to lower blood sugar) was not available for Resident 113. These failures had the potential risk for diversion (transfer of a medication from a legal to an illegal use from the individual for whom it was prescribed, to another person for illicit use) and could negatively impact Resident 113's blood sugar control. Findings: 1a. During a review of the facility's document titled, Controlled Drug Record, dated 11/17/23, the record indicated Resident 163's narcotic medication called Oxycodone (a pain medication) was removed from the CDR and was not documented in the MAR as follows: i. On 11/22/23; Oxycodone was removed from CDR at 3:20 a.m., with no corresponding documentation in the MAR for 11/22/23. ii. On 11/24/23; Oxycodone was removed from CDR at 8:00 p.m., with no corresponding documentation in the MAR for 11/24/23. 1b. During a review of the facility's document titled, Controlled Drug Record, dated 11/18/23, the record indicated Resident 999's narcotic medication called Oxycodone was removed from the CDR and was not documented in the MAR as follows: i. On 11/25/23; Two oxycodone tablets were removed from CDR at 5:20 a.m. and 1:58 p.m., with no corresponding documentation in the MAR for 11/25/23. ii. On 11/22/23; Two oxycodone tablets were removed from CDR at 6 a.m., with no corresponding documentation in the MAR for 11/22/23. iii. On 11/19/23; Two oxycodone tablets were removed from CDR at 12:36 p.m., with no corresponding documentation in the MAR for 11/19/23. iv. On 11/26/23 and 11/22/23; Two Oxycodone tablets were removed from CDR at 8:58 a.m. and 12 noon respectively, when only one tablet was documented in the MAR for 11/26/23 and 11/22/23 administration. During an interview on 11/28/23, at 3:37 p.m., with the Interim Director of Nursing (IDON), the IDON acknowledged the findings and stated she would investigate why the removals were not documented in (continued on next page) 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 12/01/2023 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 0755 the MAR. Level of Harm - Minimal harm or potential for actual harm 2. During a medication administration observation on 11/27/23, at 4:51 p.m., with Licensed Nurse (LN) 7, Resident 113 asked LN 7 for his blood sugar medication he was taking at home. Residents Affected - Few During a concurrent medication administration observation and interview on 11/28/23, at 8:20 a.m., with LN 5 at East hallway, Resident 113 once again asked LN 5 for his blood sugar medication he was taking at home. LN 5 stated the family brought in the medication and they needed an order from the doctor to administer. During a review of Resident 113's medical records, from Hospital A, titled, Hospital discharge instructions, dated 11/27/23, the records indicated Medications to continue with no changes .Semaglutide (Rybelsus [medicine to lower blood sugar ] .oral tablet) 1 tab (s) By mouth once daily . During a review of Resident 113's medical record titled, Medication Administration Record, dated 11/2023, the MAR did not indicate Rybelsus was included in the admission orders to the facility. During a review of Resident 113's medical records titled, Progress notes, for the date range of 11/17/23 to 11/27/23, the record did not indicate any note or explanation on why Rybelsus was not restarted. During a review of Resident 113's medical records titled, Progress notes, dated 11/28/2023, the note indicated, Resident requested for his Rybelsus .to be continued as he is currently taking it at home. Notified MD 2 .Son brought medication from home. Endorsed with staff. During an interview on 11/28/23, at 11:34 a.m., with Resident 113, in his room, Resident 113 stated his blood sugar had been creeping up since coming to the facility and wanted to go back to his home medicine that worked for him. Resident 113 was not sure why it was not given to him and he asked his family to bring his supply to the facility. During an interview on 11/28/23, at 3:42 p.m., with the Clinical Liaison (CL), at the [NAME] nursing station, the CL stated new admission orders were called in and reviewed over the phone with the doctor based on hospital discharge records. Then the orders were sent to the provider pharmacy for dispensing. During a telephone interview on 11/30/23, at 11:13 a.m., with Medical Doctor (MD) 2, MD 2 stated the facility would have called him with the medication list from the hospital and if the medication was not available or cost was an issue, he would substitute another medication if applicable. MD 2 further stated he was not aware that Resident 113 had been asking for the medication and the medicine was brought in by the family. During a review of the facility's policy titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner .If a drug is withheld, refused, or a given time .the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering he next ones . During a review of the facility's policy titled, Physician Services, dated 5/16/19, the policy on section 7 indicated, .Verify orders upon admission with the licensed nursing personnel .inform the (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 12/01/2023 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 0755 resident of his/her medical condition, treatments/medications, risks/benefits, and alternatives . 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 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 12/01/2023 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 insulin (a medicine to control blood sugar levels) use was documented and blood sugar monitoring was performed as ordered for 1 of 5 residents (Resident 45). Residents Affected - Few These failures had the potential to negatively impact Resident 45's blood sugar control and monitoring. Findings: During a review of Resident 45's electronic medical record titled, Medication Administration Record, (or MAR, a legal drug chart where nurse documented medications administration), dated 11/2023, the MAR indicated a doctor's medication order for blood sugar monitoring and to give insulin when indicated per parameters three times a day. Further review of Resident 45's MAR indicated the insulin was not documented with corresponding blood sugar measurements on 11/4/23 at 6:30 a.m., 11/10/23 at 6:30 a.m., and 11/14/23 at 6:30 a.m. During a review of Resident 45's medical record titled, Weights & Vitals, (a document where blood sugar monitoring is documented) dated 11/2023, the record indicated, blood sugar measurement was not documented on 11/4/23 at 6:30 a.m., 11/10/23 at 6:30 a.m., and 11/14/23 at 6:30 a.m. In a concurrent interview and record review on 11/29/23, at 3:30 p.m., with the Clinical Liaison (CL) at Nursing station [NAME] 1, the CL confirmed insulin use and blood sugar measurements were not documented for Resident 45 on 11/4/23 at 6:30 a.m., 11/10/23 at 6:30 a.m., and 11/14/23 at 6:30 a.m. During a review of the facility's policy titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner .If a drug is withheld, refused, or a given time .the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones . 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 12/01/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a psychotropic (mind-altering drug) medication called lorazepam (or Ativan, an [NAME]-anxiety medication) ordered for PRN (means as needed) use had a duration and clear direction for use in 1 out of 18 sampled residents (Resident 2). This failure could result in unsafe medication use and contribute to medication error. Findings: During a review of Resident 2's medical record titled, Medication Administration Record, (or MAR, a document that listed orders for medication and nursing care), dated 11/2023, the MAR indicated the following orders: Lorazepam Oral Tablet 0.5 MG .(or Ativan, an anxiety treatment medication; MG is milligram, a unit of measure); Give 1 tablet by mouth every 6 hours as needed for moderate anxiety and restlessness .-Start Date- 10/27/23. Lorazepam Oral Tablet 0.5 MG .; Give 1 tablet by mouth every 2 hours as needed for Severe Terminal agitation Titrate (means increase dosage) tabs 25% -100% (% is fraction of 100) every 2 hrs (Hours) PRN (as needed) for severe terminal agitation only to a max (maximum) of 4mg per dose. -Start Date-10/27/23. Further review of the electronic medical record, under Orders (means doctor's orders), on 11/28/23, the orders indicated Resident 2 had been ordered lorazepam on and off for 15 days to 1 month duration since 5/19/23. The most recent order started on 10/27/23 with no duration of use, no explanation on difference between moderate and severe anxiety and how the dose titration should have been managed by nursing staff. In an interview with the facility's Clinical Liaison (CL) on 11/29/23, at 3:36 PM, at the [NAME] nursing station, the CL stated this order was being clarified for duration of use and the clarification of dose adjustments. The CL stated, the hospice doctor had ordered the drug and was administered a few times last month. In a telephone interview with the facility's Consultant Pharmacist (CP) on 11/30/23, at 11:49 AM, the CP stated the PRN orders for psychotropic medication without duration should have been questioned by the pharmacy. The CP stated the facility should have clarified the order. In an interview with the Interim Director of Nursing (IDON), on 11/30/23, at 1:30 PM, the IDON stated the new medication orders should be reviewed by both a nurse taking the order and charge nurse for completeness, safety and meeting the resident's needs. Review of the facility's policy titled, Medication Monitoring and Management, dated 10/2019, the policy indicated when a resident received a new medication, the medication order is evaluated for the following: The dose, route of administration, duration and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer specification for use. (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 12/01/2023 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 Review of the facility's policy titled, Psychotropic Medication Use, dated 7/2022, the policy indicated Psychotropic medication are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition .PRN orders for psychotropic medications are limited to 14 days .If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Residents Affected - Few 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 12/01/2023 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, and record review, the facility failed to ensure safe medication storage practices in one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stores resident's medication and supplies) with a census of 57 when: 1. One emergency kit (or Ekit- a box that stored medication for emergency use) was opened and unsealed with no documentation of its use, 2. The medication refrigerator was frosted when medications sensitive to freezing were stored in proximity, 3. Extra supplies were placed under the sink-based cabinet in the medication storage room, 4. Staff's personal belongings were stored in the active medication storage room; and, 5. Expired (outdated) supplies and medications were stored in medication carts and hazardous liquid (medication that may pose health risk upon direct exposure to the skin and body during handling) medication was not safely labeled as hazardous. These unsafe medication storage practices could contribute to medication errors and unsafe medication use. Findings: During a concurrent observation and interview on [DATE], at 9:12 a.m., in the facility's East station medication room with Licensed Nurse (LN) 4, the following were noted and acknowledged by LN 4 as follows: 1. A black container marked as IV (intravenous injections into veins) Ekit containing two injectable medication boxes, was opened, and not sealed. Further review of the opened Ekit indicated two injectable antibiotic (Vancomycin and Rocephin- medicines that fight infections caused by bacteria) medications were missing. Furthermore, review of the Ekit log sheet indicated there was no documentation when those missing medicines were removed and who they were removed for. LN 4 confirmed the findings and stated the Ekits should have been resealed after opening and should have been documented in the removal log sheet. LN 4 further stated the staff who opened the Ekit should have notified the pharmacy for a replacement Ekit. 2. The medication refrigerator had excessive frosting on the top where the insulin pens (injectable medication to control blood sugar in a pen like form) were stored. LN 4 acknowledged the insulin pens should not have been exposed to frost and could affect the effectiveness of the insulin. 3. The cabinet underneath the sink was used to store sanitizing soap and gel supplies, and an ice chest for specimens. LN 4 confirmed there was a water stain and white spillage at the base of the cabinet. LN 4 acknowledged the supplies should not have been underneath the sink as it could be a (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 12/01/2023 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 source of contamination. Level of Harm - Minimal harm or potential for actual harm 4. Three black bags containing personal belongings of facility staff were placed on the opened black box E-kits in the active medication storage room. LN 4 acknowledged the personal belongings should not be stored in the medication storage room. Residents Affected - Few 5a. During a concurrent interview and inspection of the facility's East station medication cart on [DATE], at 9:48 a.m., with LN 4, the following were acknowledged by LN 4: i. One opened box containing two bottles of eye drop medication called Latanoprost (or Xalatan, eye drops for eye disease) was open and had no open date on the box or bottles. LN 4 confirmed there was no open date on the box and one of the bottles was unopened. The manufacturer's label and pharmacy label on the box indicated, .Store unopened bottle under refrigeration .opened bottle may be stored at room temperature .discard opened bottle after 6 weeks . ii. An undated and unopened insulin Lantus (insulin- medication to treat diabetes or blood sugar) pen was not refrigerated. LN 4 confirmed it should have been in the refrigerator for long term storage, not in the medication cart. iii. Megestrol liquid (or Megace- hormonal therapy drug used to treat cancer and used to help with appetite) was not stored safely in a zip lock bag and was not labeled as hazardous. 5b. During a concurrent interview and inspection of 1 [NAME] medication cart, on [DATE], at 12:08 p.m., the following were acknowledged by LN 1: i. A bottle of glucometer (a device for measuring blood sugar) test strips (supply used to test the blood for blood sugar) was not dated with an open date and a used by date in the West-1 medication cart. The manufacturer's label on the bottle indicated, Use within 90 days (3 months) of first opening. ii. A box of inhalation medication called Ipratropium and albuterol (or DuoNeb- a combination of two drugs in one used to treat breathing difficulty) were not dated when foil wrap was opened. The manufacturer's label on the package indicated, use within 2 weeks of removing from foil pouch. During an interview on [DATE], at 1:03 p.m., with the Interim Director of Nursing (IDON) in her office, the IDON stated staff's personal belongings should not be stored in the medication storage room. The IDON stated there should be no supplies stored under the sink cabinet due to risk of leak and contamination. The IDON stated the Ekits should have been resealed after opening and communicated to pharmacy for replacement. The IDON further stated, she was not able to figure out who opened the Ekits, when they were opened and who they were opened for. During a review of the facility's policy and procedure (P&P) titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, updated [DATE], indicated, .After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. An entry is made in the emergency logbook containing all required information .The nurse records the medication use from the emergency kit on the medication order/use form and calls the pharmacy for replacement of the kit/dose and /or flags the kit with a color-coded lock to indicate need for replacement of kit/dose as soon as possible after the medication has been administered . (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 12/01/2023 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 During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, updated [DATE], indicated, .Medications and biologicals are stored safely, securely, and properly .Medication storage areas are kept clean .and free of clutter . The P&P further indicated, Outdated, contaminated .are immediately removed from stock, disposed of according to procedures for medication .Medication storage conditions are monitored on monthly basis by the consultant pharmacist and corrective action taken if problems are identified. During a review of the facility's P&P titled, HAZARDOUS DRUGS, updated [DATE], indicated, .Facility Handling of Hazardous Drugs (HD) .HDs must be handled under conditions that promote patient and employee safety and environmental protection . 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 12/01/2023 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 Residents Affected - Many 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 maintain a kitchen free of potential hazards for food borne illnesses (nausea, vomiting, and diarrhea) for 55 residents who received and ate food from the kitchen when: 1. Perishable food items in the kitchen were not properly labeled; and, 2. The inside of the ice machine contained a black like substance. These failures had the potential to result in food borne illnesses for 55 of the residents who ate food from the kitchen. Findings: 1. During a concurrent observation and interview on 11/27/23, at 8:30 AM, with the Dietary Supervisor (DS), the large freezer was observed to have the following items without a use by date labeled on the food packages: cheese omelets (24 count), donuts (24 count), hamburger patties (6 count), and garlic (1/4 bag). The DS verified the listed food items were not labeled with a use by date. The DS stated there should have been an open date and a use by date on all opened food packages to ensure expired food items were not eaten, which could lead to the residents contracting a food borne illness. During a concurrent observation and interview on 11/27/23, at 8:35 AM, with the DS, the dry storage area was observed with the following food items that did not contain a use by date label on the packages: cake mix (1/4 bag), bag of pasta (5-pound bag), and gravy mix (1/4 bag). The DS verified there was no use by date label on the listed food items and stated, the food items should all have a use by date label. During a concurrent observation and interview on 11/27/23, at 8:40 AM, with the DS, a five pound (unit of weight) jar of peanut butter was observed to be opened with no open date or use by date label on the container. The DS verified there was no open date or use by date label and stated, the peanut butter should have been properly labeled to ensure expired foods were not served to the residents. During an interview on 11/28/23, at 9:55 AM, with the [NAME] (Cook), the [NAME] stated the expectation of labeling opened food items was, once a food package had been opened, the packaging needed to have an opened date and use by date labeled on the outside of the package, according to manufacturer's guidelines. The [NAME] stated without an opened and use by date label, there would be a potential for the residents to be served expired food, which could lead to food borne illnesses. During a concurrent interview and record review on 11/28/23, with the Registered Dietitian (RD), the Policy and Procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2020, was reviewed. The P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. PROCEDURE .Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . The RD stated when food packages were opened, there needed to be an opened date and a use by date to prevent the consumption of expired foods. The RD stated the P&P was not followed. (continued on next page) 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 12/01/2023 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 Residents Affected - Many 2. During a concurrent observation and interview on 11/28/23, at 9:28 AM, with the Maintenance Supervisor (MS), the facility's ice machine's (located in the kitchen) external lid was opened and dark black splotches were observed along the entire bottom of the interior ice cube making portion of the machine. The MS stated the black substance in the ice machine appeared to be black mold and the machine needed to be cleaned. The MS stated the ice machine should be clean at all times to prevent residents from getting sick from contaminated ice. During an interview on 11/28/23, at 9:53 AM, with the DS, current photos of the internal portion of the ice machine (taken on 11/28/23) were reviewed. The photos depicted dark black splotches along the entire bottom of the interior ice cube making portion of the machine. The DS stated the black substance in the ice machine appeared to be black mold. The DS stated it was important to maintain a clean ice machine to protect the residents from gastrointestinal illnesses (nausea, vomiting, and diarrhea). The DS stated the ice machine should not ever be dirty. During an interview on 11/28/23, at 3:41 PM, with the RD, current photos of the internal portion if the ice machine (taken on 11/28/23) were reviewed. The RD stated it appeared like there was black mold on the inside of the ice machine. The RD stated a contaminated ice machine had the potential to result in residents getting sick after consuming the ice. During an interview on 11/30/23 at 9:04 AM, with the MS, the MS stated a service technician from [COMPANY NAME], inspected the ice machine on 11/28/23 and the technician's inspection indicated, the ice machine was dirty because the internal ice machine pump needed to be removed and cleaned. The MS stated, he had not been pulling out the pump during the monthly cleanings. During a concurrent interview and record review on 11/28/23, at 10:45 AM, with the DS and MS, the ice machine handbook titled, [MANUFACTURE NAME] .Service Manual, dated 7/03, was reviewed. The manual indicated, .Interior Cleaning and Sanitizing GENERAL You are responsible for maintaining the ice machine in accordance with the instructions in this manual .Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . The MS stated, the facility did not consult a qualified service company to test the water to find out why the machine was dirty after one month of being cleaned. The MS and DS verified, the service manual guidelines for cleaning and sanitizing the ice machine was not followed. 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 12/01/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, and record review, the facility failed to maintain an accurate and complete medical record for 3 of 18 sampled residents (Resident 11, Resident 19, and Resident 165) when: Residents Affected - Some 1. Resident 11 and Resident 19's COVID immunization records was not readily available in their medical record, 2. Resident 165's Interdisciplinary (IDT- a care team consisting of different disciplines) care conference record was inaccurate and incomplete; and, 3. Resident 165's speech screening evaluation was not available in his record. This failures resulted in an incomplete and inaccurate medical documentation for Resident 11, Resident 19, and Resident 165. Findings: 1. A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility in June 2023. A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility the beginning of November 2023. Further review of Resident 11's medical records indicated Resident 11 had no immunization for COVID on file. Further review of Resident 19's medical record indicated Resident 19 had no immunization for COVID on file. During a concurrent interview and record review on 11/30/23, at 12:31 p.m., with the Infection Preventionist (IP), Resident 11 and Resident 19's clinical records were reviewed. The IP confirmed Resident 11 and Resident 19's clinical records had no COVID immunization on file and should be. The IP stated she kept track of current residents' COVID immunization on a document titled, Resident Covid-19 Vaccination Log. The IP confirmed Resident 11 and Resident 19's Covid vaccination was on the log and should have been transferred to the resident's electronic medical record. The IP stated she was the only one who had access to the log. During an interview on 11/30/23, at 3:19 p.m., with the Interim Director of Nursing (IDON), the IDON stated she expected staff to document accurately in the residents' medical record. A review of the facility's policy titled, HEALTH INFORMATION RECORD MANUAL .GENERAL RECORD POLICIES, revised date 9/18/18, the policy indicated, .Clinical records, electronic and/or manual, will be kept for each resident admitted for care .All clinical information regarding a resident's stay will be centralized in the clinical record .Records will be .Maintained in a permanent form, computerized .Reviewed periodically for currency and completion .readily available upon the request of the attending physician, facility staff, or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request . (continued on next page) 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 12/01/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident 165's IDT care conference meeting (IDT team members meet together with resident/family to share information and updates, collaborate to solve problems, and develop and update resident's care plan) dated 11/21/23, indicated the IDT care conference team meeting was conducted on 11/22/23 with Resident 165's family member. Further review of Resident 165's IDT care conference indicated the activities section was completed on 11/21/23, the social services section was completed on 11/29/23 and the nursing section was blank. During a concurrent interview and record review on 11/30/23, at 9:31 a.m., with the Assistant Director of Nursing (ADON), Resident 165's IDT care conference record was reviewed. The ADON stated Resident 165 had an IDT care conference on 11/22/23. The ADON verified the nursing section of Resident 165's IDT care conference was blank and the social services section was completed on 11/29/23, 8 days later. The ADON stated it was not acceptable, she could not tell who attended the meeting from the nursing department, what was discussed and what were the expectations. The ADON stated the IDT care conference record should be complete and accurate to reflect what was discussed, otherwise the care would not be done. During an interview on 11/30/23, at 9:40 a.m., the Director of Staff Development (DSD) stated she attended Resident 165's care conference on behalf of the nursing department on 11/22/23. The DSD stated she did not have her laptop with her during the meeting and had not been able to enter the meeting notes in Resident 165's record yet. During a concurrent interview and record review on 11/30/23, at 9:53 a.m., the Social Services Director (SSD) stated Resident 165's IDT care conference was held on 11/22/23 at 12:30 p.m. with Resident 165's family member. The SSD stated Resident 165 was not present during the meeting due to a health condition. The SSD stated the IDT care conference notes were supposed to be entered right away in the resident record. The SSD stated she should have entered her notes for Resident 165's IDT care conference right away because it was mandatory. It was also to ensure a resident's record was complete, so that other departments and staff also knew what was discussed and being done. During an interview on 11/30/23, at 12:11 p.m., the Activities Director (AD) stated she did her individual department assessment with Resident 165 on 11/21/23, a day before the IDT care conference meeting. The AD stated she did not attend Resident 165's IDT care conference meeting on 11/22/23 and entered her notes in Resident 165's IDT care conference meeting record from an assessment that she did a day before. 3. During an interview on 11/30/23, at 10:14 a.m., the Registered Dietitian (RD) stated she attended Resident 165's IDT care conference meeting on 11/22/23. The RD stated she mentioned during the meeting that Resident 165 needed to be seen by the speech therapist (ST) to evaluate if oral feedings were appropriate for him. The RD stated the rehabilitation department was also present during the meeting who would have followed up with the ST. During an interview on 11/30/23, at 11:44 a.m., the Director of Rehabilitation (DOR) stated she was not present during Resident 165's IDT care conference meeting on 11/22/23. The DOR stated she met with Resident 165 the same day after the meeting, did her own care conference with Resident 165 and entered her notes in Resident 165's IDT care conference record. The DOR stated she was not informed that Resident 165 needed to be seen by the ST. During a concurrent interview and record review on 11/30/23, at 2:41 p.m., the DOR stated the ST screened Resident 165 on 11/20/23, but the ST had not entered her notes in Resident 165's record. The (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 12/01/2023 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 0842 DOR stated the ST just entered her notes today in Resident 165's record and it was a late entry. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/23, at 2:46 p.m., the Interim Director of Nursing (IDON) stated IDT team members needed to be present during the IDT care conference meetings. The IDON further stated the purpose of an IDT care conference meeting was to provide continuity of care; if all team members did not attend the meeting then possibly the resident would not have continuity of care. The IDON explained a meeting with a resident for individual department assessments was separate than an IDT care conference meeting. The IDON stated staff entering data under an IDT care conference meeting without attending the IDT care conference was not acceptable. The IDON further stated the IDT care conference documentation was not accurate. The IDON explained individual department assessment notes should be documented in a progress note and not in the IDT care conference notes. The IDON stated staff should document their notes when they attended the IDT care conference as soon as possible within the same day, no later than the day of the meeting. The IDT stated the ST notes should be documented promptly and be available in the resident's record. The IDON further stated residents' records should be complete and accurate. The IDON stated inaccurate and incomplete records could affect resident care. Residents Affected - Some A review of the facility's policy titled, HEALTH INFORMATION RECORD MANUAL .GENERAL RECORD POLICIES, revised date 9/18/18, the policy indicated, .Clinical records, electronic and/or manual, will be kept for each resident admitted for care .All clinical information regarding a resident's stay will be centralized in the clinical record .Records will be .Maintained in a permanent form, computerized .Reviewed periodically for currency and completion .readily available upon the request of the attending physician, facility staff, or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request . Review of a facility policy titled HEALTH INFORMATION RECORD MANUAL DOCUMENTATION GUIDELINES revised 2/11/19, indciated .Promptly record as the events or observations occur; complete, concise, descriptive, factual, and accurately describe services provided to/for the resident .Never document before an event/observation/action occurs .Entries must be dated, and time recorded (as required) by the individual making the observation/providing the service, and as applicable, written in chronological sequence. Where the note or entry is not (and should be) in sequence, then entry must be identified as late entry for .or other explanation that will stand up to independent review . 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 12/01/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility's quality assessment and assurance (QAA) committee failed to meet quarterly with all the required members, when the Interim Director of Nursing (IDON) did not attend the second and third quarter meetings for the year of 2023. Residents Affected - Few This failure had the potential for quality care improvement activities not to be evaluated and revised as needed with a possible decline in residents' quality of care. Findings: During a concurrent interview and record review on 11/30/23, at 3:49 p.m., the Administrator (ADM) stated the facility's QAA committee met monthly for Quality Assurance and Performance Improvement (QAPI: a data driven and proactive approach to quality improvement) meetings rather than required quarterly to have closure view of areas needed improvement. The ADM stated the facility's QAA committee members included Medical Director (MD), ADM, IDON, Infection Preventionist (IP), Director of Staff Development (DSD), Minimum Data Set (MDS) nurse, Rehabilitation Department, Dietary Department. Facility's QAPI meetings sign-in sheets were reviewed with the ADM. The ADM verified the IDON did not attend monthly QAPI meetings on 3/23/23, 5/18/23, 6/15/23, 7/27/23, 8/17/23 and 9/14/23. The ADM stated the expectation was to have the IDON attend the QAPI meeting at least quarterly. The ADM stated the IDON gave input in QAPI meetings, followed through with the nursing plans, and oversaw the nurses. During an interview on 11/30/23, at 5:24 p.m., the ADM stated he did not have the QAPI meeting sign in sheet for the month of April 2023. The ADM verified the IDON did not attend the QAPI meetings for the second and third quarter. Review of an undated facility document titled QA & A Committee Information indicated, 1. Administrator .2. Director of Nursing - [name of the IDON] .Meetings are held on a monthly basis for QA . Review of the facility policy titled SNF [Skilled Nursing Facility] Quality Assurance Performance Improvement QAPI Plan revised 7/31/23, indicated, .our purpose is to provide excellent quality care to the residents we serve .Our QAPI committee consists of a chairperson and seven subcommittees with representation from administration, the medical director, nursing .Our QAPI Program is Chaired by the Administrator Our seven subcommittee's each has a chairperson who leads the committee and assigns indicators to members on a monthly basis. Subcommittees 1. Resident Choice .This subcommittee meets monthly to review the Resident Choice to view potentially deficient practices, identify trends, and develop a plan of correction to be implemented to ensure substantial compliance. Current Resident Choice subcommittee members: Chairperson [name of the IDON] DON .2. Quality of Life .This subcommittee meets monthly to review the Quality of Life dashboard to identify potentially deficient practices, identify trends and develop a plan of correction to be implemented to ensure substantial compliance. Current Quality of Life subcommittee members: Chairperson [name of the IDON] DON .3. Clinical Care .This subcommittee meets monthly along with the Medical Director to review the Clinical Care dashboard to identify potentially deficient practices and identify trends to develop a plan of correction to be implemented to ensure substantial compliance. Additionally, the subcommittee monitors existing QI[Quality Improvement]/QM[Quality Management] results, internal monitors for falls, medication errors, pressure ulcers, incident reports, infection reports, and any other concerns. Current Clinical Care subcommittee members: Chairperson [name of the IDON] DON .5. Facility Standards .This subcommittee meets monthly to review the Facility Standards dashboard .Current Facility Standards subcommittee (continued on next page) 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 12/01/2023 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 0868 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete members: Chairperson [name of the IDON] DON .6. Surveys addresses Resident Satisfaction Surveys .This subcommittee meets monthly .Current Surveys Subcommittee members .[name of the IDON] DON .7. Audits addresses critical areas of medical records and other documentation .This subcommittee meets monthly to review the audits . Current Audit subcommittee members .[name of the IDON] DON .The Administrator, Director of Nursing and Medical Director are responsible and accountable for developing, leading, and closely monitoring the QAPI program . 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 12/01/2023 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 infection prevention measures were followed for a census of 57 when: Residents Affected - Few 1. The shared glucometer (a device used to measure blood sugar) and blood pressure devices (or BP, Blood Pressure, measures the pressure of blood pushing against the walls of arteries) were not cleaned and sanitized in-between resident care based on manufacturer recommendation and standards of practice; and, 2. Hand hygiene was not performed in-between resident care during the medication administration task. These failures could pose health safety risks and spread of infection in the facility. Findings: 1a. During an observation with Licensed Nurse (LN) 1, in West-2 hallway, on 11/27/23, at 11:26 AM, LN 1 gathered the blood sugar supplies including a glucometer with a lancet device (spike needle) and entered Resident 43's room. LN 1 spiked Resident 43's right thumb finger to get blood and then soaked the test strip (a disposable testing strip that helped with blood sugar measurement) attached to glucometer with blood to get the blood sugar reading. After exiting the room, LN 1 placed the glucometer on top of the mobile medication cart. LN 1 with bare hands used one wipe (purple top Super Sani-Cloth disposable wipe) to quickly clean the outer surface of the glucometer and left it on top of the cart. LN 1 then proceeded to administer Insulin (blood sugar medicine shot) with a pen shape injection device. LN 1 did not sanitize the outer surface of insulin pen after use and returned it to the cart. 1b. During an observation with LN 1, in West-2 hallway, on 11/27/23, at 11:42 AM, LN 1 gathered the blood sugar supplies including a glucometer previously used, with lancet device and entered Resident 38's room. LN 1 poked Resident 38's finger to get blood and then soaked the test strip attached to glucometer with blood to get the blood sugar reading. After exiting the room, LN 1 with bare hands, used one wipe (purple top Super Sani-Cloth disposable wipe) to quickly clean the outer surface of the glucometer and left it on top of the cart. LN 1 then proceeded to administer Insulin (blood sugar medicine shot) with a pen shape injection device. LN 1 did not sanitize the outer surface of insulin pen after use and returned it to the cart. 1c. During an observation with LN 1, in [NAME] hallway, on 11/27/23, at 11:50 AM, LN 1 gathered the blood sugar supplies including a glucometer, with lancet device and entered Resident 46's room. With gloved hand, LN 1 poked Resident 46's finger to get blood and then soaked the test strip attached to glucometer with blood to get the blood sugar reading. After exiting the room, LN 1 with bare hands, used one wipe (purple top Super Sani-Cloth disposable wipe) to quickly clean the outer surface of the glucometer and left it on top of the cart. LN 1 then proceeded to administer Insulin (blood sugar medicine shot) with a pen shape injection device. LN 1 did not sanitize the outer surface of insulin pen after use and returned it to the cart. 1d. During a medication administration observation, with LN 3, in the East hallway, on 11/27/23, at 8:27 AM, LN 3 used a wrist size blood pressure device (device had a cuff that wrapped around the wrist and was attached to a digital display screen that showed the blood pressure readings) to measure (continued on next page) 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 12/01/2023 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 the Resident 40's blood pressure. After leaving the room, the BP device was not cleaned. Level of Harm - Minimal harm or potential for actual harm 1e. During a medication administration observation, with LN 3, in the East hallway, on 11/27/23, at 8:59 AM, LN 3 used the same wrist size blood pressure device to measure the Resident 263's blood pressure. After leaving the room, the BP device was not cleaned. Residents Affected - Few 2a. During a medication administration observation, with LN 3, in the East hallway, on 11/27/23, at 8:59 AM, LN 3 did not sanitize her hands when entering and exiting Resident 40's room. 2b. During a medication administration observation, with LN 3, in the East hallway, on 11/27/23, at 8:52 AM, LN 3 did not sanitize her hands when entering and exiting Resident 22's room. In an interview with LN 3 on 11/28/23, at 10:55 AM, at [NAME] nursing station, LN 3 stated she realized that she should have used the facility provided BP device for its accuracy. LN 3 stated she would have washed her hands if soiled or after providing care to 2-3 residents but using hand sanitizer before and after entering the rooms was important and she may have missed it during resident care. In an interview with Infection Prevention (IP) nurse on 11/28/23, at 11:07 AM, at [NAME] Nursing station, the IP nurse stated she expected the nursing staff to use hand sanitizer gel before and after entering the resident's rooms and to wash their hands with soap and water after providing care to the third resident. The IP nurse stated to clean the glucometer in-between resident care, the nurse with a gloved hand should have used the facility provided sanitizer wipe and allow it to be wet for 2 minutes. The IP nurse stated if an infectious diarrhea called C. diff. (or Clostridioides difficile, a highly contagious type of bug that causes diarrhea) was suspected, the nurse should use a bleach-soaked wipe to clean shared devices in-between resident care to prevent spread of the germs. The IP nurse stated, currently the facility did not stock any bleach wipes as their supply was outdated. The IP nurse acknowledged that they need to re-educate the staff on proper two step cleaning and sanitizing of the shared patient care devices including the glucometer. In an interview with the Interim Director of Nursing (IDON), in her office, on 11/28/23, at 1:30 PM, the IDON stated she expected the nursing staff to sanitize their hands before entering a resident's room and clean their hands again once exiting the room either with alcohol sanitizer or washing hands with soap and water. The IDON stated the nursing staff should have used the facility provided BP cuff that measured the blood pressure manually as it was more accurate, in addition to sanitizing them thoroughly in-between resident use. The IDON added that the shared glucometer should have been cleaned and sanitized using facility provided wipes and allowed for 2 minutes of wet time to kill germs. The IDON acknowledged that using a bleach wipe would have eliminated the infectious C. diff. bug and it was a preferred prevention method. Review of the facility's policy, titled Handwashing/Hand Hygiene, dated 8/2019, the policy indicated Wash hands with soap .and water .when hands are visibly soiled .Use an alcohol-based hand rub .for the following situations: Before and after direct contact with residents, before preparing or handling medications .after removing gloves . Review of the facility's policy, titled Cleaning and Disinfecting of Resident-Care Items and Equipment, dated 10/2018, the policy indicated Resident care equipment including reusable items .will be cleaned and disinfected according to current CDC (or Center for Disease Control, a federal agency) recommendations for disinfection . The policy further indicated Reusable items are cleaned and disinfected .between residents . (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 12/01/2023 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 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy, located in a binder on each medication cart, titled Cleaning and Disinfecting Assurance Platinum Glucose Meter, (a brand name for glucometer) the policy indicated to use a disinfectant with bleach and the glucose (sugar) meter (glucometer) needs to be cleaned and disinfected after each use. Cleaning can be accomplished by wiping the meter .Disinfecting can be accomplished with .disinfectant with bleach. Residents Affected - Few Review of the facility's approved disinfectant wipe, labeled as Super Sani-Cloth Germicidal Disposable Wipe, with a purple color top, the label indicated When using this product, wear disposable protective gloves .cleaning procedure: All blood .must be thoroughly cleaned from surfaces before disinfection by the germicidal wipe. Open, unfold and use first germicidal wipe to remove visible soil .Use second germicidal wipe to thoroughly wet surface. Allow to remain wet two (2) minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555186 If continuation sheet Page 40 of 40