Health inspection·April 10, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (DON) and IP reviewed the names of residents who were Covid-19 positive, with the corresponding room assignments from 3/29/24 until 4/7/24. The DON stated there were fifteen (15) residents who were positive for Covid-19. As off today, 4/8/24, the Infection Preventionist (IP) stated, currently there were a total of six (6) residents who were positive for Covid-19 infection. The IP stated an additional three residents converted to positive for Covid 19. Resident 20 and one active staff converted positive for Covid-19. The IP stated it was not mandatory for residents, staff, and visitors to wear facial masks in the facility. The IP stated it was only mandatory to wear facial masks for staff and visitors when entering the isolation room of residents who were positive for Covid-19 infection. The IP stated residents would be out of isolation after six days without symptoms and after finishing the medication for Covid-19. During a concurrent observation and interview on 4/8/24 at 12 p.m., with the IP and DON, while on a tour of the facility, a family member (wife) put on an isolation gown outside a resident room, and the IP assisted and helped her put on her face shield. The wife entered the room (an isolation room with Covid 19) to visit Resident 12. This Surveyor immediately asked the IP if the wife wore an appropriate mask to protect herself from Covid-19 infection. The IP checked the mask the wife wore and then asked wife to change her mask to N95 (protective mask to wear for Covid-19 isolation). The activity room had residents present without wearing masks. The community dining room was filled with residents without wearing masks. Staff in the dining room wore regular masks, not N95. The Physical Therapist was actively treating residents without wearing masks in the Physical Therapy room. During an interview on 4/8/24 at 12:30 p.m. in the ADM ' s office with the ADM, the IP and the DON, the IP was asked what guidance she followed for Covid-19 prevention. The IP stated she followed the Covid-19 Guidance by the State. The IP stated the reason she did not test all residents was because of psychosocial concerns. The IP stated the State and CDC guidelines provided only, recommendation to conduct Covid-19 tests to exposed residents, it did not say, required. The IP stated that fit testing for N95 was done in 2022. The IP stated the fit testing was not done yearly. When asked if this outbreak was reported to the State Public Health, the IP stated, No only to the Local Public Health thru, Spot (computer reporting to LPH). When the DON was asked if she conducted exposed residents from any other source of airborne infection such as Tuberculosis (TB), the DON stated, Yes to detect if anyone was infected with TB to prevent the spread of infection and treat it accordingly. The ADM stated the Policy & Procedures (P&P) they followed was the letter from the Director of State Public Health. A review of the Policy & Procedure (P&P) titled, Infection Prevention and Control Program, dated 10/2018), indicated: An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Under Policy Interpretation and implementation: 1) The infection prevention and control program are developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary 4) the elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety 10) Outbreak Management B) Outbreak management is a process that consists of . 3) preventing the spread to other residents; 4) reporting the information to appropriate public health authorities 9) recommending new or revised policies to handle similar events in the future. During an interview on 4/8/2024 at 3:55 p.m., Licensed Nurse (LN) D stated she provided in-services for Personal Protective Equipment (PPE). LN D stated everyone was responsible to teach the family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 2 of 4 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 04/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some how to put on and remove PPE. LN D stated, residents who were treated for Covid-19 were isolated for five days, did not repeat the Covid-19 test, and they only tested if residents had symptoms or family asked to do a test for their loved ones. LN D stated Resident 15, who tested positive for Covid-19 was transferred to emergency room (ER) today for low blood pressure 87/60 (normal blood pressure value 120/80), pulse at 111 (normal pulse 60-100), no fever, with mild shortness of breath. Resident 15 refused to wear a mask. LN D stated she called the ER, and was informed Resident 15 would be admitted in the hospital due to low blood pressure and a fast heart rate. During a telephone interview on 4/10/2024 at 2 p.m., the Local Public Health Epidemiologist (LPH) stated the facility must follow the most stringent regulations and guidelines for prevention of Covid-19 in Long Term Care facilities (LTC). The LPH stated the facility reported an outbreak of Covid 19 in their facility, dated 4/2/24, via the, SPOT portal (electronically-reported Covid 19). The LPH stated they provided the facility with LPH outbreak guidance as well. The LPH was asked if they helped the facility when an outbreak occurred,and the LPH stated the facility did not ask for an assistance. (2) A review of the IP ' s list of residents who were confirmed positive for Covid-19 as follows: 3/29/24-Resident 1, positive for Covid 4/01/24-Residents 3, 5, 7, 18 4/02/24-Residents 2, 6, 19, 10 4/03/24-Residents 11, 9 4/04/24-Residents 8, 12 4/05/24-Resident 4 4/06/24-Resident 13 4/7/24-Resident 14, & Resident 15 4/8/24- Resident 20 The IP did not provide a list of names of staff and the contractor who were positive for Covid-19 in the facility. The IP provided list of residents who were exposed with no Covid-19 tests done. A review of the Local Public Health Recommendations for the Prevention and Control of Viral Respiratory illness in Long Term Care Facilities, dated 10/23, indicated under definition of outbreak of Covid-19: >3 people with confirmed diagnostic test for Covid-19 within seven days who are epi-linked to the facility. Discontinue group activities, unless necessary. Discuss with Local Public Health any group activity/therapy that needed to continue. Close communal dining; serve meals in resident rooms (3) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 3 of 4 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 04/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/8/2024 at 12: 40, the ADM submitted to this Surveyor a letter from the Director of State Public Health. The ADM stated this was the facility ' s Policy & Procedure that was used. A letter from the Director of State Public Health, dated 1/09/24, addressed to, Public Health Officials, Healthcare Provider and Laboratories, under the subject, Updated Covid-19 Testing Guidance, indicated, under, Who should have diagnostic testing? Diagnostic testing is recommended for all people with new symptoms of Covid-19 .Diagnostic testing is recommended for exposed people without symptoms who are at higher-risk of severe Covid-19 infection and may benefit from treatment if infected or who have contact with people at high risk for severe infection. What is diagnostic screening testing? Diagnostic screening testing is testing of people without symptoms or known exposure to detect Covid-19 early, stop transmission, and prevent outbreak or control outbreaks. When the ADM was asked whether the facility tested the exposed residents and staff for Covid-19, the ADM stated the facility did not test exposed residents without symptoms. The facility only tested residents with symptoms of Covid-19. The ADM stated, since the State and Center for Disease Control (CDC), recommended not required to test exposed residents, We don ' t have to follow recommendations. The ADM submitted a copy of facility ' s committee-approved Policy & Procedure titled, Covid-Manual, dated 4/20/23. The ADM identified the, Mitigation Plan for Recommendations for testing as the facility's Covid-Manual. The ADM stated the facility did not use the Mitigation Plan anymore because it was obsolete. The ADM presented the All-Facility Letter (AFL) 22-13.1, dated 10/5/22, which indicated, This AFL is no longer in effect and is for historical purposes only. Please refer to the most recent CDC guidance. A review of the email response from the IP, dated 4/12/24 at 4:31 p.m., the IP stated she received the Local Public Health Guidance for Covid-19 in October 2023. When the IP was asked which guidance the facility followed when it had multiple guidance's in hand, the IP replied, We follow the most recent. During a telephone interview on 4/13/24 at 10 a.m., a hospital staff member stated Resident 15 was admitted on [DATE], for low blood pressure, a fast heart rate, and dehydration due to a Covid-19 infection. A review of Guidelines from California Department of Public Health (CDPH) Health Association-Infection Program indicated, Recommendations for Prevention and Control of COVID-19, Influenza, and Other Respiratory Viral Infections in California Skilled Nursing Facilities – 2023-24. This CDPH guidance aligns with the Centers for Disease Control and Prevention (CDC) Viral Respiratory Pathogens Toolkit for Nursing Homes (www.cdc.gov/longtermcare/prevention/viral-respiratory-toolkit.html). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555349 If continuation sheet Page 4 of 4