Health inspection·August 3, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure the resident needs and preferences were accommodated for four of 25 sampled residents (Resident 14, Resident 23, Resident 13, and Resident 51), when: Residents Affected - Some 1. Resident 14 did not receive bottled water and food requests; 2. Resident 23 did not receive food requests and an adaptive device; and 3. Resident 13 and Resident 51's call light buttons were found on the floor out of their reach. These failures had the potential to result in the residents not attaining their unmet needs, not maintaining their highest practicable physical, emotional and psychosocial well-being, as well the potential to result in compromised resident safety. Findings: 1. Resident 14 was admitted to the facility in the middle of 2016 with diagnoses which included stroke, acid reflux disease, and difficulty swallowing. During a review of Resident 14's Nursing Care Plan (NCP) dated 4/27/17, the NCP indicated, [Resident 14] exhibits excessive demands .Anticipate and meet [Resident 14's] needs. During a review of Resident 14's Order Summary Report (OSR) dated 8/15/19, the OSR indicated, Regular diet. During a review of Resident 14's Minimum Data Set (MDS, an assessment tool), dated 6/20/23, the MDS indicated Resident 14 had no memory impairment, was independent with eating and no problem with swallowing. During a concurrent observation and interview on 7/31/23 at 10:15 a.m., Resident 14 sat in a wheelchair, alert and awake, verbally responsive, and stated, I'm not getting what I order and my requests. I order my preferences, and on the menu, I make choices about what kinds I want and I choose what I like and then they don't give it to me .I also don't get bottled water as I requested for a while. They said they ran out since Saturday .Right now, we're not getting any bottled water. I don't like the pitcher of water. I told them I need bottled water and they know I want it .When you're close to [AGE] years old, you are not supposed to be treated like this. During an interview on 7/31/23 at 10:25 a.m. with Licensed Nurse 5 (LN 5), LN 5 stated, If she requested something like bottled water, she should get it. LN 5 verified there was no bottled water in the room, and stated, In her case, she has been requesting for bottled water. The last time we checked, the kitchen was out of the bottled water. I checked yesterday because I was here yesterday and there was none .Most of the time she gets the bottled water. Resident 14 stated, There has not been any bottled water since Saturday. During an interview on 7/31/23 at 11:25 a.m. with Family Member 1 (FM 1) and Resident 14, FM 1 stated, If you request something, they have to accommodate what your requests are, like the bottled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 2 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 0558 water. Resident 14 stated, I want that bottled water and the other food requests which they're not providing. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/31/23 at 12:08 p.m. with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated, [Resident 14] is very alert and oriented and she is able to make her needs known .She had requested bottled water every meal. Right now, I think the kitchen ran out of bottled water. I don't see a problem on how fast can the kitchen go and buy bottled water at the convenience store. Residents Affected - Some During a concurrent observation and interview on 7/31/23 at 12:13 p.m., Resident 14 was having lunch in her room, appeared upset, and stated, I didn't get the garlic bread I requested .I don't know what's going on. Resident 14 indicated she circled the 'garlic bread' in the menu sheet she was provided before meals. The resident stated, I don't have the garlic bread. [LN 5] is aware and acknowledged it but she never said anything and never came back. During a concurrent observation and interview on 7/31/23 at 12:37 p.m. with the Restorative Nursing Aide 1 (RNA 1), RNA 1 confirmed Resident 14 circled garlic bread in the menu sheet and none was found on the meal tray, and stated, I know [LN 5] was aware of the issue .I don't think she went to get the garlic bread. During an interview on 8/1/23 at 8:45 a.m. with the Social Services Manager (SSM), the SSM stated, In terms of mood and emotional stability, [Resident 14's] orientation is intact. She wouldn't be saying something that's made up .I'll just take what she tells because she's very alert and oriented. Her needs and requests should be accommodated to maintain her emotional and psychosocial well-being. During an interview on 8/3/23 at 7:40 a.m. with the Administrator (ADM), the ADM stated, [Resident 14] is very alert and oriented and there are specific ways the staff provides care .If the regular CNA knows already what the resident wants, there is no problem. 2. Resident 23 was admitted to the facility early 2020 with diagnoses which included difficulty swallowing, facial nerve pain, and tremors. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had no memory impairment and needed supervision with eating. During a concurrent observation and interview on 7/31/23 at 12:28 p.m., Resident 23 had lunch in her room, alert and verbally responsive, and stated, They did not give me what I wanted. I thought I had ginger chicken because that's what I circled in the menu sheet .but there is no ginger chicken .I don't know what the problem is. This morning I had no cream in my coffee. They have not given any bottled water for three days now. I asked for the bottled water and they told me they don't have any. I've been drinking bottled water and when I specifically asked them for a bottled water, they gave me a glass of water .I don't even have a sippy cup. During a concurrent observation and interview on 7/31/23 at 12:32 p.m. with CNA 2, CNA 2 verified there was no bottled water on the Resident 23's meal tray, and stated, She doesn't have one because they're out of bottled water .Everyone has been asking for a creamer and there is no creamer either. Resident 23's meal card indicated, Adaptive Equip: Sippy cups with handles. CNA 2 verified there was no sippy cup provided for Resident 23, and stated, There should be a sippy cup because she has some shakiness when she's drinking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 3 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 8/1/23 at 8:21 a.m. with RNA 2, Resident 23 sat in her wheelchair having breakfast, alert and verbally responsive. RNA 2 entered the room, and stated, I had to get her the sippy cup because if she does not have the double handed cup, she would spill the coffee. During an interview on 8/2/23 at 12:38 p.m. with LN 2, LN 2 stated, [Resident 23's] chief complaint is the pain in her face .She is alert and oriented times four (person, time, place and situation). 3. Resident 13 was admitted to the facility in the summer of 2019 with diagnoses which included malignant cancer and comfort care. During a concurrent observation and interview on 7/31/23, at 10:34 a.m. with Director or Nursing (DON), the DON confirmed the call light device was on the floor next to the bed of Resident 13. The DON indicated the call light should be within reach of Resident 13 at all times. Resident 51 was admitted to the facility in the fall of 2022 with diagnoses which included amyotrophic lateral sclerosis (a nervous system disease that affects nerve cells in the brain and spinal cord, causing loss of muscle control) and quadriplegia (both arms and legs not working). During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 was able to think and reason. During a concurrent observation and interview on 7/31/23, at 9:53 a.m., with the DON, the DON came to Resident 51's bedside and confirmed the call light device was out of Resident 51's reach, and stated, [Resident 51] uses a blow light [a device that the resident blows into to turn on the call light]. The DON stated the call light device should be within reach of Resident 51 at all times. During a review of Resident 51's NCP dated 10/4/22, the NCP indicated, [Resident 51] uses a blow-in call light .and the resident is totally dependent. During a review of an undated facility's policy and procedure (P&P) titled, Call Light System, the P&P indicated, Each resident will have their call light system within reach at all times. During a review of the facility's P&P titled, Quality of Life - Accommodation of Needs, revised 3/09, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning .including the need for adaptive devices. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 4 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - Some 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** Based on interview and record review, the facility failed to develop and implement comprehensive care plan for two out of 25 sampled residents (Resident 41 and Resident 53), when: 1. Resident 41's communication care plan intervention was not implemented; and 2. Resident 53's care plan did not include interventions to monitor for side effects of an anticoagulation (blood thinner) medication. These failure had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 41 was admitted in the middle of 2020 with diagnoses which included anxiety, depression, right hip pain, and difficulty walking. During a review of Resident 41's Nursing Care Plan (NCP), dated 6/2/20, the NCP indicated, [Resident 41] has a communication problem r/t [related to] Language barrier. She speaks Spanish .Spanish communication sheets placed at bedside. During a review of Resident 41's Minimum Data Set (MDS, an assessment tool), dated 5/4/23, the MDS indicated Resident 41 had mild memory impairment, spoke the Spanish language and needed an interpreter to communicate, and required extensive assistance with activities of daily living (ADLs). During a concurrent observation and interview on 7/31/23 at 9:58 a.m., Resident 41 sat in a wheelchair, awake, alert, and answered and talked in Spanish when spoken to. Certified Nursing Assistant 2 (CNA 2) entered the room and indicated she knew the resident, and stated, [Resident 41] speaks Spanish. CNA 2 verified there was no communication resources in the room, and stated, There is no communication board in here. We don't use communication board when we talk to her. During a concurrent observation and interview on 7/31/23 at 11:20 a.m. with License Nurse 5 (LN 5), LN 5 verified there was no communication sheet at the bed side, and stated, [Resident 41] is Spanish speaking .The communication board should be at the bedside as a resource to make sure that care was provided on what the resident needs. During an interview on 7/31/23 at 12:08 p.m. with CNA 5, CNA 5 stated, I don't use any resource for communication with her because I don't use it .If they don't know how to communicate with her, I don't really know what they do or how they do it, we don't have any resource binder at the bedside, that would be difficult for [staff] to communicate with the resident. During a concurrent observation and interview on 8/1/23 at 8:19 a.m. with Restorative Nursing Aide 2 (RNA 2), RNA 2 verified there was no communication resource at the bedside, and stated, They have the paper supposedly in the bedside, for her. There should be a communication binder here .Sometimes, we don't understand some of her language .I'm not sure what they do if there is no staff to interpret for her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 5 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - Some During an interview on 8/3/23 at 7:43 a.m. with the Administrator (ADM), the ADM stated, I don't necessarily negate the situation when there is a need for communication resources at the bedside for staff to use in case of urgent needs. During a concurrent observation and interview on 8/3/23 at 10 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated, [Resident 41] will talk but she will say it in Spanish. When asked to review the NCP, the MDSC verified and confirmed Resident 41's care plan included the communication sheet at the bedside, and stated, If there's nobody around that can speak Spanish then we have to have the communication board or communication sheet at the bedside as a part of the intervention. 2. Resident 53 was admitted to the facility in the winter of 2023 with diagnoses that included atrial fibrillation (irregular heart rate). During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 was receiving an anticoagulant medication. During a review of Resident 53's Order Summary Report (OSR), dated 7/13/23, the OSR indicated, Resident 53 received apixaban (blood thinner medication) irregular heart rate. During a concurrent interview and record review on 8/01/23 at 12:52 p.m. with LN 2 (LN 2), Resident 53's NCP was reviewed. LN 2 was unable to find any monitoring interventions related to anticoagulation medication. LN 2 stated it is important to monitor for signs of bleeding when a resident is on an anticoagulant medication, and this should be included in Resident 53's NCP. During an interview on 8/04/23 at 8:40 a.m. with the Director of Nursing (DON), DON indicated it was the expectation for residents on anticoagulant medications to have a NCP for monitoring in place, and stated, This is important because the resident could bleed out. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/19, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 6 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 25 sampled residents (Resident 512), when nursing staff failed to verify the contents of a probiotic (a supplement to support and promote gut health) administered to Resident 512. Residents Affected - Few This failure resulted in Resident 512 receiving the incorrect probiotic and the potential for worsening of their clinical condition or complications related to gut health such as diarrhea, nausea and vomiting. Findings: During a medication pass observation on 7/31/23 at 8:23 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed preparing ten medications for Resident 512, including Florastor (a probiotic used to maintain or promote gut health) 250 milligrams (mg, a unit of measurement) 1 capsule. During a review of Resident 512's medical record indicated a physician's order, dated 7/30/23, for lactobacillus (a probiotic) 500 million units, 1 capsule once daily for seven days for GI (gastrointestinal) prophylaxis (protection). During an interview on 7/31/23 at 10:55 a.m. with LN 1, LN 1 confirmed she was not aware of the difference between Florastor and lactobacillus, and stated, I was just informed that that's the probiotic that is used here. She stated she was told by other nursing staff that if she saw an order for lactobacillus in a resident's record, the Talyst (an automated drug delivery system) filled it with Florastor. LN 1 stated there were no drug information resources available on the medication cart to verify the contents of Florastor and that, I normally rely on the DON [Director of Nursing] to confirm information. During an interview on 8/01/23 at 9:35 a.m. with the Director of Nurses (DON), DON stated nursing staff were expected to review the medication administration record (MAR) and the physician's orders to ensure they administered medications accurately. During a review of the facility's policy and procedure (P&P) titled, IC-4 Drug Information, dated 3/2018, the P&P indicated, Policy: The licensed nursing staff has access to reference materials that include current information on medication effects, cautions, available strengths, dosage forms, recommended doses, and nomenclature .Procedure .G. Reference materials or the pharmacist are consulted before administering an unfamiliar medication. During a review of the facility's P&P titled, IIA-2 Medication Administration Guidelines, dated 3/2018, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing priniciples and practices .Procedures: A . 3) Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 7 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the communication needs were met for one of 25 sampled residents (Resident 41), when there was no communication sheet or device accessible for the staff to communicate with the resident. Residents Affected - Few This failure had the potential to result in not meeting the resident's highest practicable well-being. Findings: Resident 41 was admitted in the middle of 2020 with diagnoses which included anxiety, depression, right hip pain, and difficulty walking. During a review of Resident 41's Nursing Care Plan (NCP), dated 6/2/20, the NCP indicated, [Resident 41] has a communication problem r/t Language barrier. She speaks Spanish .Spanish communication sheets placed at bedside. During a review of Resident 41's Minimum Data Set (MDS, an assessment tool), dated 5/4/23, the MDS indicated Resident 41 had mild memory impairment, spoke Spanish language and needed interpreter to communicate, and required extensive assistance with activities of daily living. During a concurrent observation and interview on 7/31/23 at 9:58 a.m., Resident 41 sat in a wheelchair in her room, awake and alert and answered in Spanish when spoken to. Certified Nursing Assistant 2 (CNA 2) entered the room and indicated she knew the resident, and stated, [Resident 41] speaks Spanish. CNA 2 verified there was no communication resources in the room, and stated, There is no communication board in here. We don't use communication board when we talk to her. During a concurrent observation and interview on 7/31/23 at 11:20 a.m. with License Nurse 5 (LN 5), LN 5 verified there was no communication sheet at the bed side, and stated, [Resident 41] is Spanish speaking .The communication board should be at the bedside as a resource to make sure that care was provided on what the resident needs. During an interview on 7/31/23 at 12:08 p.m. with CNA 5, CNA 5 stated, I don't use any resource for communication with her .If they don't know how to communicate with her, I don't really know what they do or how they do it, we don't have any resource binder at the bedside, that would be difficult for them to communicate with the resident. During a concurrent observation and interview on 8/1/23 at 8:19 a.m. with Restorative Nursing Aide 2 (RNA 2), RNA 2 verified there was no communication resource at the bedside, and stated, They have the paper supposedly at the bedside, for her. There should be a communication binder here .Sometimes, we don't understand some of her language .I'm not sure what they do if there is no staff to interpret for her. During an interview on 8/3/23 at 7:43 a.m. with the Administrator (ADM), the ADM I don't necessarily negate the situation when there is a need for communication resources at the bedside for staff to use in case of urgent needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 8 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 8/3/23 at 10 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated, [Resident 41] will talk but she will say it in Spanish. I would say there are some other language sometimes that she can understand. She can understand some simple words. When asked to review the NCP, the MDSC verified and confirmed Resident 41's care plan included the communication sheet at the bedside, and stated, If there's nobody around that can speak Spanish then we have to have the communication board or communication sheet at the bedside as a part of the intervention. During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, dated 5/17, the P&P indicated, The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. During a review of facility's P&P titled, Resident Rights, dated 3/23, the P&P indicated, If a resident's knowledge of English or the predominant language of the facility is inadequate for comprehension, a means to communicate the information concerning rights and responsibilities in a language familiar to the resident will be made available and implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 9 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 safety and supervision for one of 25 sampled residents (Resident 8), when the resident was left in a wheelchair unattended and unsupervised during care with hot water left running in the resident's room sink. This failure had the potential to result in accidents and falls and not maintaining the resident's physical and psychosocial well-being. Findings: Resident 8 was admitted in the middle of 2020 with diagnoses which included traumatic brain injury (TBI, an injury that affects how the brain works), memory impairment, and anxiety. During a review of Resident 8's Nursing Care Plan (NCP), dated 11/2/18, the NCP indicated, [Resident 8] is at risk for falls secondary to poor safety awareness .impaired mobility .unsteady gait/balance .has history of falls .Assist with ADL's [activities of daily living]. During a review of Resident 8's Order Summary Report (OSR), dated 11/9/18, the OSR indicated, [Resident 8] has no mental capacity to make decisions. Due to TBI. During a review of Resident 8's Minimum Data Set (MDS, an assessment tool), dated 6/19/23, the MDS indicated Resident 8 had moderate memory impairment and needed extensive assistance with personal hygiene (washing/drying face and hands, brushing teeth) and ADLs. During a concurrent observation and interview on 7/31/23 at 10:44 a.m., Resident 8 sat in a wheelchair, alert and verbally responsive, and noted in the room was a sink left with a hot water running, with no staff supervising or monitoring the resident. Resident 8 stated, I can't see anyone to get help from. They left me alone and got the water running in the sink. The water gets hot and I'm afraid I will burn my face and hands. I wish I could get help. They do that every day. I think they don't have enough people to help. During a concurrent observation and interview on 7/31/23 at 10:47 a.m. with Housekeeper 1 (HSK 1) and Resident 8, HSK 1 entered Resident 8's room, and stated, Staff were here but I don't know where they are. I don't see any CNA around here, I think [the CNA] is on break. Resident 8 stated, Right now, I guess I don't have anyone to assist me. During a concurrent observation and interview on 7/31/23 at 10:48 a.m. with HSK 1, HSK 1 stated, I don't think it is safe to leave her with the hot water on. She could hurt herself. HSK 1 verified the water temperature at 111.6 F (Fahrenheit, measure for temperature), and stated, I've seen [Resident 8] sitting for a while with the water running with nobody assisting her. During a concurrent observation and interview on 7/31/23 at 10:50 a.m. with the Director of Nursing (DON) and Resident 8, the DON entered Resident 8's room, checked and verified the sink with the hot water was running and turned off the faucet. Resident 8 stated, It is very hot and I'm worried because I was left alone and nobody helped me. It's like that every day, like they just turn it on and leave the water on for me to clean my face and all that, and nobody's helping me. The DON stated, She needs to have standby assistance .It's a concern that we need to know what's going on, but we want (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 10 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 to make sure the resident was safe. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/31/23 at 12:08 p.m. with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated, [Resident 8] is forgetful .She has a little bit of dementia [impaired memory], so she needs to be supervised. I left somebody to take over for me because I had to go on my break .I think she does need supervision because she's forgetful as she has memory problems and she is unpredictable. She is vulnerable and she needs to be supervised to make her safe and not harmed. I mean, if she touched the hot water it would be unsafe .somebody has to be with her during her hygiene and don't leave her alone to prevent accidents and falls. Residents Affected - Few During an interview on 8/2/23 at 8:24 a.m. with Licensed Nurse 5 (LN 5), LN 5 stated, [Resident 8] is confused as per her baseline. She is not safe when unsupervised. She's like independent with some activities but she is supposed to be watched. We really have to observe her closely like close monitoring, especially when she needs help. I mean, it's not really a lot of help but she needs monitoring all the time for her safety. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/17, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .These risk factors and environmental hazards include: bed safety .safe lifting and movement of residents, falls .water temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 11 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - Some 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: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents Resident 22, Resident 314, and Resident 315) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 84. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 22 had a physician's orders, dated 8/30/22, for oxycodone (a medication to treat pain) 5 milligrams (mg, a unit of measurement), 1 tablet one time a day for pain management and 1 tablet every 4 hours as needed for moderate to severe pain. The CDR indicated 2 tablets were signed out on 7/11/23 and 1 tablet on 7/27/23 at 5:32 a.m. The MAR did not indicate oxycodone was administered to Resident 22 on these dates or times. Resident 314 had a physician's orders, dated 7/26/23, for hydrocodone/acetaminophen (a medication to treat pain) 5/325 mg, 1 tablet one time a day for pain management, give 1 hour prior to therapy; and 1 tablet every 4 hours as needed for moderate to severe pain. The MAR indicated 1 tablet was administered to the resident on 7/28/23 at 9 a.m., but the tablet was not signed out on the CDR. Resident 315 had a physician's order dated 7/25/23, for dronabinol (a medication to treat nausea) 2.5 mg, 1 capsule one time a day for nausea. The MAR indicated 1 capsule was administered on 7/31/23 but the capsule was not signed out on the CDR. During an interview on 7/31/23 at 4:12 p.m. with Licensed Nurse 4 (LN 4), LN 4 stated whenever a controlled drug was administered to a resident, the dose was to be documented on both the CDR and the MAR. During an interview on 8/1/23 at 9:43 a.m. with Director of Nursing (DON), DON stated whenever nursing staff administered a controlled medication, the expectation was to confirm the count then sign out the dose on the CDR. She stated once the dose was administered, it was to be documented in the MAR and the CDR. DON stated it was important to document administered doses on the MAR to inform the next shift when a medication was last administered. During a review of the facility's policy and procedure (P&P) titled, IIA-7 Controlled Medications, dated 3/2018, the P&P indicated, Procedures . D. When a controlled medication is administered, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 12 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - Some licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered. 3) Signature of the nurse administering the dose, completed after the medication is actually administered. 2. During an inspection of the Medication Storage Room on 7/31/23 at 3:46 p.m. with LN 4, the E-Kit containing oral antibiotics was observed with a red tag (indicating the E-Kit had been opened by the facility). The E-Kit logs inside indicated 2 tablets ciprofloxacin (a medication to treat infection) 500 milligrams (mg, a unit of measurement) were removed on 7/29/23, and 1 tablet amoxicillin/clavulanate potassium (a medication to treat infection) 875/125 mg were removed on 7/30/23. During an inspection of the Medication Storage Room on 7/31/23 at 3:46 p.m. with LN 4, the narcotics (medications with a high potential for abuse or diversion) E-Kit was observed with a red tag. The E-Kit logs inside indicated 1 tablet lorazepam (a medicated to treat anxiety) 0.5 mg was removed on 7/18/23, 1 tablet oxycodone (a medication to treat pain) 5 mg was removed on 7/19/23, 1 bottle morphine sulfate (a medication to treat pain) 100 mg/5 ml was removed on 7/22/23, and 1 tablet oxycodone/acetaminophen (a medication to treat pain) 5/325 was removed on 7/25/23. An inspection of the list of contents affixed to the inside of the E-Kit indicated it was provided to the facility with 8 oxycodone/acetaminophen tablets, 1 that was documented on an E-Kit log, which left 1 tablet undocumented and unaccounted for. LN 4 confirmed the finding. During an interview on 7/31/23 at 3:53 p.m. with LN 4, LN 4 stated nursing staff were expected to re-order and replace the E-Kit from the pharmacy immediately after it was opened. LN 4 stated whenever a medication was needed from an E-Kit, nursing staff were expected to fill out the E-Kit log. During an interview on 8/01/23 at 9:51 a.m. with DON, DON stated nursing staff were expected to fill out the E-Kit log each time a medication as removed from the emergency supply. She stated if it was a medication from the narcotic E-Kit, nursing staff should call the pharmacy to get an authorization code and approval for removal. DON stated whoever opens the E-Kit was responsible for reordering it from the pharmacy so they would not end up in a situation where they would not have the medication available for use. During a review of the facility's P&P titled, IC-3 Emergency Pharmacy Service and Emergency Kits, dated 3/2018, the P&P indicated, Procedures .G. as soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit by transmitting the entire order for the resident and indicating that the first dose was used from the kit . I. The nurse opening the kit also records use of the kit in the emergency kit log book. The nurse records the date, time resident name, medication name, strength and dose . K. If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 13 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 11.11% error rate when three medication errors out of 27 opportunities were observed during a medication pass for two of five Residents (Residents 21 and 512). Residents Affected - Some This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 7/31/23 at 8:23 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed preparing ten medications, including glipizide (a medication to treat diabetes) 5 milligram (mg, a unit of measure) and aspirin (a medication to prevent blood clots) 81 mg delayed release (DR, a slow-release formulation) for Resident 512. LN 1 looked inside the medication cart and medication storage room for the aspirin but was unable to locate it. A review of Resident 512's medical record indicated the following physician's orders: - Glipizide 5 mg: 1 tablet two times a day. Give 30 minutes prior to meals, dated 7/26/23 - Aspirin (medication to prevent blood clots) 81 mg DR: 1 tablet one time a day for DVT (deep venous thrombosis, a blood clot in the legs), dated 7/26/23 During an interview on 7/31/23 at 10:50 a.m. with LN 1, LN 1 confirmed Resident 512's glipizide was ordered to be administered at 7 a.m. and stated, She got it maybe [at] 8:50 a.m. LN 1 stated it was administered after breakfast but it was important for the medication to be given before so it would work properly. She confirmed the resident did not receive her dose of aspirin scheduled for the day. When asked what the expectation was when a medication could not be administered on time, she stated the physician should have been contacted to see if it was still appropriate to administer the medication late or notified if it could not be given at all. LN 1 stated, I haven't called the doctor. During a medication pass observation on 7/31/23 at 9:38 a.m. with LN 2, LN 2 was observed preparing eight medications, including levothyroxine (a medication to treat thyroid disease) 175 micrograms (mcg, a unit of measure). A review of Resident 21's medication record indicated a physician's order, dated 6/26/23, for levothyroxine 175 mcg, 1 tablet once daily, give before breakfast. The administration time on the medication administration record (MAR) indicated the medication was scheduled to be administered at 7 a.m. (before breakfast). During an interview on 7/31/23 at 11:17 a.m. with LN 2, LN 2 confirmed levothyroxine should have been administered on an empty stomach but was not. When asked what the expectation was if a medication could not be administered as ordered by the physician or specified by the manufacturer he stated, I'll have to find that answer out and get back to you. A review of Lexi-comp, a nationally recognized drug information resource, indicated, Administer consistently in the morning on an empty stomach, at least 30 to 60 minutes before food . Taking levothyroxine with enteral nutrition may cause reduced bioavailability and may lower serum thyroxine levels (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 14 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some leading to signs or symptoms of hypothyroidism. Soybean flour (infant formula), soy, grapefruit juice, espresso coffee, cottonseed meal, walnuts, calcium, iron, and dietary fiber may interfere with absorption of levothyroxine from the GI tract. (www.lexicomp.com; accessed 8/7/2023) During an interview on 8/01/23 at 9:35 a.m. with Director of Nursing (DON), DON stated nursing staff were expected to review the MAR and the physician's orders to ensure they administered medications correctly. She stated any changes that needed to be made to a resident's medications needed to be done so with the physician's review and approval. DON stated for time specific medications or medications ordered before or after meals, We [nursing staff] should be giving it according to the directions, however the order is written. DON stated nursing staff were expected to notify the physician for guidance if medications could not be given as ordered. During a review of the facility's policy and procedure (P&P) titled, IIA-2 Medication Administration- General Guidelines, dated 3/2018, the P&P indicated, B. Administration . 2. Medications are administered in accordance with written orders of the attending physician . Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 15 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 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. Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some - Medication carts were kept securely locked when left unattended; - Opened biologicals, multi-dose inhalers, and inhalation solutions were dated with an open and discard date, to ensure they were not used beyond the discard date; - Medications and single resident over-the-counter (OTC) products were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; - Food was stored separately from resident medications in the Medication Storage Room refrigerator; - Expired medications were not available for resident use; and - Biologicals were stored in accordance with facility policy and procedure. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and diversion or misuse of medications from not being securely stored in medication carts. Findings: During an observation on 7/31/23 at 8:14 a.m., the Medication Cart (med cart) in Elm Hall was observed unlocked, unattended and facing towards the hall while a resident sat nearby in a wheelchair. During an interview on 7/31/23 at 8:18 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the nurse responsible for the med cart was in the dining room attending a resident. During a concurrent observation and interview on 7/31/23 at 8:20 a.m. with Director of Nursing (DON), the med cart was observed still unlocked and unattended. DON stated nursing staff were expected to keep the med carts locked if they were unattended and the nurse responsible for the med cart was in the dining hall caring for a resident. During a review of the facility's policy and procedure (P&P) titled, IIA-2 Medication Administration- General Guidelines, dated 3/2018, the P&P indicated, Procedures . B. Administration 13) . the medication cart is kept closed and locked when out of sight of the medication nurse . During a concurrent observation and interview on 7/31/23 at 12:32 p.m. with Licensed Nurse 1 (LN 1), an inspection of Med Cart #2 in Bamboo Lane identified opened medications and biologicals unlabeled with an open date. LN 1 reviewed the manufacturer's labeling on each item and confirmed the specifications for use as follows: - 2 boxes levalbuterol (a medication to treat asthma) 0.042% inhalation solution, use within 1 week after opening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 16 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - 2 Anoro Ellipta (a medication to treat chronic obstructive pulmonary disease) 62.5/25 microgram (mcg, a unit of measurement) inhaler, discard 6 weeks after removal from foil tray - 2 pouches ipratropium/albuterol (a medication to treat asthma) 0.5 mg/3 mg per 3 milliliters (ml, a unit of measurement), use within 2 weeks after opening Residents Affected - Some - 1 vial EvenCare G2 test strips (used to test blood glucose levels), use within 6 months after opening During the same inspection of Med Cart #2 with LN 1, one vial Tubersol (an injectable solution used to test for tuberculosis) was identified stored at room temperature. LN 1 stated, This is supposed to be in the fridge. In addition, 1 opened bottle carbamide peroxide (used to remove ear wax) 6.5% ear drops were observed in the med cart without a label on it to identify which resident it was for. LN 1 agreed there should have been a label with a resident's name on the ear drops and stated, There's no clear instructions for this either. During a concurrent observation and interview on 7/31/23 at 12:46 p.m. with LN 3, an inspection of Med Cart #1 in Bamboo Lane identified opened medications and biologicals unlabeled with an open date. LN 1 reviewed the manufacturer's labeling on each item and confirmed the manufacturer's specifications for use as follows: - 1 pouch ipratropium/albuterol 0.5 mg/3 mg per 3 ml, use within 2 weeks after opening - Advair Diskus (a medication to treat asthma) 250 mcg/50 mcg inhaler, use within 60 days after first use - 1 Spiriva Respimat 2.5 mcg/puff (a medication to treat asthma) inhaler, use within 3 months after first use During the same inspection of Med Cart #1 with LN 3, 1 box EvenCare G2 control solutions (solutions used to calibrate blood glucose monitors) labeled opened on 4/10/23 was identified. LN 3 stated the solutions expired 90 days after opening and should have been discarded. Inside the med cart were four green tablets in plastic cups without a pharmacy label. LN 3 stated she was unsure what the tablets were, and it was not appropriate to have loose tablets inside the med cart. A vial of Tubersol was also observed in the med cart and LN 3 stated, Not sure how this got here. LN 3 confirmed a bottle of carbamide peroxide 6.5% ear drops and nitroglycerin (a medication to treat chest pain) 0.4 mg sublingual (under the tongue) were also in the med cart without resident identifiers or pharmacy labels them. During a concurrent observation and interview on 7/31/23 at 3:28 p.m. with LN 4, an inspection of the Medication Storage Room identified the following expired medications and medical supplies: - 6 tubes Cavilon (moisturizer to treat dry, itchy skin) cream, expired 6/2023 - 4 tubes clotrimazole (a topical to treat athlete's foot) 1% cream, expired 11/2022 - 7 tubes Coloplast (a topical to treat dry skin), 3 tubes expired 3/2023 4 tubes expired 2/2023 - 1 Theraworx relief (a topical to treat achy joints), expired 11/2021 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 17 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - 1 jar Ca-Rezz (an antibacterial skin cream), no expiration date on package Level of Harm - Minimal harm or potential for actual harm - 3 packets Phytoplex (a topical to treat dry skin) cream, expired 2/2020 - 1 packet Dyna-Hex 4 (a topical antiseptic), expired 6/2023 Residents Affected - Some - 1 box hypodermic needle 25 g x 1'', expired 5/30/23 - 1 box compound benzoin tincture (a topical antiseptic) swabsticks, expired 6/20/23 - 2 boxes Biopatch (a topical used to clean the skin and prevent infection), expired 1/2023 & 3/2023 - 1 tube metronidazole (used to treat fungal infection) 0.75% cream, expired 8/2022 - 1 silicone super absorbent dressing (a wound dressing used to absorb large amounts of fluid and discharge from a wound), expired 11/14/22 - 2 Hydrofera antibacterial foam dressing, expired 1/1/23 - 1 Elasto-Gel (wound dressing used to control healing), expired 11/22 - 1 tube bacitracin (a topical to prevent infection) ointment, expired 2/22 LN 4 confirmed the items identified in the Medication Storage room were expired and should have been removed from the facility's stock and placed in the drug disposal bin. She stated any medications without an expiration date were to also be removed from stock. During a concurrent observation and interview on 7/31/23 at 3:58 with LN 4, the Medication Storage Room refrigerator was inspected. Inside the refrigerator were medications along with an opened bottle of de-alcoholized wine in the refrigerator door. LN 4 stated the de-alcoholized wine was stored in the refrigerator for one of the facility's residents. During an interview on 8/1/23 at 10:01 a.m. with DON, DON stated nursing staff were expected to check expiration dates of medications and supplies during medication administration. She stated it was not appropriate for expired medications to be in the facility's stock and should have been removed and disposed of. DON stated it was not acceptable to store Tubersol at room temperature in med carts and nursing staff were expected to store it in the refrigerator. DON confirmed any loose tablets in the med carts should be discarded and medications with shorter expiration dates after first use should have been labeled with an open date. DON stated any OTC medications that were isolated to one resident should be labeled with a resident identifier to ensure it was used for the correct individual each time. When asked if it was acceptable to store resident beverage or food items along with facility medications, DON stated she did not consider the de-alcoholized wine as food. During a review of the facility's policy and procedure (P&P) titled, IIA-3 Dating of Containers When Opened, dated 3/2018, the P&P indicated, Procedures .C. Medication in Multi-dose (injection) vials: are to be dated when opened and discarded after 28 days unless the manufacturer recommends shorter expiration date . E. Eye drops: .2) .Over-the-counter eye drops need to also have the resident (last) name on the container, not just a room number .E. Inhalers: Some inhalers require a shortened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 18 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 expiration date when first put in use .1) Inhalers dispensed by [supplier pharmacy] will either have a 'date opened' sticker place on the inhaler container or a shortened expiration date placed on the prescription label if once in use there is a shortened expiration date .F. Glucose Meter Test Strips: Glucose meter test strips need to be dated when opened and discarded after the specified number of days per manufacturer directions. Residents Affected - Some During a review of the facility's P&P titled, Medication Storage in the Facility, dated 3/2018, the P&P indicated, Procedures .A. The provider pharmacy dispenses medications in containers that meet legal requirements . Medications are kept in these containers . K. Medications requiring 'refrigeration' .are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage 'in a cool place' are refrigerated unless otherwise directed on the label. L. Refrigerated medications are kept .separate from fruit juices, applesauce, and other foods .Other foods .are not stored in this refrigerator. M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .and reordered from the pharmacy .if a current order exists. During a review of the facility's P&P titled, IC-6 Medication Labels, dated 3/2018, the P&P indicated, Procedures .A. Labels are permanently affixed to the outside of the prescription container .If a label does not fit directly onto the product, e.g., eye drops, the label may be affixed to an outside container or carton, but the resident's name, at least, must be maintained directly on the actual product container .D. Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name. Facility personnel may write the resident's name on the container or label . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 19 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - Some 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, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 67 residents eating facility prepared meals, when: 1) Two concentrated juice boxes were not labeled and dated; 2) Five plastic tubs were found wet, stacked in the ready to use shelves; 3) Five pieces of equipment were found worn, dirty and/or rusted; 4) One diet aide did not cover his beard adequately while working around food; and 5) One cook failed to follow food safety/sanitation procedures while preparing pureed meals. These failures had the potential to lead to food-borne illnesses. Findings: 1) During the initial kitchen tour on 7/31/23 at 9:05 a.m., two 3.5-liter boxes of orange guava juice concentrate did not have a received, use-by, or expiration label. During a concurrent observation and interview on 7/31/23 at 9:40 a.m., with the Dietary Supervisor (DS), the DS confirmed that there was no label on the orange guava juice. The DS stated, The lack of labels mean we do not have any dates to show if it is fresh or if it should be thrown out. During a review of The Food and Drug Administration (FDA) Food Code 2022, 3-501.17 (A) (B) (C) (D), the food code indicated, Discussed required food labeling and dating. It states the day the original container was opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. 2) During the initial kitchen tour on 7/31/23 at 9:30 a.m., five plastic containers were observed to be stacked wet (wet nesting) on the bottom shelves in the food prep area, which indicated they were ready to use. During an interview on 7/31/2023, at 9:40 a.m., with the DS, the DS stated, Staff are trying to stay on top of things, but wet nesting is not desirable. During a review of the facility's policy and procedure (P&P) titled, Sanitizing, dated 2001, the P&P indicated, Food preparation equipment and utensils that are .washed will be allowed to air dry whenever practical. During a review of the Food and Drug Administration (FDA) Food Code 2022, the food code indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. (FDA Food Code Annex 4-901.11). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 20 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 - Some 3.a. During the initial kitchen tour on 7/31/23 at 8:44 a.m., a green cutting board was observed with a deep gouge of approximately 1 inch in length. During a subsequent interview with the DS, the DS concurred there was a gouge and that deep gouges are hard to sanitize. During a review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 4-501.12, titled Cutting Surfaces, 1/18/23 version, the food code indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 3.b. During the initial kitchen tour on 7/31/23 at 8:57 a.m., the surface around the wok was observed with a build-up of black/brown residue of up to 6 inches in depth. The deep fryer, which had been used the previous day to make French fries, was observed to have a collection of tan food particles covering the sides and front of the fryer ledge. During a review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, the food code indicated, .(C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 3.c. During the initial kitchen tour on 7/31/23 at 9:08 a.m., the table holding the steamer was observed with rust and a white residue covering the four legs and bottom ledge. The tray line area had a metal piece insert (approximately 10 inches by 24 inches) with an approximately 10-inch long section that was rusted. During a subsequent visit to the kitchen with the Plant Operations Manager (POM) on 7/31/23 at 3:02 p.m., the POM confirmed the presence of rust on these items, and indicated that he had not been asked to address them. 3.d. During the kitchen observation on 7/31/23 at 3:18 p.m., the can opener was observed with a worn tip (having metal chipped-off close to 1/4 inch) and food buildup above the tip. During a review of the 2022 Federal Food and Drug Administration Food Code, Section 4-501.11, Good Repair and Proper Adjustment, the food code indicated, (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. During a review of the facility's policy and procedure (P&P) titled, Sanitation (MED-PASS, Inc., Revised October 2008), the P&P indicated, Food service area shall be maintained in a clean and sanitary manner. The following procedures were included: 1. All Kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from . corrosions .and chipped areas that may affect their use or proper cleaning; 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 21 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 chemical sanitizing solutions; and Level of Harm - Minimal harm or potential for actual harm 7. Cutting boards will be washed and sanitized between uses. Residents Affected - Some 4) During a visit to the kitchen on 8/1/23 at 9:17 a.m., Diet Aide 1 (DA 1) was observed washing dishes wearing a surgical mask. The mask partially covered his beard but allowed for at least an inch of his beard to escape under his chin. As he spoke, the mask moved, exposing more of his beard. During a review of facility P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices (MED-PASS, Inc., Revised October 2017), the P&P indicated, Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The procedures included the following: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code 2-402.11, the food code indicated, Food employees shall wear hair restraints such as .beard restraints .that are designed and worn to effectively keep their hair from .clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 5. During a kitchen visit on 8/1/23 at 10:30 a.m., [NAME] 1 (CK 1) demonstrated food preparation for lunch, including the steps needed for mechanically altered diets. While placing the salmon into a bowl to be pureed, a piece of the salmon fell next to the bowl. CK 1 removed the salmon piece from the counter with her gloved hand and placed it into her mouth. No handwashing or changing of her gloves occurred after her fingers entered her mouth. CK 1 proceeded to puree the fish. To check the consistency of the pureed fish, CK 1 placed some salmon on a spatula and used a spoon to spread it. Using this spoon, CK 1 took a bite of the pureed salmon, then placed the same spoon and spatula back into the bowl of fish. She then used the spoon and spatula to transfer the fish into a steam table pan and placed the pan on the stove for lunch service. During a interview on 8/1/23 at 11:17 a.m. with CK 1, CK 1 stated, Gloves should be changed after touching something, when working with raw meats, and when changing tasks. During a review of the P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices (MED-PASS, Inc., Revised October 2017), the P&P indicated, Food and nutrition service employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The procedures included the following: 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .6. Employees must wash their hands: f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination .; and/or h. after engaging in other activities that contaminate their hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 22 of 23 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 555261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Acc Care Center 7801 Rush River Drive Sacramento, CA 95831 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 maintain an infection prevention and control program for one of 25 sampled residents (Resident 13), when an outdated nebulizer mask (breathing treatment device) was still in use and should have been discarded. Residents Affected - Few This failure increased the potential risk for respiratory infection. Findings: Resident 13 was admitted to the facility in the summer of 2019 with diagnoses which included malignant cancer and comfort care. During a record review of Resident 13's Order Summary Report (OSR), dated 7/18/23, the OSR indicated, Albuterol sulfate (a medication used to treat shortness of breath), one vial inhale orally via nebulizer every six hours as needed. During a concurrent observation and interview on 7/31/23 at 10:34 a.m. with Director of Nursing (DON), DON confirmed Resident 13's nebulizer mask was dated 7/30/23. The DON indicated 7/30/23 was the expiration date and the mask should have been replaced with a new one on that date. The DON stated, The mask should be replaced every seven days to prevent infection. During an interview on 8/2/23, at 2:30 p.m., with Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP stated, The nebulizer masks should be changed every week or sooner if soiled to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Prevention of Respiratory Infections, revised 11/11, the P&P indicated, Infection Control Considerations related to Medication Nebulizers .discard the administration set up every seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555261 If continuation sheet Page 23 of 23