Health inspection·June 10, 2021

F 0803 Residents 31, 1, 556, 357, 52, 356, 506, 55, and 508 were on the first 2 carts served in the kitchen. Level of Harm - Minimal harm or potential for actual harm During a review of the Resident Listing Report printed on 6/7/2021, showed that four of the residents were on mechanical soft ground diets (Resident #31, 1, 556, 357), one resident was on mechanical soft chopped diet (Resident #52), two residents were on cut meat diets (Resident #356, 506), and two residents were on pureed diets (Resident #55, 508). Residents Affected - Some During an interview with KS on 6/9/21 at 9:43 a.m., KS confirmed [NAME] 1 used the wrong scoop sizes for the ham for the lunch meal service on 6/7/21. During an interview with RD 1 on 6/9/21 at 10:11 a.m., RD 1 stated she expects kitchen staff to follow the menu. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 2 of 6 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 observations, interviews, and facility document review, the facility failed to ensure food and ice were stored and served, and dishes and utensils were cleaned according to standards for food service safety when: 1. An ice machine was not kept in a sanitary condition putting residents at risk for foodborne illness. 2. A kitchen aid had long painted fingernails with no gloves while handling uncovered plates of food during meal service. 3. A potentially hazardous food capable of supporting bacterial growth associated with foodborne illness was not logged for proper cool down. 4. Dish machine water temperatures were low on several occasions. These failures had the potential to cause the growth of microorganisms and foodborne illness in a medically vulnerable resident population who consumed food at the facility. The facility census was 58. Findings: 1. During an observation on 6/8/21 at 10:53 a.m. of the ice machine in the kitchen in the presence of the Maintenance Supervisor (MS). MS removed the cover of the ice machine. Surveyor noted a pink substance along the bottom edge of grate where ice is formed and was able to wipe it off with a white paper towel. During a concurrent interview with MS, MS confirmed and acknowledged the pink substance and stated it was almost time to clean the ice machine again since the last cleaning was on 5/15/21 and he cleans it on a monthly basis. MS stated in the summer the ice machine seemed to look like this by the time he cleaned it; however, in the winter, it does not happen as quickly. During a review of the previous five months of the facility document titled VHHC Condensing Coil Log, indicated Ice machine cleaned per manufacturer recommendations on the following dates 1/29/21, 2/21/21, 3/19/21, 4/9/21, and 5/14/21. During a review of facility provided document titled How to Clean a Manitowoc Ice machine dated 1/9/14, indicated It is recommended that you clean and sanitize your ice machine at least every 6 months, however must be done on an as needed basis. 2. During an observation of the lunch meal service on 6/7/21 starting at 11:51 a.m. in the presence of Registered Dietitian 1 (RD 1), Food Service Worker 1 (FSW 1) called out diet orders while [NAME] 1 plated the meals. [NAME] 1 handed uncovered plated meals to FSW 1 and FSW 1 placed dome covers over the meals and plastic covers on soups, mashed potatoes, and gravy in bowls. FSW 1 put the meals on the trays and then on the carts for delivery to residents. FSW 1 had long purple painted fingernails and was not wearing gloves for the entire lunch meal service. During an interview with Kitchen Supervisor (KS) on 6/9/21 starting at 9:18 a.m., in the presence of RD 1 and RD 2, KS stated kitchen staff should not have artificial nails. KS further stated FSW 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 3 of 6 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 is new and had not gone over all orientation paperwork yet. KS stated new staff usually go over orientation paperwork in the first few days after hire and FSW 1 was hired on 5/17/21. KS confirmed she should have done orientation paperwork with FSW 1 within the first couple days of starting work. Review of facility document titled Employee Sanitary Practices, undated, indicated fingernails should be clean and neat and fingernail polish can get into food and therefore painted fingernails are not allowed. Review of facility document titled Food and Nutrition Services - Dress Code Policy, undated, indicated the following guidelines shall be used for proper safe food handling, storage, and preparation .no false nails, fingernail tips or fingernail polish. Review of facility document titled New Employee Orientation Checklist, undated, indicated under Proper Hygiene and Uniform Protocol .No nail polish. According to the Food and Drug Association (FDA) Food Code under section 2-302.11 Personal Cleanliness: (A) Food employees shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. 3. On 6/7/21 starting at 8:58 a.m., during the initial tour of the kitchen, an observation of a container of chicken soup in the walk-in refrigerator dated 6/4 and use by 6/7. During an interview on 06/07/21 at 3:07 p.m., [NAME] 2 stated that soups are cooled down and written on a log. During a review of facility document, titled Cooling Down Foods - Tracking Chart, indicated Date: 6/4; Food: Chicken Noodle; Start Time and Temperature: 1:30 210°; After 1 hour: no time 120°; the remaining lines were blank: After 2 hours, 135°Farenheit (F) to 70°F in 2 hours?, After 3 hours, After 4 hours, 70°F to 41°F in 4 hours?, Corrective actions?, Employee, and Verified by manager. 4. During a concurrent observation and interview with FSW 2 on 6/8/21 starting at 8:33 a.m., FSW 2 was using the dish machine to wash dishes. FSW 2 stated he checks the dish machine temperatures at start up and was looking for wash temperatures between 110°F and 140°F. FSW 2 then ran dishes through the dish machine; the wash temperature was 110°F on the thermometer on the machine. During an interview on 06/09/21 at 9:18 a.m. with KS, in presence of RD 1 and RD 2, KS stated the wash temperature for a low temperature dish machine should be 120°F or 110°F. KS stated she was not sure and would have to look it up. After looking up the temperature, KS stated the wash temperature should be 120°F. During a concurrent review of facility document titled Dish machine Temperature Log (Low Temperature Machine) dated June 2021, KS stated she checks the log daily but acknowledged several low wash temperatures. KS stated she thought the wash temperature should be 110°F so did not catch the low temperatures on the log. KS stated she would look at the logs differently from then on and look for 120°F for wash temperatures. KS further stated FSW 2 needs to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 4 of 6 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 re-educated on proper wash temperatures for the dish machine. Level of Harm - Minimal harm or potential for actual harm Review of the data plate (manufacturer's specifications affixed to the dish machine outlining requirements for proper functioning) titled NSF Machine Operational Requirements as Manufactured by CMA Dish machines, revealed Wash temperatures minimum 120°F, recommended 140°. Residents Affected - Many Review of facility document titled Dishmachine Temperature Log (Low Temperature Machine) dated April 2021, showed 26 out of 90 wash temperatures were below 120°F. Review of facility document titled Dishmachine Temperature Log (Low Temperature Machine) dated May 2021, showed 40 out of 93 wash temperatures were below 120°F. Review of facility document titled Dishmachine Temperature Log (Low Temperature Machine) dated June 2021, showed 14 out of 25 wash temperatures were below 120°F. The bottom of each of the three Dishmachine Temperature Logs read NOTE: Report a wash temperature less than 120 degrees F and/or PPM below 50 to CDM (Certified Dietary Manager i.e. Kitchen supervisor). Review of facility document titled In-Service Training Report Dietary Staff, #7 Dishwasher and Three Compartment Sink, dated 7/24/20, showed FSW 2 did not attend this in-service. The document attached to the In-Service Training Report titled Dietary Competency Program: In-services, Dietary Competency: In-Service #7 Dishwasher and Three-Compartment Sink, undated, indicated the minimum wash and rinse temperatures for a low temperature dishwasher is 120°F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 5 of 6 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 555220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Hills Health Center 290 Heather Court Templeton, CA 93465 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and review of facility documents, the facility failed to ensure the walk-in freezer was maintained in safe operating condition when ice was built up in the freezer. Residents Affected - Few Findings: During an observation on 6/7/21 starting at 8:58 a.m., during the initial tour of the kitchen, surveyors noted ice build-up in the walk-in freezer on the vent above the door, in the door frame, and dripping from a pipe inside the freezer near the ceiling. On 06/08/21 03:08 p.m. ice build-up observed in same areas of walk-in freezer and when surveyors pointed it out to [NAME] 2, [NAME] 2 stated he was not aware of the ice in the walk in freezer and had not noticed it until surveyors pointed it out. On 06/08/21 03:10 p.m. during an interview with RD 1, she stated she was not sure how often the ice build-up occurs in the freezer but that it happens from time to time. During an interview on 06/09/21 at 9:18 a.m. with Kitchen Supervisor (KS), in presence of Registered Dietitian 1 (RD 1) and Registered Dietitian 2 (RD 2), KS indicated ice can build up in the freezer during defrost mode. KS confirmed ice on vent is not okay and would need to notify maintenance. During an interview on 06/09/21 at 10:40 AM with Maintenance supervisor (MS) 1 in the walk-in freezer, MS stated he had not seen the ice before and that the heater above door for the vent was probably broken. He indicated the ice on the pipe meant the pipe needs to be reinsulated. During a review of Dietary Maintenance binder showed no request for repair for ice build-up in the walk-in freezer, and that the last entry was for repair of cart wheels on 5/28/21. During a review of the facility document titled Preventative Maintenance Program dated 1/22/08, indicated the goals of the preventative maintenance program are accomplished by detecting and correcting minor defects before they develop into serious problems and performing the services necessary to prevent undue wear and subsequent breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555220 If continuation sheet Page 6 of 6