Health inspection·January 23, 2026

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interview and record review on 1/22/26 at 11:30 a.m. with Minimum Data Set Coordinator (MDSC), Resident 10's medication orders were reviewed. The MDSC stated, Resident 10's psychotropic medication order was incomplete and monitoring was incomplete. The MDSC stated the monitoring of behavior should have been started when the medication was started. The MDSC stated it was her responsibility and other licensed nurses to ensure monitoring was started when psychotropic medications are prescribed. During an interview on 1/23/26 at 10:50 a.m. with the Director of Nursing (DON), the DON stated her expectation was to ensure behavior monitoring was in place when starting resident on psychotropic medication. The DON stated behavior monitoring was important in order to evaluate if medications are working and to track episodes residents are having. The DON stated the licensed nurse receiving the order was responsible in ensuring there was a behavior monitoring started. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, Revision date 2/25, the P&P indicated, .Psychotropic medication is any medication that affects brain activity associated mental processes and behavior . Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: a. determining adequate indications for use; . c. adequate monitoring for efficacy and adverse consequences . Documentation must include that behavioral [non-pharmacological] interventions were attempted . Diagnosis alone does not necessarily warrant the use of psychotropic medication . Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records . Event ID: Facility ID: 555244 If continuation sheet Page 2 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 2) when Resident 2 did not have a care plan for a diagnosis of dementia (a progressive state of decline in mental abilities).This failure placed Resident 2 at risk for harm by not identifying and monitoring signs and symptoms and care of resident with dementia. During a concurrent observation and interview on 1/20/26 at 10:15 a.m. during initial tour in Resident 2's room, Resident 2 was observed sitting at the edge of her bed, oxygen concentrator (medical device that takes in the air around you, removes impurities (mostly nitrogen), and delivers purified, high-concentration oxygen to breath) at bedside with nasal cannula (flexible tube with two small prongs placed just inside the nostrils to deliver supplemental oxygen) placed in a plastic bag. Resident 2 stated she did not have any complaints.During a review of Resident 2's admission Record [AR- a document containing resident profile information], dated 1/22/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder (a mental illness that is can affect thoughts, mood, and behavior), and bipolar disorder (mental health condition causing extreme shifts in mood, energy, and activity levels, swinging between intense highs (mania or hypomania) and deep lows (depression -persistently sad, empty, or hopelessness).During a review of Resident 2's Minimum Data Set (MSA- a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 2's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit. 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 2 had no cognitive deficit.During a concurrent interview and record review on 1/22/26 at 9:38 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's clinical record was reviewed. LVN 1 stated she was familiar with Resident 2's care. LVN 1 stated Resident 2 has a diagnosis of dementia. LVN 1 stated she did not find a care plan initiated to care for Resident 2's diagnosis of dementia. LVN 1 stated it was the responsibility of licensed nurses to make sure care plan was initiated for resident's diagnosis.During a concurrent interview and record review on 1/22/26 at 11:10 a.m. with Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 2's clinical record. The MDSC stated Resident 2 had a diagnosis of dementia since admission on [DATE]. MDSC stated she did not find a care plan for dementia and a care plan should have been initiated when Resident 2 was admitted to the facility. The MDSC stated she was responsible in ensuring care plan was initiated for Resident 2's diagnosis of dementia. The MDSC stated Resident 2 had other care plans but were not focused on dementia. The MDSC stated, Care plan should be focused on the diagnosis of dementia in order to care for Resident 2's behaviors. The MDSC stated a care plan was important for facility staff to care for Resident 2.During an interview on 1/23/26 at 10:55 a.m. with the Director of Nursing (DON), the DON stated her expectation and the expectation of department heads was for licensed nurses are responsible in developing their own care plan. The DON stated, Care plan was important so everyone can follow residents plan of care. The DON stated care plans should be individualized and specific to resident needs. The DON stated the MDSC was responsible in ensuring there were care plans for resident diagnosis's when completing MDS assessments. The DON stated if the MDS encounters a missing care plan the MDS would create care plans when needed. During a review of facility's document titled, Charge Nurse Job Description, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 3 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dated 2003 the Job Description indicated, . Completing medical forms, reports, evaluations, studies, charting .Review care plans daily to ensure that appropriate care is being rendered. Inform the Nurse Supervisor of any changes that need to be made on the care plan . Review resident care plans for appropriate resident goals, problems approaches, and revisions based on nursing needs .During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered. Revision date: 3/22, the P&P indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being . Event ID: Facility ID: 555244 If continuation sheet Page 4 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain professional standards of practice for one of six sampled residents (Resident 48) when Resident 48's physician's orders had directions to give a total dosage of 150 milligrams (mg- a unit of measurement) of clozapine (medication used for reducing hallucinations, delusions, and risk of suicide) when Resident 48 was prescribed 175 mg.This failure had the potential to cause Resident 48 to receive less medication than what was prescribed.Findings:During a review of Resident 48's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/22/26, the AR indicated Resident 48 was admitted on [DATE] with diagnoses which included: schizoaffective disorder, bipolar type ( a mental health condition where a person has symptoms of psychosis [hallucinations and delusions] and strong mood changes like mania [very high energy] and depression [extreme sadness]) and anxiety disorder (mental health conditions characterized by excessive, persistent fear and worry about everyday situations). During a concurrent interview and record review on 01/23/26 at 8:37 a.m. with Registered Nurse (RN) 2, Resident 48's Order Summary Report, dated 1/23/26 was reviewed. The Order Summary Report, indicated Resident 48 had three orders for clozapine to add up to a total of 175 mg. Resident 48's clozapine orders were the following: clozapine oral tablet 100 mg, clozapine oral tablet 25 mg, and clozapine oral tablet 50 mg all three clozapine tablets were to add up to a total of 175 mg. The summary on the 50 mg order indicated, . Give 1 tablet by mouth two times a day for SCHIZOEFFECTIVE DISORDER, BIPOLAR TYPE to be given with 50 mg tablet total dose 150 mg . RN 2 stated the summary in the order stated the total medication should add up to 150 mg when Resident 48 was supposed to be on 175 mg. RN 1 stated this could be confusing to a new nurse or one unfamiliar with the actual order and could lead to potentially giving Resident 48 more than his prescribed dosage of medication.During a concurrent observation and interview on 1/23/26 at 9:17 a.m. Resident 48's clozapine medication blister packs were reviewed. RN 2 stated Resident 48's blister pack should have contained an orange sticker on top of them to ensure nurses were aware of a medication order change. RN 1 stated Resident 48 had his dosage of clozapine increased from 150 mg to 175 mg on 1/14/26 and nurses needed to double check the order to make sure Resident 48 did not receive the wrong dose of medicine.During an interview on 1/23/26 at 11:15 a.m. with the Director of Nursing (DON), the DON stated all the dosage information listed in the resident's medication orders should match. Matching the dosage information with the summary helped eliminate the chance for potential medication administration errors.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2/25, the P&P indicated . psychotropic medication management is an interdisciplinary process involves the resident, family, and /or the representative and includes: . b. establishing appropriate dose . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 5 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: 5Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure residents who were not able to carry out activities of daily living (ADLs- routine tasks/activities a person perform daily to care for themselves) were provided assistance to maintain personal hygiene and grooming for two of five sampled residents (Resident 4 and 56) when Resident 4 and Resident 56 had fingernails that were long, jagged and had colored particles under their fingernails.These failures resulted in poor personal hygiene and had the potential to result in serious health condition for Resident 4 and Resident 56. During a concurrent observation and interview on 1/20/26 at 10:45 a.m. during initial tour in Resident 56s room, Resident 56 was observed lying in bed with the TV on. Resident stated she had been in the facility since 2001 and had no issues or concerns. Resident 56 fingernails were observed and appeared long, jagged and with some discolored particles under the nails. Resident stated she did not remember the last time her fingernails were trimmed and stated she did not mind the long nails as long as they had smooth edges. During a review of Resident 56's admission Record [AR-a document containing resident profile information], dated 1/23/26, the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and anxiety (feeling of worry, nervousness, or unease about an imminent event or something with an uncertain outcome, triggering the body's stress response). During a review of Resident 56's Minimum Data Set (MDS-a federally mandated resident assessment tool) assessment dated [DATE]. The MDS indicated, Resident 56's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 56 had no cognitive deficit. During concurrent observation and interview on 1/20/26 at 10:58 a.m. during initial tour in Resident 4's room, Resident 4 was observed lying in bed watching TV. Resident 4 stated he had been in the facility for a long time. Resident 4's was observed with long and jagged fingernails with dark colored particles under the nails. Resident 4 stated he did not like having long nails because he always scratched self especially during shower and he was afraid he will develop an infection. Resident 4 stated he did not remember the last time his fingernails were cut or trimmed. Resident 4 stated he was not sure how many times a week were to provide nail care. Resident 4 stated he was wearing a sling on his left arm because he had a stroke and it affected his left side. Resident 4 stated he was not able to move his left side. During a review of Resident 4's AR dated 1/22/26, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness or incomplete paralysis on one side), Diabetes Mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Resident 4's MDS assessment dated [DATE], the MDS indicated, Resident 4's BIMS-assessment score was 15 out of 15 indicating Resident 4 had no cognitive deficit. During a concurrent observation and interview on 1/22/26 at 9:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 checked Resident 56 and Resident 4's fingernails. CNA 1 stated Resident 56 fingernails are long with jagged edges. CNA 1 stated Resident 56 had refused care including nail care. CNA 1 stated Resident 56 fingernails should at least been filed and reported to licensed nurse when she refused nail care. CNA 1 stated Resident 4 is diabetic, and his fingernails are long, dirty, with rough edges and needed to be trimmed. CNA 1 stated licensed nurses provide nail care to diabetic residents and CNAs Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 6 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete perform nail care to non-diabetic residents. CNA 1 stated long jagged fingernails were not safe because Residents' 56 and 4 could scratch themselves which could lead to infection. CNA 1 stated she did not know why Resident 4 and Resident 56's fingernails were not trimmed because nail care is scheduled on resident's shower days and every Sunday. During a concurrent interview and record review on 1/22/26 at 9:48 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated nail care is scheduled every Sunday. LVN 1 stated she was familiar with Resident 4 and Resident 56 and stated Resident 4 is diabetic and sometimes refused nail care. LVN 1 reviewed Resident 4's care plan and stated she did not find a care plan indicating Resident 4 refusing care. LVN 1 stated she did not remember any CNAs' reporting long fingernails for Resident 4 and Resident 56's and that they needed to be trimmed. LVN 1 stated she did not remember checking their fingernails and whether they needed to be trimmed or filed. LVN 1 stated long fingernails could lead to residents scratching themselves creating breaks in the skin and if not treated could lead to infection. LVN 1 stated fingernails should be kept clean, trimmed, and filed. During an interview on 1/23/26 at 10:58 a.m. with the Director of Nursing (DON), the DON stated her expectation was to make sure CNAs are checking resident's fingernails on their shower days. The DON stated the CNAs complete a shower form of their observations and give to the licensed nurse for her signature. The form is then filed in a binder. The DON stated licensed nurses are responsible for taking care of diabetic residents nails. The DON stated fingernails or nail care are also scheduled every Sunday since there are no scheduled showers. The DON stated her expectation was to ensure all residents' nails are clean, trimmed and filed because residents could scratch themselves with their long and dirty nails which could lead to infection. During a review of facility document titled, Job Description: Certified Nursing Assistants, dated 2003, the Job Description indicated, . Participate in and receive the nursing report upon reporting for duty .Assist residents with bath functions .Assist resident with nail care(i.e., clipping, trimming, and cleaning the finger/toenails) .During a review of facility document titled, Job Description: Charge Nurse, dated 2003, the Job Description indicated, .Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas . Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect .During a review of facility policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated 2001, the P&P indicated, . Nail care includes regular cleaning and trimming. Proper nail care can aid in the prevention of skin problems around the nail bed .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Documentation . If the resident refused the treatment, the reason(s) why and the intervention taken . Reporting: Notify the supervisor if the resident refuses the care . Event ID: Facility ID: 555244 If continuation sheet Page 7 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for five of nine sampled residents (Residents 7, 8, 52, 63, and 92) when the Controlled Substance Record (CSR) and the Controlled Drug Record (CDR) (a mandatory document used for tracking drugs from the moment they arrive at a facility until they are given to a patient or destroyed, acting as a security measure to prevent theft or misuse) were not completed by the Licensed Nurses upon receipt from the pharmacy.These failures had the potential to result in compromised resident safety including medication errors and drug diversion (the illegal transfer of prescription drugs-especially controlled substances from their intended legal recipient to someone else for personal use or sale).During a review of Resident 7's admission Records (AR) dated January 23, 2026, the AR indicated, Resident 7 was admitted on [DATE] and had a diagnosis of chronic pain. During a review of Resident 7's Order Summary Report (OSR) dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .HYDROcodone-Acetaminophen [a medication prescribed for moderate to severe pain] Oral Tablet 5-325 MG [milligram - unit of measurement] (Hydrocodone-Acetaminophen) Give 1 tablet via G-Tube [a small tube placed directly into the stomach through a small, surgical opening in the belly that acts as a direct, alternative route to deliver formula, liquids, and medication directly to the stomach] every 6 hours as needed for chronic pain. HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet via G-Tube two times a day for chronic pain.During a concurrent interview and record review on 1/22/26 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 1, Residents 7's CDR, (undated) was reviewed. The CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. LVN 1 stated it was important to fill out and sign the CDR, so medication could be tracked and to minimize the risk of diversion. LVN 1 stated the record should be filled out with the nurses first name, last name, signature, title, and date.During a review of Resident 8's AR dated January 23, 2026, the AR indicated, Resident 8 was admitted on [DATE] and had a diagnosis of Pain in the left hip. During a review of Resident 8's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 0.5 ml by mouth every 3 hours as needed for Severe Pain .During a concurrent interview and record review on 1/22/26 at 3:02 p.m. with LVN 1, Residents 8's CSR, (undated) was reviewed. The CSR did not indicate the received date, received time, or the nurses signature. LVN 1 stated the record should have been filled out with the nurses' first name, last name, signature, title, and date.During a review of Resident 52's AR dated January 23, 2026, the AR indicated, Resident 52 was admitted on [DATE] and had a diagnosis of low back pain and other chronic pain. During a review of Resident 52's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .traMADol [a medication prescribed for moderate to moderately severe pain] HCL [hydrochloride - salt] Oral Tablet 50 MG (Tramadol HCL) Give 1 tablet by mouth two times a day for pain.During a concurrent interview and record review on 1/22/26 at 3:05 p.m. with LVN 1, Residents 52's CDR, (undated) was reviewed. The CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. LVN 1 stated the record should have been filled out with the nurses first name, last name, signature, title, and date.During a review of Resident 63's AR dated January 23, 2026, the AR indicated, Resident 63 was admitted on [DATE] and had a diagnosis of other chronic pain. During a review of Resident 63's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .Morphine Sulfate [a medication prescribed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 8 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 Residents Affected - Many for severe pain] (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 3 hours as needed for severe pain .traMADol HCL Oral Tablet 100 MG (Tramadol HCL) Give 1 tablet by mouth two times a day for for chronic pain. During a concurrent interview and record review on 1/22/26 at 3:08 p.m. with LVN 1, Residents 63's CSR, (undated) was reviewed. The CSR did not indicate the received date, received time, or the nurses signature. Resident 63's CDR, (undated) did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. LVN 1 stated the record should have been filled out with the nurses' first name, last name, signature, title, and date.During a review of Resident 92's AR dated January 23, 2026, the AR indicated, Resident 92 was admitted on [DATE] and had a diagnosis of other chronic pain, muscle wasting and atrophy [waste away], not elsewhere classified, unspecified site, and Hypopituitarism [when a gland at the base of the brain does not produce enough hormone]. During a review of Resident 92's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .Testosterone Cyplonate Solution [hormone replacement] 200 MG/ML [mililiter - unit of measurement] inject 1 ML intramuscularly [given into the muscle] one time a day every 3 month(s) starting on the 17th for 1 day(s) for Hormone replacement therapy .During a concurrent interview and record review on 1/22/26 at 3:10 p.m. with LVN 1, Residents 92's CSR, (undated) was reviewed. The CSR did not indicate the start quantity, number of CC (cubic centimeter - unit of measure) remaining, received date, received time, or the nurses signature. LVN 1 stated the record should have been filled out with the nurses first name, last name, signature, title, and date. LVN 1 stated the record was not filled out and does not have the start quantity, or signature on the document. During a concurrent interview and record review on 1/23/26 at 2:02 p.m. with the Director of Nursing (DON), Resident 92, 63, 52, 8, and 7's Controlled Substance Record/ Controlled Drug Record, (undated) were reviewed. Resident 92's CSR did not indicate the start quantity, number of CC (unit of measure) remaining, received date, received time, or the nurses signature. The DON validated the CSR was not filled out and had no starting amount, initial of nurse receiving it, and no date on the record. DON stated the CSR needed to have the date, time, and signature on it. Resident 63's CSR did not indicate the received date, received time, or the nurses signature. Resident 63's CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. The DON validated the CSR and CDR should have been signed by the receiving nurse. Resident 52's CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. The DON validated the CDR should have been signed by the receiving nurse. Resident 8's CSR did not indicate the received date, received time, or the nurses signature. DON validated the CSR should have been signed by the receiving nurse. Resident 7's CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. DON validated the CDR should have been signed by the receiving nurse. The DON validated that the process when receiving medications from pharmacy was to document when they received the narcotics on a log and place the count sheet (CDR/CSR) in the count book. The DON validated the CDR/CSR was required and should be signed, dated, and initialed to ensure medications that come into the facility are accounted for because of the potential for drug diversion.During a concurrent interview and record review on 1/23/26 at 2:07 p.m. with the DON, the facility's policy and procedure (P&P) titled, Controlled Substances, dated November 2022, was reviewed. The P&P indicated, . Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substance together. Both individuals sign the designated controlled substance record.This record contains. quantity received. number on hand. date and time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 9 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 received. signature of person receiving medication.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The DON stated the facility's policy was not followed if the date, time, and signature was not filled out on the CDR/CSR. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 10 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 store and prepare food in accordance with professional standards for food service safety when:A pot with food and debris in it was stored in the clean area.A black bean veggie patty bag with one patty in it, in the walk-in freezer, was open and undated.The walk-in freezer fan had ice buildup on it. A plastic container in the walk-in refrigerator with sliced pink fruit inside was unlabeled and undated. A box of mushrooms and a box of celery was open and exposed to air in the walk-in refrigerator.Mushrooms and white liquid were observed on the walk-in refrigerator floor.The sanitizer spray bottle used for cleaning food countertops, contained water in it instead of the sanitizer. These failures had the potential to cause cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for 90 of the 97 residents that consumed food from the kitchen.1. During a concurrent observation and interview on 1/20/26 at 10:40 a.m. with the Certified Dietary Manager (CDM) in the kitchen, a pot was observed stored upright with white and brown debris inside, in the food prep area. CDM stated the area was a clean area and was used to store clean pots. During an interview on 1/23/26 at 10:20 a.m. with the CDM stated the pot with white and brown debris inside appeared to have grease and food debris inside of it. CDM stated if the pot was stored in the food prep area it should be clean. CDM stated the pot should've been clean and maintained as such. CDM stated the general best practice was food contact areas on pots are stored inverted/face down to prevent possible contamination (the presence of unwanted, harmful, or impure substances in or on a material making it unsafe or unsuitable for use). During an interview on 1/23/26 at 11:50 a.m. with the Registered Dietician (RD), RD stated the pot with white and brown debris inside appeared to have food particles in it and was dirty. RD stated the pots should be stored inverted/face down to avoid getting anything inside that could contaminate it. 2. During an observation on 1/20/26 at 10:21 a.m. in the kitchen walk-in freezer, a black bean veggie (non-meat) patty was in an open plastic bag. The plastic bag was not labeled with an open date or expiration date. During an interview on 1/23/26 at 10:05 a.m. with the CDM, CDM stated it appeared the veggie patty bag was open with one burger in the bag. CDM stated his expectation was that when food was opened, there should have been an open and use by date on the package of the burger patties. CDM stated there was no open date or use by date on the bag. CDM stated it was important for open dates to be on the packages so that staff adequately rotated the food in a manner that everything opened got used first. CDM stated his expectation was to have an open date on the package/bag of the item because once the package/bag is open, it is good for a certain amount of time. CDM stated dating food items when they were opened was important because it ensured residents were given in-date quality food and ensured meals being provided to the residents were safe.During an interview on 1/23/26 at 11:35 a.m. with the RD, RD stated the opened bag had one black bean burger was not dated. RD stated the bag needed to be labeled with an opened and used by date to prevent cross-contamination and food-borne illness. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the Refrigerators and Freezers P&P indicated, .All food is appropriately dated to ensure proper rotation by expiration dates. Use by dates are completed with expiration dates on all prepared food in refrigerators. use by dates are indicated once food is opened. Supervisors inspect refrigerators and freezers monthly for.fan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 11 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 condition.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, (undated), the Food Receiving and Storage P&P indicated, .Refrigerated/Frozen Storage. All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date) .Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. 3. During an observation on 1/20/26 at 10:22 a.m. in the kitchen walk-in freezer, the walk-in freezer fan was observed with ice buildup on it. During an interview on 1/23/26 at 9:50 a.m. with the CDM, CDM stated he saw ice buildup on the bottom of the unit and on the fan in the walk-in freezer. CDM stated the ice buildup could cause freezer burn on the food and could diminish the food quality. CDM stated his expectation was that there be a minimal amount of ice on the unit so that it did not interfere with the function of the unit. CDM stated that to his personal standards, he would want to remove the ice buildup on the unit that was currently on the walk-in freezer fan. During a concurrent interview and record review on 1/23/26 at 9:54 a.m. with the CDM, the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022 was reviewed. The P&P indicated, .Supervisors inspect refrigerators and freezers monthly for gasket conditions, fan conditions, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed.Refrigerator and freezer are kept clean, free of debris. The CDM stated that when inspecting the fan condition as stated in the P&P, he checked that there was no excessive ice buildup in freezer, it was running smoothly, and there were no unusual noises coming from the unit. CDM stated, having no ice buildup on the unit was important for the unit to continue to run efficiently and maintain appropriate temperatures. CDM stated the accumulation of ice could get on the food.During an interview on 1/23/26 at 11:30 a.m. with the RD, RD stated the ice buildup on the walk-in freezer was under and around the fan. RD stated if the ice buildup thawed, the water liquid could meet items stored in the freezer and could cause cross-contamination and food-borne illness.4. During an observation on 1/20/26 at 10:25 a.m. in the kitchen walk-in refrigerator, the walk-in refrigerator had a metal rack with an unlabeled and undated plastic container containing sliced pink fruit. During an interview on 1/23/26 at 10:59 a.m. with the CDM, CDM stated the pink fruit that was in the unlabeled undated plastic container was watermelon that had been cut the night before [Monday 1/19/26] on the evening shift for lunch dessert Tuesday [1/20/26]. CDM stated all food items should be labeled. CDM stated, once food is put into another container for use, it should be labeled with the date that it is made, use by date, and the employees initials. CDM stated it was important to label and put expiration dates on food items for quality and to ensure food does not sit in the refrigerator for a time that would make it unsafe.During an interview on 1/23/26 at 11:17 a.m. with the RD, RD stated the plastic container containing watermelon in the walk-in refrigerator was not labeled. RD stated, the cook missed the labeling of the food. RD stated her expectation was that all food needed to be labeled and dated. RD stated it was important to label and date food items to identify the food, identify when the food was made, and to determine when the food should be discarded if not used. RD stated they would not want to use expired food items that could lead to food-borne illness. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the P&P indicated, .All food is appropriately dated to ensure proper rotation by expiration dates. Use by dates are completed with expiration dates on all prepared food in refrigerators. use by dates are indicated once food is opened.Supervisors inspect refrigerators and freezers monthly for.fan condition.During a review of the facility's P&P titled, Food Receiving and Storage, (undated), the P&P indicated, .Refrigerated/Frozen Storage.All foods stored in the refrigerator or freezer are covered, labeled, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 12 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 and dated ( use by date).Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded .5. During an observation on 1/20/26 at 10:24 a.m. inside the walk-in refrigerator, a metal rack had an one open uncovered box containing mushrooms and one open uncovered box containing celery. During an interview on 1/23/26 at 10:50 a.m. with the CDM, CDM stated, the walk -in refrigerator had an open box of mushrooms and celery. CDM stated, the mushrooms and celery were delivered in the manufacturer's original packaging. CDM stated, most food items were stored in the manufacturer's box. CDM stated, the celery box needed to be closed, and the mushroom box kept open for good air flow. CDM stated, I would bring up the idea to the corporate team, I think it is better for the mushrooms. CDM stated, all food items should be covered to prevent contamination. CDM stated, the facility's policy and procedures said all food should be covered.During an interview on 1/23/26 at 11:27 a.m. with the RD, RD stated mushroom and celery box were opened and not covered. RD stated, all foods should be covered and stored properly to prevent cross contamination, food borne illnesses and potential harm to anyone who eats it. During a review of the facility's policy and procedure (P&P) titled, Food receiving and Storage, dated 2001, the P&P indicated, .All foods stored in the refrigerator or freezer are covered. 6. During an observation on 1/20/26 at 10:27 a.m., inside the walk-in refrigerator, a couple of mushroom slices and a white liquid residue consistent with milk were on the floor. During an interview on 1/23/26 at 9:57 a.m. with CDM, CDM stated, milk drippings and couple of mushrooms were observed on the floor inside the walk-in refrigerator. CDM stated, the floor appeared unclean but did not believe it would cause harm. CDM stated, mushrooms were served Monday [1/19/26] night. CDM stated, all kitchen staff were responsible for maintaining cleanliness. CDM stated, nothing should be on the floor. I would expect them to be cleaned up at the end of the night when they were served, and the next day. During an interview on 1/23/26 at 11:20 a.m. with RD, RD stated, Cleanliness of the freezer, everyone is responsible. RD stated, a white liquid spill, which may be milk and a couple of slices of mushrooms, were on the floor inside the walk-in refrigerator. RD stated, her expectation was for staff to clean it right away. RD stated, it is a safety issue, and we don't want to contaminate anything else. During a review of the facility's P&P titled, Refrigerators and Freezers, dated November 2022, the P&P indicated, .Refrigerators and freezers are kept clean, free of debris.7. During a concurrent observation and interview on 1/21/26 at 8:35 a.m. with Dietary Aid (DA), in the kitchen, the DA tested the sanitizer sprayer bottle used for cleaning countertops with a sanitizer test strip (a little paper strip that changes color to tell how acidic or alkaline something is) by spraying liquid from the bottle unto the test strip and the test result was zero. DA stated, zero meant the sanitizer sprayer bottle did not have enough sanitizer. DA stated, maybe its water, if you don't let the water run long enough, the sanitizer won't come out. DA stated the test result should have been at 400 parts per million (ppm- unit of measurement), not zero. DA stated, the sanitizer sprayer bottle was refilled in the sink and water needed to run for 30 seconds to a minute, then it should be tested to check the result to make sure it worked properly. DA stated the test result should be between 200 - 400 ppm. DA stated, someone could get sick if surfaces were not properly sanitized and became contaminated. During an interview on 1/23/26 at 10:41 a.m. with CDM, CDM stated, the manufacturer-recommended sanitizer was used to wipe down food-prep countertops. CDM stated, everyone in the kitchen was responsible for cleaning them after use, after food preparation or when visibly soiled. CDM stated, the kitchen staff must test the water from the dispenser at the faucet. CDM stated, water pressure can fluctuate throughout the day. CDM stated test results were normally 200 ppm and not zero. CDM stated, the acceptable range of sanitizer was 150-400 ppm. CDM stated, the task may have been overlooked from the previous night. CDM stated the kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 13 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 FORM CMS-2567 (02/99) Previous Versions Obsolete staff were required to empty and refill the sanitizer sprayer bottle at the beginning of each shift. CDM stated, it was not acceptable for the food countertops to be improperly sanitized. CDM stated, if food countertops were not properly sanitized, food could be unsafe, and residents who were served unsafe food could develop foodborne illnesses. During an interview on 1/23/26 at 11:51 a.m. with RD, RD stated kitchen staff used a manufacturer-recommended sanitizer and test strips to ensure countertops were properly sanitized. RD stated, the sanitizer should be maintained at 200-400 ppm per manufacturer guidelines. RD stated 200 to 400 ppm was important for effectively reducing microbes and bacteria on surfaces to prevent food-borne illnesses. RD stated if the sanitizer test strip result was zero, the kitchen staff need to recheck the sanitizer. During a review of the manufacturer's guidelines titled, [brand name of sanitizer], undated, the manufacturer's guidelines indicated, .The solution's broad efficacy range of 150-400 ppm stays within proper range longer. Event ID: Facility ID: 555244 If continuation sheet Page 14 of 15 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 555244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301 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 record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when:The food preparation sink did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 2.The ice machine that supplies ice to the residents in the facility did not have an air gap. These failures had the potential to contaminate food sources for 90 of 97 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death.Findings:1. During a concurrent observation and interview on 1/20/26 at 3:05 p.m. with the Dietary Manager (DM) in the kitchen, the food prep sink was piped directly into the wall. On the floor, under the food prep sink there was a drain without any piping going to it. The DM stated they were not using an air gap and the pipe from the food prep table went directly into the city sewer.During an interview on 1/23/26 at 1:54 p.m. with Maintenance Director (MD), MD stated there was no air gap in the food prep sink and it should not be like that. MD stated the backflow could get into the food and could cause infection or food borne illness when no airgap was utilized.During an interview on 1/23/26 at 11:17 a.m. with Registered Dietician (RD), RD stated, Food prep sink has no air gap is an oversight and we have an old building. RD stated, We know there is supposed to be airgap. RD stated if there is a back flow, it could potentially cause food borne illnesses.2.During a concurrent observation and interview on 1/20/26 at 2:56 p.m. with the DM, in the breakroom, the ice machine was observed with the hose hanging over the rim of the drain passing below the level of the floor. DM stated the ice machine drainpipe was sitting past the threshold of the floor. DM stated the ice machine in the breakroom was the only ice machine of the facility. DM stated there was no air gap for the ice machine.During an interview on 1/23/26 at 11:17 a.m. with RD, RD stated the ice machine drainpipe was below the floor and needed to be above the floor. RD stated it should be one and a half to two inches above to prevent back flow. RD stated the piping should not ever be below the floor. RD stated when the piping went past the floor, there was potential for backflow and food borne illnesses.During an interview on 1/23/26 at 1:52 p.m. with MD, the MD stated the ice machine drainpipe was sitting level with the drain on the floor. MD stated there should be an air gap at least two times the size of the pipe. MD stated with no air gap there was a potential for backflow problems and possibility for causing infectious diseases to residents.During a review of the facility's policy and procedure (P&P) titled, Drainage Air Gap Policy, dated March 8, 2019, the P&P indicated, .This policy outlines our policy on the air gap requirement for drains in all areas of the facility .All air gaps (the distance between the button of the pipe and the drain it flows into),must be twice (2 times) the diameter of the pipe. The distance between the pipe and the top of drain is defined as an air gap .The purpose of this air gap is to allow for proper space in the case of the drain backing up, the soiled water will not re-enter the drainpipe and result in unsanitary conditions.This policy applies to all on ice machines, dish machines, floor drains under sinks, etc. to include any drain is seen in which a pipe if flowing to.If at any time a drain is seen to be not meeting regulation, action steps of notifying the maintenance director and administrator should occur.Maintenance Director is responsible for ensuring drain meet the regulations. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555244 If continuation sheet Page 15 of 15