Health inspection·December 16, 2022

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Non-Coverage (NOMNC, a form completed by the facility to notify a resident of his or her right to a decision of non-coverage for services). During concurrent review of the electronic health record for Resident 47 with SSD E, SSD E verified Resident 47 was still admitted in the facility. When SSD E was asked when facility staff should issue the SNF-ABN form to the residents, SSD E stated she had never provided the SNF-ABN form to residents and did not know what the form looked like. Also, SSD stated she did not know she had to issue a SNF-ABN if the resident expected to stay at the facility after the last day of Medicare coverage. SSD E stated Business Office Manager (BOM) F was responsible for discussing with residents or a resident's representative about their potential financial obligations after the issuance of the NOMNC. During an interview with BOM (Business Office Manager) F on 12/15/2022, at 9:45 a.m., BOM F was asked who was responsible for issuing a SNF-ABN form to residents or their representatives, BOM F stated SSD E would issue the notices and BOM F was responsible for retaining resident-signed notices. RESIDENT 62 During a record review for Resident 62, the Face sheet indicated Resident 62 was admitted on [DATE] with diagnoses including Left Femur Fracture (a break in the thigh bone), Hypertension (High Blood Pressure) and Chronic Obstructive Pulmonary Disease (COPD, diseases that cause airflow blockage and breathing-related problems). During a record review for Resident 62, the MDS, dated [DATE], indicated Resident 62 began receiving Medicare benefits at the facility as of 10/17/2022. The MDS indicated Resident 62 received Orthopedic aftercare (e.g, the care provided after initial treatment of femur fracture has been performed, to aid the healing or recovery phase, or for the long-term consequences of the disease) at the facility. Review of the form SNF Beneficiary Notification Review indicated Resident 62's last covered day of Medicare Part A Services was on 11/19/2022. The form indicated the facility initiated Resident 62's discharge from Medicare Part A Services when his benefit days were not exhausted. The facility indicated a SNF-ABN form was not provided to Resident 62 as the resident had been discharged from the facility and did not receive non-covered services. During an interview and concurrent record review with SSD E on 12/15/2022, at 9:30 a.m., SSD E was asked why the SNF-ABN was not provided to Resident 62, and SSD E stated Resident 62 was discharged from the facility after he received the NOMNC. After review of the electronic health record for Resident 62 with SSD E, SSD E verified Resident 62 was still in the facility. Review of the Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections, revised 1/21/2022, indicated: A [SNF-ABN] is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a [SNF-ABN] must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 2 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool completed by clinical staff) was accurately completed for five of five sampled residents (Resident 4, 50, 8, 29, and 42) when Residents 4, 50, 8, 29, and 42 did not receive follow-up Pneumococcal vaccination as recommended by the Centers for Disease Control and Prevention (CDC) but the MDS for each resident indicated their Pneumococcal vaccination was up-to-date. This failure resulted to residents not getting the recommended Pneumococcal vaccine, putting each at-risk for increased respiratory infection. (Reference

F883). Residents Affected - Some Findings: RESIDENT 4 During a record review for Resident 4, the Immunization Record indicated Resident 4 received PCV13 (PneumoConjugate, a version of pneumococcal vaccine) on 3/27/2015. The Immunization Record indicated Resident 4 was past due for Pneumococcal 23, since 5/22/2015. During a record review for Resident 4, Section O0300 of the MDS, dated [DATE], indicated Resident 4's Pneumococcal vaccination was up-to-date. RESIDENT 50 During a record review for Resident 50, the Immunization Record indicated Resident 50 received PCV13 on 11/06/2017. The Immunization Record indicated Resident 50 was past due for Pneumococcal 23, since 1/01/2018. During a record review for Resident 50, Section O0300 of the MDS, dated [DATE], indicated Resident 50's Pneumococcal vaccination was up-to-date. RESIDENT 8 During a record review for Resident 8, the Immunization Record indicated Resident 8 received PCV13 on 12/22/2016. The Immunization Record indicated Resident 8 was past due for Pneumococcal 23, since 2/16/2017. During a record review for Resident 8, Section O0300 of the MDS, dated [DATE], indicated Resident 8's Pneumococcal vaccination was up-to-date. RESIDENT 29 During a record review for Resident 29, the Immunization Record did not indicate Resident 29 received Pneumococcal vaccine. The Immunization Record indicated Resident 29 was past due for Pneumococcal 23, since 10/26/1991. During a record review for Resident 29, Section O0300 of the MDS, dated [DATE], indicated Resident 29's Pneumococcal vaccination was up-to-date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 3 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 RESIDENT 42 Level of Harm - Minimal harm or potential for actual harm During a review of the document titled Pneumococcal Immunization Informed Consent indicated Resident 42 received Pneumococcal vaccine few years ago. Residents Affected - Some During a record review for Resident 42, the Immunization Record did not indicate Resident 42 received Pneumococcal vaccine. During a record review for Resident 42, Section O0300 of the MDS, dated [DATE], indicated Resident 42's Pneumococcal vaccination was up-to-date. During an interview and concurrent record review with the MDS Coordinator (MDSC) on 12/16/2022, at 9:25 a.m., the MDSC was asked how she reviewed data related to a resident's Pneumococcal vaccination status and entered that data into residents' medical records. The MDSC stated she would either get the information through resident interview or record review. The MDSC stated residents over [AGE] years old would be given a one-time dose of Pneumococcal vaccine and she recorded each administered dose in the resident's MDS, indicating resident's Pneumococcal vaccination was up-to-date. The MDSC stated she was not aware of CDC or ACIP recommendations that PPSV23 (pneumococcal polysaccharide vaccine, which can protect against 23 types of pneumococcal bacteria) should be administered at least one year after a resident received PCV13. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, effective October 2019, under Section O0300: Pneumococcal Vaccine, indicated: 'Up to date' in item O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations. Review of the Pneumococcal Vaccine Timing for Adults indicated, CDC recommends 1 dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least 1 year after PCV13 was received. Their pneumococcal vaccinations are complete. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 4 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 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 interview and record review, the facility failed to follow the physician's Protocol for Constipation for one of 5 sampled residents (Resident 280), causing Resident 280 to not have a bowel movement (BM) for eight days in a row. This had the potential for Resident 280's abdomen feeling full and bloated, and cause pain, hemorrhoids (swollen veins in your lower rectum) and unexplained weight loss, which could lead to Resident 280 being hospitalized . Residents Affected - Some Findings: A review of Resident 280's admission Record, dated 12/15/22, indicated Resident 228 was admitted on [DATE], with a diagnosis including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), gastro-esophageal reflex disease (GERD, a chronic disease where stomach acid goes up into the esophagus (the muscular tube through which food passes from the throat to the stomach), causing inflammation and pain), dysphagia (swallowing difficulties), altered mental status, severe sepsis (infection causes organ damage) with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection), amongst others. A review of Resident 280's admission MDS (Minimum Data Set, a clinical assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/12/22, indicated Resident 280 was not able to complete the BIMS (Brief Interview of Mental Status) interview, he had a memory problem, and Resident 280's cognitive skills were moderately impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 280 needed one-person physical assist with toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), was frequently incontinent of urine, and bowel continence was not rated (meant resident did not have a bowel movement for the entire 7 days). A review of Resident 280's Admit/Readmit Screener - V2, dated 12/6/22, indicated Resident 280 was totally dependent on staff assistance for toilet use and Resident 280 had a small, formed BM last night (12/5/22), which was the day before he was admitted to the facility. A review of Resident 280's Bowel and Bladder Elimination, dated 12/6-12/15/22, indicated Resident 280 had not had a BM since he was admitted on [DATE], total of eight days. A review of Resident 280's Skilled Nursing Assessment, dated 12/8/22 at 1:05 a.m. and 12:02 p.m., indicated Resident 280's bowel function was unchanged. incontinent of BM, and bowel sounds were present. Resident 280's Skilled Nursing assessment dated [DATE] at 12:45 a.m., indicated Resident 280's bowel function was unchanged and bowel sounds were present. Resident 280's Skilled Nursing Assessment, date 12/10/22 at 5:29 p.m. and 12/11/22 at 3:22 p.m., indicated Resident 280's bowel function was unchanged. Resident 280's Skilled Nursing Assessment, dated 12/12/22 at 3:06 p.m., 12/13/22 at 3:54 p.m., and 12/14/22 at 3:03 p.m., indicated Resident 280's bowel function was not assessed. Resident 280's Skilled Nursing Assessment, date 12/15/22 at 3:44 p.m., indicated Resident 280 had bowel sounds and was constipated (condition of the bowels in which the stool is dry and hardened and evacuation is difficult and infrequent). A review of Resident 280's Medication Review Report, dated 12/6/2022, indicated Resident 280 was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 5 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be given Colace 100 mg (milligrams) one tablet by mouth prn (as needed) for constipation, two to three times per day. Resident 280 was to be given MOM (Milk of Magnesia) 30 ml every 24 hours prn for constipation. Resident 280 was to be given a Bisacodyl suppository (form of medication that is inserted into the rectum), every 24 hours prn for constipation if MOM is ineffective. A review of Resident 280's MAR (Medication Administration Record), dated 12/2022, indicated Resident 280 was given Colace 100 mg by mouth on 12/10/22 at 7:53 a.m., the fourth day after no BM. No other medication for constipation was given to Resident 280 until 12/14/22 at 5:16 p.m., when MOM 30 ml by mouth was given, eight days after no BM. Resident 280 had not been given the MOM until the surveyor had pointed out to the DON and Licensed Staff A Resident 280 had not had a BM in eight days. A review of Resident 280's Nurse's Progress Notes, dated 12/6/22 - 12/15/22, indicated Resident 280's issue with constipation was not addressed until 12/15/22 at 11:54 a.m., whereby the nurse indicated Resident 280 had not had a BM, Resident 280's physician was aware, and interventions were in place. During a concurrent interview and MAR review on 12/14/22 at 5:07 p.m., the Director of Nursing (DON) stated Resident 280 was given Colace 100 mg one tablet by mouth for constipation on 12/10, which was the fourth day of no BM. The DON stated a resident would normally be started on the physician's bowel care orders addressing constipation after the third day of no BM. The DON stated the resident would be given Colace first and if Colace did not work, MOM would be given. The DON stated the nurse giving report to the oncoming nurse should have made the nurse aware Resident 280 was having an issue with constipation. The DON stated if the Colace and MOM did not work, the nurse should have given Resident 280 the Bisacodyl suppository. The DON stated it was the nurse's responsibility to make sure a resident was having a BM routinely. The DON stated there was no Policy and Procedure on Bowel Care for constipation; it was a Standard Nursing Practice to make sure a resident has a BM routinely. During an interview on 12/14/22 at 5:11 p.m., Licensed Staff A stated she had not been informed by the A.M. nurse giving her report about Resident 280 not having a BM since he was admitted on [DATE], eight days ago. During an interview on 12/15/22 at 11:00 a.m., Unlicensed Staff B stated she if the resident had not had a BM by the second and third day, she would inform the resident's nurse. During an interview on 12/15/22 at 11:05 a.m., Licensed Staff C stated if a resident did not have a BM after one day, she would give them a stool softener or a laxative such as Senna. Licensed Staff C stated if the stool softener and laxative did not work by the next day, she would give the resident MOM per the physician's order. Licensed Staff C stated if the MOM did not work, she would give the resident a suppository. Licensed Staff C stated there was an electronic tab alerting the nurse in regard to the resident not having a BM in so many days. Licensed Staff C stated the oncoming nurse should have been notified about a resident not having a BM by the nurse giving them report and/or by the CNA caring for the resident, and by the charge nurse. Licensed Staff C stated the nurses should have been charting in the resident's Nurse's Progress Notes about the resident having issues with constipation and what the nurse had done to address the issue. Licensed Staff C stated normally the CNA would make her aware of the resident not having a BM daily. Licensed Staff C stated if the resident was not having a routine BM and it had been several days, she would assess the resident for abdominal extension, bowel sounds, and pain. Licensed Staff C stated the resident's physician should be notified if the medication ordered for constipation did not help the resident have a BM. Licensed Staff C stated a resident should have been started on the physician's Bowel Protocol for constipation if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 6 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 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 a resident had not had a BM in six days and the physician should have been made aware. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/15/22 at 11:10 a.m., Licensed Staff D stated Resident 280's wife stated Resident 280 had a BM the Saturday before his admission, which was 12/5/22. Licensed Staff D stated if a resident had not had a BM by the third day, she would start giving the resident the stool softener first and then MOM if the stool softener did not give results per the physician's orders. Licensed Staff D stated if no medication ordered for constipation was helping the resident have a BM, she would check the resident's abdomen for bowel sounds, abdominal extension, and abdominal pain. Licensed Staff D stated she would then call the resident's physician. Licensed Staff D stated normally the CNA would let the resident's nurse know if the resident had not had a BM that day. Licensed Staff D stated the nurse giving report to the oncoming nurse should let the nurse know the resident had not had a BM in so many days. Licensed Staff D stated Resident 280's nurse should have documented in the Nurse's Progress Notes about what had been done to help Resident 280 have a BM and the results, if any. Licensed Staff D stated if a resident refused medication to treat their constipation, the nurse should have documented. Residents Affected - Some The facility job description titled, Charge Nurse, dated 7/10/17, indicated: . Essential Duties and Responsibilities include the following: . Supervises and evaluates all direct resident care provided by nursing staff to ensure adherence to facility guidelines and initiates corrective action as necessary . Conducts resident rounds daily initiating corrective action as necessary and reports problem areas to nurse supervisor promptly. Provides oncoming charge nurse with concise, accurate report and takes follow-up action as necessary. Assumes responsibility for compliance with federal, state and local regulations within the station on the assigned shift of duty . The facility job description titled, Certified Nurses Aide, dated 7/10/17, indicated: Summary: Cares for patients and performs basic nursing tasks directed toward the safety, comfort, personal hygiene and protection of patients in convalescent facility, under direction and supervision of (licensed) nursing and medical staff, by performing the following duties. Must possess a genuine interest and concern for geriatric and disabled persons . Assist patients need for elimination with correct use of bedpan, commode, urinal . Be aware of routine measures to prevent constipation . Records and reports observations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 7 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases) for five of five sampled residents (Resident 4, 50, 8, 29, and 42). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result to serious respiratory infections. Residents Affected - Some Findings: RESIDENT 4 During a record review for Resident 4, the Face sheet (A one-page summary of important information about a resident) indicated Resident 4 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Hypertension (High Blood Pressure) and Spondylosis (abnormal wear on the cartilage and bones of the neck). Resident 4 was [AGE] years old. During a record review for Resident 4, the Immunization Record indicated Resident 4 received PCV13 (PneumoConjugate) on 3/27/2015. The Immunization Record indicated Resident 4 was past due for Pneumococcal 23 since 5/22/2015. RESIDENT 50 During a record review for Resident 50, the Face sheet indicated Resident 50 was admitted on [DATE] with diagnoses including Dementia, Anxiety (intense, excessive, and persistent worry and fear about everyday situations) and Depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). Resident 50 was [AGE] years old. During a record review for Resident 50, the Immunization Record indicated Resident 50 received PCV13 on 11/06/2017. The Immunization Record indicated Resident 50 was past due for Pneumococcal 23 since 1/01/2018. RESIDENT 8 During a record review for Resident 8, the Face sheet indicated Resident 8 was admitted on [DATE] with diagnoses including Diabetes (chronic [long-lasting] health condition that affects how body turns food into energy), Chronic Kidney Disease (CKD - gradual loss of kidney function) and Dementia. Resident 8 was [AGE] years old. During a record review for Resident 8, the Immunization Record indicated Resident 8 received PCV13 on 12/22/2016. The Immunization Record indicated Resident 8 was past due for Pneumococcal 23 since 2/16/2017. RESIDENT 29 During a record review for Resident 29, the Face sheet indicated Resident 29 was admitted on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 8 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with diagnoses including Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath ), Hypertension and Dementia. Resident 29 was [AGE] years old. During a record review for Resident 29, the Immunization Record did not indicate Resident 29 received Pneumococcal vaccine. The Immunization Record indicated Resident 29 was past due for Pneumococcal 23 since 10/26/1991. RESIDENT 42 During a record review for Resident 42, the Face sheet indicated Resident 42 was admitted on [DATE] with diagnoses including Malignant Neoplasm of Prostate (cancer of the prostate gland), Anemia (condition in which the body does not have enough healthy red blood cells) and Anxiety. Resident 42 was [AGE] years old. During a review of the document titled Pneumococcal Immunization Informed Consent indicated Resident 42 received Pneumococcal vaccine few years ago. During a record review for Resident 42, the Immunization Record did not indicate Resident 42 received Pneumococcal vaccine. During an interview with the Medical Director on 12/15/2022 at 1:36 p.m., when asked about the resident's pneumococcal vaccination status, the Medical Director stated he was not aware that resident's did not get the recommended Pneumococcal vaccine. He stated nurses would have to let him know if the resident's pneumococcal vaccine was not up to date. The Medical Director stated he would coordinate with the facility and start giving the Pneumococcal vaccine according to ACIP recommendation. During a record review and concurrent interview with the Infection Preventionist Nurse (IPN) on 12/15/2022 at 1:55 p.m., the IPN verified the immunization record for Residents 4, 50, 8, 29 and 42 indicated the residents did not receive the recommended Pneumococcal vaccine. The IPN stated she was not aware of the ACIP Pneumococcal vaccine recommendation therefore residents were not offered of the PPSV23 (pneumococcal polysaccharide vaccine - protects against 23 types of pneumococcal bacteria) ; however, she stated the facility will start working on the consents to be sent to the residents and to the resident's representatives. During an interview with the Director of Nursing (DON) on 12/16/22 at 9:14 a.m., the DON stated she was not aware of the ACIP Pneumococcal vaccine recommendation. The DON stated they had called the pharmacy and confirmed the vaccine is available and now working on getting the consent from the residents and resident's representatives. DON stated the vaccines have already been ordered. When the DON was asked about the risks for the residents of not having the right Pneumococcal vaccine, she stated residents were prone for Pneumonia (lung inflammation caused by bacterial or viral infection). Review of the Facility policy and procedure titled Influenza and Pneumococcal Vaccinations of Residents revised in 11/2016 indicated, All residents will be offered vaccinations that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. The Centers for Disease Control and Prevention (CDC) recommended Pneumococcal vaccination for adults [AGE] years old and older; adults 19 through [AGE] years old with certain underlying medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 9 of 10 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 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 0883 Level of Harm - Minimal harm or potential for actual harm condition or other risk factor including: Generalized malignancy, Alcoholism, Chronic Heart Disease, Chronic Liver Disease, Chronic Lung Disease, Cigarette Smoking, Diabetes Mellitus, CDC recommended revaccination of PPSV23 at least 1 year after PCV13 (Pneumococcal conjugate vaccine) dose and at least 5 years after any PPSV23 dose for resident over [AGE] years old with underlying medical condition. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 10 of 10