Inspection·May 6, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, this requirement was not met when the facility failed to provide a sanitary environment for 18 of 53 sampled residents who used the shower near Nursing Station 1 (NS1), when the facility failed to clean a shower room between residents. Findings: In an interview on 5/4/2021, at 8:15 AM., Resident #20 stated, The shower room on station 1 is filthy. I almost don't want to put my feet on the ground in there. There is dirt on the floor and the curtains are filthy. I don't even consider myself clean when I come out. I've seen some of the other residents and I don't want to get infections from them. On 5/5/2021 at 8:30 AM the shower room on NS1 was observed to have dirty tile, shoe prints on floor, a plastic medicine cup and bits of plastic wrap, and drains clogged with debris and hair. In an interview on 5/5/2021 at 10:16 AM, Housekeeping (HK) confirmed that she was responsible for cleaning the shower room once each day, in the afternoon, and that it was expected that CNAs would clean in between residents. In an interview on 5/5/2021 at 10:28 AM, Rehabilitation Assistant (RH) stated, Showers are cleaned after each shower by the last person who assisted with a shower. In an interview on 05/05/2021 at 11:12 AM, Registered Nurse (RN B) stated, Showers are given right after breakfast. The showers should be cleaned after each resident is finished, and all personal belongings collected In an observation of the shower room on NS1 on 5/5/2021 at 11:14 AM, the shower room still appeared not to have been cleaned. The medicine cup, hair and plastic were still observed in shower drains, and dirty footprints were on the floor. In an observation on 5/6/2021 at 08:15 AM, the shower room on NS1 contained a dirty shower chair soiled with a brown substance. A similar substance appeared to be on the floor of the shower. The Director of Nursing (DON) confirmed the substance to be feces, stating, This is unacceptable and should not be this way. CNAs (Certified Nursing Assistants) are supposed to clean between residents' showers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 2 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for three of 60 sampled residents (Resident 3, Resident 80 and Resident 65) when Resident 118 wandered into their rooms uninvited. This resulted in uninvited touching, anxiety, and put all residents at risk for injury and altercations. Findings: A review of Resident 118's record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills.), mood disorder (includes depression and intense mood swings) and Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills). He was not his own decision maker. A review of the facility's policy and procedure titled Prevention, Identification and Reporting of Abuse last revised on 12/18/2019, indicated Each resident has the right to be free from verbal, sexual, physical, and mental abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident. A record review of Resident 118's nursing progress notes from 10/22/2020 to 4/3/2021, showed: A. On 10/22/2020 at 4:11 PM by Licensed Vocational Nurse (LVN L), indicated, Resident 118 punched another resident and pulled the staff. He was punched, scratched and kicked. B. On 10/25/2020 at 11:07 PM by LVN J, indicated, Resident 118's roommate informed LVN J that Resident 118 was standing at his bedside shaking him and woke him up at 3 am. The roommate turned on the call light and a Certified Nursing Assistance (CNA) came into the room. C. On 11/1/2020 at 4:44 PM by LVN L, indicated, Resident 118 attempted to hit a CNA and he hit the railing instead. He had a skin tear with bruising to his left hand and wrist. D. On 11/2/2020 at 4:39 PM by LVN L, indicated, Resident 118 has been hitting at staff, grabbing other residents and hitting at them, causing injury to self, scaring other residents. E. On 11/2/2020 at 5:56 PM by LVN L, indicated, Resident 118 has been going into other residents' rooms, when this author attempted to take him out of the room, he grabbed my hand and scratched my thumb causing bleeding. F. On 11/18/2020 at 2 PM by LVN M, indicated, Resident 118 was up in his wheelchair, pushing other residents' wheelchairs and trying to touch them. G. On 11/19/2020 at 2:18 PM by LVN X, indicated, Resident 118 was pushing other residents and trying to grab females. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 3 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0600 Level of Harm - Minimal harm or potential for actual harm H. On 12/9/2020 at 3:19 AM by LVN J, indicated, Resident 118 was up all night, wandering, roaming and opening other residents' doors. I. On 4/3/2021 at 2:47 PM by LVN L, indicated, Resident 118 went into another resident's room, slid from his wheelchair and sat on the floor. (witnessed by the resident in the room.) Residents Affected - Some A record review of Resident 118's social services progress note dated 10/22/2020 at 3:12 pm by the Director of Social Services (DSS), stated, Resident 118 continues to be extremely aggressive and difficult to redirect. He is aggressive with staff and does not think twice about punching, kicking, grabbing and pinching staff. Today was the first time he directed his aggression towards his peers and punched another male resident on his arm. A record review of Resident 118's social services progress note dated 4/13/2021 at 9:52 am by DSS, indicated, Resident 118 got confused at times and would seek out one of the female residents, took a firm hold on her wheelchair and tried to keep her from leaving his side. The facility had difficulty to redirect him from and he could be quite aggressive. During a confidential interview held on 5/4/2021 at 9:38 am, a Resident stated, Resident 118 walked into her room and touched her foot at 4 am last week. She was terrified. She reported to a CNA and was told that resident was on medication and would do better. Another Resident stated she was scared of Resident 118. One Resident also stated her roommate was frightened by Resident 118. Four out of 9 residents sated Resident 118 went into their room uninvited. During an interview on 5/5/2021 at 8:30 AM, CNA T stated, Resident 118 had been on one on one monitor (provides constant observation and interaction with the resident by a designated staff to ensure his/her safety.) since he was admitted on [DATE] and it was canceled two months ago. CNA T stated Resident 118 would go into other residents' rooms uninvited and while the staff was trying to pull him out of the room, he would get mad and become very agitated. During an interview on 5/5/2021 at 8:35 AM, CNA R stated, Resident 118 did go to other resident's room. We tried to pull him back and told him that was not his room, he got mad. During an interview on 5/5/2021 at 8:40 AM, Resident 80 stated, Resident 118 came into my room a couple weeks ago at night. She also stated that Resident 118 went into her room [ROOM NUMBER] weeks ago during the day. She said I yelled at him and said get out, and he yelled back at me and he was laughing. She added, one day I met him in the hallway outside my room, he raised his fits up like he was about to fight me, I was mad and so I raised my fits to protect myself. We did not get into any physical contact, but it upset me. During an interview on 5/5/2021 at 9 AM, Resident 65 stated, Resident 118 came into my room at 6 am today. The nurse was here and she pushed him out of my room. She could not recall the name of the staff. She stated Resident 118 had come into her room [ROOM NUMBER] times since she resided in the facility and it bothers her. During an interview on 5/5/2021 at 9:05 AM, Resident 3 stated, Resident 118 did not come to her room last night, but she was still worried he might come into her room and she had hard time to fall asleep at night. She stated he scared me, now I can't sleep. During a concurrent interview and record review of Resident 118's progress notes on 5/5/2021 at 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 4 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0600 Level of Harm - Minimal harm or potential for actual harm PM, Director of Nursing (DON) admitted , Resident 118 was off from one on one care two months ago, but was unable to provide the record of the facility Interdisciplinary Team assessment on Resident 118 indicated that the resident could be safely taken off from one on one care. DON stated she was not aware of any resident to resident abuse that involved Resident 118. She stated my staff did not report to me, it did not happen. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 5 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the required agencies involving resident to resident abuse that involved Resident 118. This failure resulted in ongoing resident to resident abuse and put all residents at risk for injuries, anxiety, and abuse. Findings: A review of Resident 118's record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills.), mood disorder (includes depression and intense mood swings) and Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills). He is not his own decision maker. A review of the facility's policy and procedure titled Prevention, Identification and Reporting of Abuse last revised on 12/18/2019, section 7 - Reporting indicated: a. All mandated reporters are required by law to report incidents of known or suspected abuse in two way: 1. by telephone immediately or as soon as practically possible to the local ombudsman or the local law enforcement agency. 2. by written report. b. It is this facility's policy that any known or suspected abuse will be reported by completing an incident report. c. The first responder or first staff member informed will be responsible for informing the immediate supervisor and initiating an incident report. d. The administrator shall report all incidents of alleged abuse or suspected abuse to The Department of Health and Human Services (DHS) within 24 hours, and the results of investigation to DHS within 4 working days of the incident. A record review of Resident 118's nursing progress notes from 10/22/2020 to 11/19/2020, indicated there were 6 incidents/ resident to resident abuses noted: A. On 10/22/2020 at 4:11 PM by Licensed Vocational Nurse (LVN L), indicated, Resident 118 punched another resident and pulled the staff. He was punched, scratched and kicked. B. On 10/25/2020 at 11:07 PM by LVN J, indicated, Resident 118's roommate informed LVN J that Resident 118 was standing at his bedside shaking him and woke him up at 3 am. The roommate turned on the call light and a Certified Nursing Assistance (CNA) came into the room. C. On 11/1/2020 at 4:44 PM by LVN L, indicated, Resident 118 attempted to hit a CNA and he hit the railing instead. He had a skin tear with bruising to his left hand and wrist. D. On 11/2/2020 at 4:39 PM by LVN L, indicated, Resident 118 has been hitting at staff, grabbing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 6 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0609 other residents and hitting at them, causing injury to self, scaring other residents. Level of Harm - Minimal harm or potential for actual harm E. On 11/18/2020 at 2 PM by LVN M, indicated, Resident 118 was up in his wheelchair, pushing other residents' wheelchairs and trying to touch them. Residents Affected - Some F. On 11/19/2020 at 2:18 PM by LVN X, indicated, Resident 118 was pushing other residents and trying to grab females. None of the incidents/resident to resident abuses were reported to the required agencies. During a confidential interview held on 5/4/2021 at 9:38 am, a Resident stated, Resident 118 walked into her room and touched her foot at 4 am last week. She was terrified. She reported to a CNA and was told that resident was on medication and would do better. Another Resident stated she was scared of Resident 118. One Resident also stated her roommate was frightened by Resident 118. Four out of 9 residents sated Resident 118 went into their room uninvited. During an interview on 5/5/2021 at 8:30 AM, CNA T stated, Resident 118 had been on one on one monitor ( provides constant observation and interaction with the resident by a designated staff to ensure his/her safety.) since he was admitted on [DATE] and it was canceled two months ago. CNA T stated Resident 118 would go into other residents' rooms uninvited. CNA T stated as long as it's not a rough touch, we do not have to report it. During an interview on 5/5/2021 at 9 AM, Resident 65 stated, Resident 118 came into my room at 6 am today. The nurse was here and she pushed him out of my room. She could not recall the name of the staff. She stated Resident 118 had come into her room [ROOM NUMBER] times since she resided in the facility and it bothers her. No related incident/ resident to resident abuse report were found on the record. During an interview on 5/5/2021 at 10 AM, Director of Social Services stated, I would report it if it was a rough touch. We would place a stop door banner outside the residents' room, so a wander won't go into other resident's room. She admitted that the facility hasn't been making rounds on the residents since Covid-19 started. She also admitted that the staff did not report to her about any resident to resident abuse. She was not aware that if it was an unwanted touch, she needed to report it. DSS admitted that she made the progress notes on 10/22/2020 and 4/13/2021 stating Resident 118 was confused, aggressive toward to the staff and other residents, however, no referral to other secured dementia facility was made and there's no stop door banner placed outside the resident's room. During an interview on 5/5/2021 at 1 PM with RN D about reporting resident to resident abuse , she stated if there is no harm, we do not have to report it. During an interview on 5/5/2021 at 2 PM, Director of Nursing (DON) stated, if resident to resident abuse happened between demented residents, the facility did not have to report it. If it happened between one alert resident to one demented resident, it does not matter whether it was harm or no harm, the facility has to report it. DON also stated she was not aware of any resident to resident abuse that involved Resident 118, she stated My staff is very good at reporting. If my staff did not report to me, it did not happen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 7 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0610 Respond appropriately to all alleged violations. 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 investigate resident to resident abuse that involved Resident 118. Residents Affected - Some This failure resulted in ongoing resident to resident abuse and put all residents at risk for injuries, anxiety, and abuse. Findings: A review of Resident 118's record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills.), mood disorder (includes depression and intense mood swings) and Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills). He is not his own decision maker. A review of the facility's policy and procedure titled Prevention, Identification and Reporting of Abuse last revised on 12/18/2019, indicated: 1. Section 6, titled Investigation: All incidents of suspected or alleged abuse will be investigated by assigned staff. The assigned staff will be informed of the nature of the incident and continue the investigation process. 2. Section 9, titled Administrative procedure showed: a. The administrator or designee will serve as the Abuse Prevention Coordinator. b. The administrator or designee shall initiate an investigation immediately, which may include interviews of the involved resident(s), and other parties (employees, visitors, other residents, volunteers, family members, etc.) who have knowledge of the alleged incident. A record review of Resident 118's nursing progress notes from 10/22/2020 to 11/19/2020, indicated there were 6 incidents/ resident to resident abuses noted, but no incident/ resident to resident abuse investigation reports were found: A. On 10/22/2020 at 4:11 PM by Licensed Vocational Nurse (LVN L), indicated, Resident 118 punched another resident and pulled the staff. He was punched, scratched and kicked. B. On 10/25/2020 at 11:07 PM by LVN J, indicated, Resident 118's roommate informed LVN J that Resident 118 was standing at his bedside shaking him and woke him up at 3 am. The roommate turned on the call light and a Certified Nursing Assistance (CNA) came into the room. C. On 11/1/2020 at 4:44 PM by LVN L, indicated, Resident 118 attempted to hit a CNA and he hit the railing instead. He had a skin tear with bruising to his left hand and wrist. D. On 11/2/2020 at 4:39 PM by LVN L, indicated, Resident 118 has been hitting at staff, grabbing other residents and hitting at them, causing injury to self, scaring other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 8 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0610 Level of Harm - Minimal harm or potential for actual harm E. On 11/18/2020 at 2 PM by LVN M, indicated, Resident 118 was up in his wheelchair, pushing other residents' wheelchairs and trying to touch them. F. On 11/19/2020 at 2:18 PM by LVN X, indicated, Resident 118 was pushing other residents and trying to grab females. Residents Affected - Some During a confidential interview held on 5/4/2021 at 9:38 am, a Resident stated, Resident 118 walked into her room and touched her foot at 4 am last week. She was terrified. She reported to a CNA and was told that resident was on medication and would do better. Another Resident stated she was scared of Resident 118. One Resident also stated her roommate was frightened by Resident 118. Four out of 9 residents sated Resident 118 went into their room uninvited. No related incident/ resident to resident abuse report were found on the record. No investigation reports were located. During an interview on 5/5/2021 at 9 AM, Resident 65 stated, Resident 118 came into my room at 6 am today. The nurse was here and she pushed him out of my room. She could not recall the name of the staff. She stated Resident 118 had come into her room [ROOM NUMBER] times since she resided in the facility and it bothers her. No related incident/ resident to resident abuse report were found on the record. No investigation report was located. During an interview on 5/5/2021 at 2 PM, Director of Nursing (DON) stated, if resident to resident abuse happened between demented residents, the facility did not have to report it. If it happened between one alert resident to one demented resident, it does not matter whether it was harm or no harm, the facility has to report it. DON also stated she was not aware of any resident to resident abuse that involved Resident 118, she stated My staff is very good at reporting. If my staff did not report to me, it did not happen. During a interview on 5/6/2021 at 12:30 PM, Administrator, DON and Director of Staff Development admitted , they were not aware of any resident to resident abuse involved Resident 118, and the facility did not report or investigate any resident to resident abuse that involved Resident 118. They also admitted that they were not aware of the most current resident to resident abuse regulation and guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 9 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and update care plan interventions for effectiveness and modify them to prevent future falls for two of three residents(Resident 26, and 66). This failure resulted in Resident 26 and Resident 66 having falls with injuries including falls with a fracture and falls with head injuries. Findings: Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses of dementia and fracture of right femur. Resident 26's Minimum Data Set (MDS)(a clinical assessment of a resident's functional capabilities and health needs), dated 1/30/2021, indicated that she needed extensive assistance with transfers, walking and toilet use. She scored a 15 on her Brief Interview for Mental Status(BIMS)(A structured evaluation aimed at evaluating a resident's processes involved in gaining knowledge and comprehension) which indicated she was cognitively intact. A review of Resident 26's interdisciplinary progress notes (IPN) dated from 8/28/2020 to 4/18/2020 indicated she had seven falls. -On 8/28/2020, she had an unwitnessed fall at 4:31 AM, and sustained a right femur distal fracture. -On 11/3/2020, she had an unwitnessed fall at 7:50 AM, and received a minor injury. Care plan Interventions included; Monitor her neurological signs per facility protocol, provide treatment if needed/ordered, observe and report any change in level of consciousness (LOC) or range of motion (ROM) or complaint of (c/o) new or abnormal pain. Notify MD and family of fall. Ensure that call light is within easy reach and provide non-skid footwear if necessary. -On 11/24/2020, she had an unwitnessed fall at 3:25 AM, and sustained a skin tear to right elbow. Care plan interventions were the same as above. -On 1/15/2021, she had an unwitnessed fall at 6:50 AM, and sustained a skin tear to her right elbow. Care plan interventions were the same as above. -On 1/21/2021, she had an witnessed fall at 7:45 AM, and hit the back of her head. Care plan interventions were the same as above. -On 3/13/2021, she had an unwitnessed fall at 9:25 PM, due to self ambulating to turn the TV on in her room. Care plan interventions were the same as above. -On 4/18/2021, she had a witnessed fall at 10:49 AM, during toileting. She lost her balance during a staff assisted transfer and was unable to get hold of the bathroom bars. She sustained a skin tear to her right elbow and a small bump on the back of her head. Care plan interventions were the same as above. During a concurrent observation and interview on 5/06/2021, at 9:51 AM, with Resident 26 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 10 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Licensed Vocational Nurse (LVN) H, in Resident 26's room, Resident 26 was observed in bed, her slippers were next to her bed. There was a large colorful note on the wall that was unreadable because it was covered with cards and a calendar. Resident 26's wheel chair (w/c) was unlocked next to her bed. An automatic w/c anti-rollback device (a device that as the resident gets up, a pair of brake arms instantly grab the tires to prevent the chair from rolling backwards. The chair remains locked while the resident is out of the chair. They are used to prevent falls) was attached to Resident 26's w/c. This intervention was not on her care plan. The anti-rollback brake arms were not firmly attached to the wheels. LVN H pushed the w/c to demonstrate the device's function and the chair moved easily when it should have been locked. LVN H agreed that the anti-rollback device was not working correctly, because the w/c should not move when the resident was not in the chair. LVN H stated Resident 26 was not suppose to take herself to the bathroom but sometimes she did not use her call light and she would go to the bathroom by herself. LVN H pointed to a sign on the wall. The sign was covered up. She then uncovered the sign on the wall and it displayed the words [Resident 26's name] wait for help. She agreed that the sign was covered with a calendar and cards, and that Resident 26 could not read the sign because it was covered. During an interview on 5/6/2021, at 9:58 AM, with certified nurse assistant (CNA) T, she indicated that Resident 26 was a fall risk because she had fallen a few times. She said Resident 26 would fall at night in the bathroom when she would go by herself. CNA T indicated that last month she was assisting Resident 26 to the bathroom and Resident 26 fell. CNA T explained that she wheeled Resident 26 into the bathroom. Resident 26 held on to the grab bar next to the toilet and stood up. CNA T moved the w/c away from the Resident. Resident 26 then put her hand on the commode arm support and the commode tipped over. Resident 26 lost her balance and fell to the ground scratching her elbow and hitting her head. CNA T confirmed she was not close enough to Resident 26 to support her. No gait belt was used. CNA T was not aware of any new interventions that had been implemented since that fall. CNA T confirmed that Resident 26's anti-rollback device was not working and that it put her at risk for falls. During an interview on 5/06/2021, at 10:48 AM, with the Director of Rehabilitation (DOR), she recommended that staff should use a gait belt when assisting residents with transfers. The DOR indicated that Resident 26 should be transferred with a gait belt. An interview on 5/6/2021, at 11:15 AM, with Director of Nursing (DON) and Director of Staff Development (DSD) confirmed that Resident 26's care plan had not been updated to reflect interventions for a gait belt with transfers and an anti-rollback device on her w/c. A review of Resident 66's medical record indicated she was admitted on [DATE] with diagnoses that included a fracture of her right femur. Her MDS dated [DATE], section C indicated her BIM's score was 14, indicating her cognition was intact. Section G of the MDS indicated she needed limited assistance with the assistance of one staff for transferring, walking and toileting. She used a walker and w/c for locomotion. Section D recorded she was at risk for falls related to advanced age, decreased mobility, history of falls, impaired balance and muscle weakness. Section H recorded no bowel and bladder training. A review of Resident 66's interdisciplinary progress notes dated from 8/9/2020 thru 4/9/2021 indicated that she had 5 unwitnessed falls. -8/9/2020 she had an unwitnessed fall with a skin tear to her left shoulder. Interventions included reminding her to use the call light if she needed assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 11 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -11/29/2020 she had an unwitnessed fall and sustained a hematoma (a localized collection of blood that accumulates under the tissue) to her right forehead and a fracture to her sternum (the breastbone). Interventions included reminding her to use the call light for assistance and to provide one to one supervision when able. -1/28/2021 she had an unwitnessed fall and sustained a skin tear. Resident stated I slid out of the w/c. Interventions included reminding her to use her call light for assistance, and a non-skid mat in her w/c. -4/3/21 she had an unwitnessed fall and sustained a laceration to her forehead and a bruise to her left knee. Interventions were to, keep the bed in a low position, keep the call light within reach and encourage her to use the call light. -4/5/21 she had an unwitnessed fall with bruising to her left eye, bruising to her right eye, a laceration to her left forehead, a hematoma to her left forehead, a laceration to the back of her head, and a skin tear to her left elbow. Interventions were to instruct resident to use call light, and staff to do frequent checks on resident. An interview on 5/05/2021 at 11:50 AM, with MDS/IP, she stated Resident 66's fall interventions were: non-skid socks, call light within reach, rehabilitation evaluation and follow up as ordered, non-skid mat in w/c to avoid sliding out of chair, safety training and education, installation of w/c antilock brakes, have Resident 66 ask for assistance, and provide one on one when able. During a concurrent observation and interview on 5/05/2021, at 2:39 PM, with Resident 66. Resident 66 was observed in her bed. She had bruises on her forehead and under her eyes. She was barefoot. She stated she wore nothing on her feet at night. In the winter time she wore sticky socks. She described the socks they gave her as slippers. She stated she had to ask for socks if she wanted to wear them because they did not ask her. Her call light was clipped on her sheets up near the top of her bed. She sat up and reached her arm back to feel for her call light. She could not find it or reach it. She stated that once in a while I cannot get it with my arm backwards. She had an anti-rollback device on her w/c, but her w/c rolled forward and backwards when she was not in it. There was not a non-skid mat on top of her cushion in her w/c. During an interview on 5/05/2021, at 3:06 PM, with RN A, RN A indicated Resident 66's care plan interventions for her 4/3/2021 and 4/5/2021 falls included; frequent checks, keep the call light within reach and provide non-skid socks. She confirmed that Resident's 66's fall care plan was not updated with new interventions after the above mentioned falls. During an interview on 5/6/2021, at 10:30 AM, with MDS/IP, MDS/IP stated that the interdisciplinary team (IDT) (a group of health care professionals with various areas of expertise who work together toward the goals of their residents) had meetings to discuss falls and the care plan would get updated. MDS/IP stated IDT meetings were hit-and-miss since COVID. I can't tell you 100% if IDT meetings happened. During an interview on 5/6/2021, at 11:15 AM, with the DON and IP, the DON and IP were unaware that the anti-roll back device was not working for Resident 26 and Resident 66. They indicated that there was not a system in place to check for the function of the anti-rollback devices after they were installed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 12 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 118's record indicated, he was admitted to the facility on [DATE] with diagnoses including dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills.), mood disorder (includes depression and intense mood swings) and Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills). He is not his own decision maker. Fall risk assessment score 27. ( full score is 30, higher score, higher risk of fall.) A review of Resident 118's Occupational Therapy (OT) Evaluation titled, OT Evaluation & Plan of Care, dated 10/6/2020, indicated, Resident 118 had strength impairments, balance deficits, decreased functional capacity, ADL (activities of daily living) impairments and decreased mobility. Recommend Broda wheelchair seating system (a large padded chairs with wheeled bases and are designed to assist seniors with limited mobility) to promote safety and mobility. A review of Resident 118's Fall nursing progress notes dated from 10/7/2020 to 5/5/2021, indicated Resident 118 had 12 falls: A. On 10/7/2020 at 5:15 PM, he was found sitting on the floor in the bathroom leaning against the wall. B. On 10/8/2020 at 10:45 PM, he was found on the floor in room [ROOM NUMBER] B with his back against the foot of the bed, small amount of blood was noted on his brief. His Foley catheter was found attached to his bed with bulb inflated. (A flexible plastic tube (a catheter) inserted into the bladder to provide continuous urinary drainage. The Foley has a balloon (bulb) on the bladder end. After the catheter is inserted in the bladder, the balloon is inflated (with air or fluid) so that the catheter cannot pull out.) C. On 10/9/2020 at 6:30 PM, he was found on the floor on his knees with bruise on left lateral hip. D. On 10/9/2020 at 7:30 PM, he was trying to transfer himself from the wheelchair and fell on the floor. He hit his right lateral side of the head to the ground and with redness on the left knee, scratches on his right side lower back. E. On 10/13/2020 at 1:25 PM, he fell on the floor in the hallway next to room [ROOM NUMBER]. He was found next to his Broda wheelchair, faced down on the floor with both hands under his forehead. F. On 10/20/2020 at 8 AM, he had a witnessed fall in his room. He fell on his right buttock. G. On 11/4/2020 at 3 AM, he was in his bed, but a CNA found blood on his bathroom floor, bathroom door, the floor next to his bed and his bedsheet. He was found to have bruises to his left upper arm, forearm, and elbow. A 3 cm x 4 cm V-shaped skin tear was noted to his right lateral forearm near elbow. H. On 3/11/2021 at 11:39 AM, he was found sitting on the floor next to his wheelchair in the bathroom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 13 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 I. On 3/28/2021 at 2:56 AM, he was found sitting on the floor in his room. Level of Harm - Minimal harm or potential for actual harm J. On 4/3/2021 at 2:47 PM, he was found sitting on the floor in from of his wheelchair in another resident's room. Residents Affected - Some K. On 4/30/2021 at 12:44 AM, he was found sitting on the floor next to the foot of his bed, his wheelchair was at his right-hand side. A skin tear to the right posterior elbow was noted. L. On 5/2/2021 at 5 AM, he was found sitting on the floor near the nursing station and trying to scoot himself across the floor on his buttocks. A review of Resident 118's Fall risk care plan implemented on 10/5/2020, showed that there was only one intervention implemented on 12/1/2020, stated, Allow resident's door to be open, while under droplet precautions isolation, secondary to current policy of facility, for closer observation to possibly prevent future falls, and for resident's safety. There was no fall intervention or modification care plan implemented from 10/6/2020 to 5/2/202. A review of Resident 118's Fall short term care plan dated 10/7/2020, indicated the last date of modifying and revising the care plan was on 10/16/2020. Resident 118 continued to fall for additional 6 times after 10/16/2020. During an interview on 5/3/2021 at 1:05 PM with LVN I, stated, according to the facility's fall policy, the fall care plan would be updated each time after a resident fell. An intervention would also be implemented based on how the resident fell. She stated, it doesn't matter how many times a resident fell, we have to update the care plan right after he/she fell. During a concurrent interview and record review of Resident 118's fall care plan on 5/3/2021 at 2 PM, Director of Nursing admitted , Resident 118' Fall care plan had not been up to date and implemented with effective interventions. She stated, at this point, we only focus on no injury to Resident 118. 4. A review of Resident 110 's record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills.), behavioral disorder (includes physical or verbal aggression, general emotional distress, restlessness, pacing, shredding paper or tissues and/or yelling) and Parkinson's disease (a progressive nervous system disorder that affects movement.) He is not his own decision maker. Fall risk assessment score 24. ( full score is 30, higher score, higher risk of fall.) During a record review of Resident110 's progress note on 4/11/2021 at 2:15 PM, indicated, he was transferred to ER due to fall. During an interview on 5/5/2021 at 9:20 AM, CNA U and CNA O stated, on 4/11/2021, while a CNA was assisting Resident 110's roommate, Resident 110 was on his wheelchair and trying to roll backward towards the closet, the wheelchair tilted over, and he fell backward and hit his head. He had blood coming out the back of his head. A record review of Resident 110's Fall risk care plan dated 4/11/2021, indicated, the intervention was not modified to prevent future falls while he is using the wheelchair. The current fall care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 14 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 plan included: Level of Harm - Minimal harm or potential for actual harm A. Assess the ability to transfer/ambulate safely. B. Provide assistance/supervision as needed when ambulating/transfers. Residents Affected - Some C. Provide needed equipment to ambulate/transfer. D. Use skid proof footwear when ambulating. During a concurrent interview and record review of Resident 100's fall care plan on 5/3/2021 at 2 PM, Director of Nursing admitted , Resident 110' Fall care plan did not meet the need of the resident. She stated, I would do something on his wheelchair and make sure the wheelchair has anti-rollback device and it won't rollback. A review of the facility's policy titled, Incident and Falls Assessment and Tracking , indicated: A. Licensed nurse will enter problems, goals and interventions in the care plan and update the CNA of any new interventions needed due to the incident.(interventions shall include preventative measures.) B. Director of Staff Development (DSD) will review circumstances, determine causal factors if possible, make recommendations for additional interventions as appropriate and assure care plan is updated. C. Individual plans of care will be reviewed for appropriate changes during weekly summaries and quarterly assessments. Based on observation, interview and record review, the facility failed to evaulate falls and develop new care plan interventions for four of five sampled residents (Residents 26, 66, 118 and 110) to prevent further falls and injuries. This failure resulted in Resident 26, 66, 118 and 110 to have injuries related to falls and had the potential for all residents to be at risk for accidents and hazards. Findings: 1. Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses of dementia and fracture of right femur. Resident 26's Minimum Data Set (MDS)(a clinical assessment of a resident's functional capabilities and health needs), dated 1/30/2021, indicated that she needed extensive assistance with transfers, walking and toilet use. She scored a 15 on her Brief Interview for Mental Status(BIMS)(A structured evaluation aimed at evaluating a resident's processes involved in gaining knowledge and comprehension) which indicated she was cognitively intact. A review of Resident 26's interdisciplinary progress notes (IPN) dated from 8/28/2020 to 4/18/2020 indicated she had seven falls. -On 8/28/2020, she had an unwitnessed fall at 4:31 AM, and sustained a right femur distal fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 15 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 -On 11/3/2020, she had an unwitnessed fall at 7:50 AM, and received a minor injury. Care plan Interventions included; Monitor her neurological signs per facility protocol, provide treatment if needed/ordered, observe and report any change in level of consciousness (LOC) or range of motion (ROM) or complaint of (c/o) new or abnormal pain. Notify MD and family of fall. Ensure that call light is within easy reach and provide non-skid footwear if necessary. Residents Affected - Some -On 11/24/2020, she had an unwitnessed fall at 3:25 AM, and sustained a skin tear to right elbow. Care plan interventions were the same as above. -On 1/15/2021, she had an unwitnessed fall at 6:50 AM, and sustained a skin tear to her right elbow. Care plan interventions were the same as above. -On 1/21/2021, she had an witnessed fall at 7:45 AM, and hit the back of her head. Care plan interventions were the same as above. -On 3/13/2021, she had an unwitnessed fall at 9:25 PM, due to self ambulating to turn the TV on in her room. Care plan interventions were the same as above. -On 4/18/2021, she had a witnessed fall at 10:49 AM, during toileting. She lost her balance during a staff assisted transfer and was unable to get hold of the bathroom bars. She sustained a skin tear to her right elbow and a small bump on the back of her head. Care plan interventions were the same as above. During a concurrent observation and interview on 5/06/2021, at 9:51 AM, with Resident 26 and Licensed Vocational Nurse (LVN) H, in Resident 26's room, Resident 26 was observed in bed, her slippers were next to her bed. There was a large colorful note on the wall that was unreadable because it was covered with cards and a calendar. Resident 26's wheel chair (w/c) was unlocked next to her bed. An automataic w/c anti-rollback device (a device that as the resident gets up, a pair of brake arms instantly grab the tires to prevent the chair from rolling backwards. The chair remains locked while the resident is out of the chair. They are used to prevent falls) was attached to Resident 26's w/c. This intervention was not on her care plan. The anti-rollback brake arms were not firmly attached to the wheels. LVN H pushed the w/c to demonstrate the device's function and the chair moved easily when it should have been locked. LVN H agreed that the anti-rollback device was not workng correctly, because the w/c should not move when the resident was not in the chair. LVN H stated Resident 26 was not suppose to take herself to the bathroom but sometimes she did not use her call light and she would go to the bathroom by herself. LVN H pointed to a sign on the wall. The sign was covered up. She then uncovered the sign on the wall and it displayed the words [Resident 26's name] wait for help. She agreed that the sign was covered with a calendar and cards, and that Resident 26 could not read the sign because it was covered. During an interview on 5/6/2021, at 9:58 AM, with certified nurse assistant (CNA) T, she indicated that Resident 26 was a fall risk because she had fallen a few times. She said Resident 26 would fall at night in the bathroom when she would go by herself. CNA T indicated that last month she was assisting Resident 26 to the bathroom and Resident 26 fell. CNA T explained that she wheeled Resident 26 into the bathroom. Resident 26 held on to the grab bar next to the toilet and stood up. CNA T moved the w/c away from the Resident. Resident 26 then put her hand on the commode arm support and the commode tipped over. Resident 26 lost her balance and fell to the ground scratching her elbow and hitting her head. CNA T confirmed she was not close enough to Resident 26 to support her. No gait belt was used. CNA T was not aware of any new interventions that had been implemented since that fall. CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 16 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 T confirmed that Resident 26's anti-rollback device was not working and that it put her at risk for falls. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/06/2021, at 10:48 AM, with the Director of Rehabilitation (DOR), she recommended that staff should use a gait belt when assisting residents with transfers. The DOR indicated that Resident 26 should be transferred with a gait belt. Residents Affected - Some An interview on 5/6/2021, at 11:15 AM, with Director of Nursing (DON) and Director of Staff Development (DSD) confirmed that Resident 26's care plan had not been updated to reflect interventions for a gait belt with transfers and an anti-rollback device on her wheelchair. 2. A review of Resident 66's medical record indicated she was admitted on [DATE] with diagnoses that included a fracture of her right femur. Her MDS dated [DATE], section C indicated her BIM's score was 14, indicating her cognition was intact. Section G of the MDS indicated she needed limited assistance with the assistance of one staff for transferring, walking and toileting. She used a walker and w/c for locomotion. Section D recorded she was at risk for falls related to advanced age, decreased mobility, history of falls, impaired balance and muscle weakness. Section H recorded no bowel and bladder training. A review of Resident 66's interdisciplinary progress notes dated from 8/9/2020 thru 4/9/2021 indicated that she had 5 unwitnessed falls. -8/9/2020 she had an unwitnessed fall with a skin tear to her left shoulder. Interventions included reminding her to use the call light if she needed assistance. -11/29/2020 she had an unwitnessed fall and sustained a hematoma (a localized collection of blood that accumulates under the tissue) to her right forehead and a fracture to her sternum (the breastbone). Interventions included reminding her to use the call light for assistance and to provide one to one supervision when able. -1/28/2021 she had an unwitnessed fall and sustained a skin tear. Resident stated I slid out of the w/c. Interventions included reminding her to use her call light for assistance, and a non-skid mat in her w/c. -4/3/21 she had an unwitnessed fall and sustained a laceration to her forehead and a bruise to her left knee. Interventions were to, keep the bed in a low position, keep the call light within reach and encourage her to use the call light. -4/5/21 she had an unwitnessed fall with bruising to her left eye, bruising to her right eye, a laceration to her left forehead, a hematoma to her left forehead, a laceration to the back of her head, and a skin tear to her left elbow. Interventions were to instruct resident to use call light, and staff to do frequent checks on resident. An interview on 5/05/2021 at 11:50 AM, with MDS/IP, she stated Resident 66's fall interventions were: non-skid socks, call light within reach, rehabilitation evaluation and follow up as ordered, non-skid mat in w/c to avoid sliding out of chair, safety training and education, installation of w/c antilock brakes, have Resident 66 ask for assistance, and provide one on one when able. During a concurrent observation and interview on 5/05/2021, at 2:39 PM, with Resident 66. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 17 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 - Some 66 was observed in her bed. She had bruises on her forehead and under her eyes. She was barefoot. She stated she wore nothing on her feet at night. In the winter time she wore sticky socks. She deswcribed the socks they gave her a slippery. She stated she had to ask for socks if she wanted to wear them because they did not ask her. Her call light was clipped on her sheets up near the top of her bed. She sat up and reached her arm back to feel for her call light. She could not find it or reach it. She stated that once in a while I cannot get it with my arm backwards. She had an anti-rollback device on her w/c, but her w/c rolled forward and backwards when she was not in it. There was not a non-skid mat on top of her cushion in her w/c. During an interview on 5/05/2021, at 3:06 PM, with RN A, RN A indicated Resident 66's care plan interventions for her 4/3/2021 and 4/5/2021 falls included; frequent checks, keep the call light within reach and provide non-skid socks. She confirmed that Resident's 66's fall care plan was not updated with new interventions after the above mentioned falls. During an interview on 5/6/2021, at 10:30 AM, with MDS/IP, MDS/IP stated that the interdisciplinary team (IDT) (a group of health care professionals with various areas of expertise who work together toward the goals of their residents) had meetings to discuss falls and the care plan would get updated. MDS/IP stated IDT meetings were hit-and-miss since COVID. I can't tell you 100% if IDT meetings happened. During an interview on 5/6/2021, at 11:15 AM, with the DON and IP, the DON and IP were unaware that the anti-roll back device was not working for Resident 26 and Resident 66. They indicated that there was not a system in place to check for the function of the anti-rollback devices after they were installed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 18 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure two out of three certified nursing assistant (CNA) (CNA Q and CNA P), were able to locate a resident's wishes for cardiopulmonary resuscitation (CPR). This failure resulted in the potential for unnecessary or unwanted medical procedures being performed on them and violating their wishes. Findings: During an interview on [DATE], at 9:52 AM, with CNA Q, CNA Q stated that if she found Resident 45 unconscious and not breathing, she would check Resident 45's pulse and breathing and scream for help and initiate CPR. A record review on [DATE] at 9:55 AM, of Resident 45's Physician Orders for Life-Sustaining Treatment (POLST) revealed that Resident 45's wishes were to not be resuscitated. During an interview on [DATE] at 9:56 AM, with CNA P, CNA P indicated that if she found Resident 45 unresponsive, without a pulse she would call a code red and start CPR. When asked where she would find Resident's 45 wishes for CPR she said there was a sticker on Resident 45's medical chart. CNA P went to the chart to show me and when she did not see a sticker she asked RN C where she would find it. RN C opened Resident 45's medical chart and showed CNA P, Resident 45's POLST. CNA P then indicated that Resident 45 is a DNR (Do Not Resuscitate). She agreed that she verbalized starting CPR on a resident that did not want it. She denied doing any CPR drills with a trainer. During an interview on [DATE], at 10:05 AM, with CNA Q, she indicated that she had been a CNA for 10 years and was CPR certified. She was unaware of where to find Resident 45's wishes for CPR. CNA Q walked to the nurses desk and grabbed Resident 45's chart and looked past the POLST sheet and flipped thru the chart. After one minute she was still looking. LVN E showed her where the information was found in the chart. CNA Q stated that Resident 45 did not want CPR. She confirmed that she should check the Resident's CPR wishes before she initiated CPR. She agreed that she verbalized starting CPR on a resident that did not want it. She denied doing any CPR drills with a trainer. During an interview on [DATE] at 9:28 AM, with Infection Preventionist (IP), she confirmed that she was responsible for competency over site. The last in-service on CPR was in 2019. She confirmed that when there was a resident that was not breathing and with no pulse the rule was to check the resident's wishes and then to call a code blue over the loud speaker. She said that education had fallen off since COVID. She agreed that education was needed and confirmed she had never done a CPR drill with staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 19 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0790 Provide routine and 24-hour emergency dental care for 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, residents' need to obtain dental care was not met when five of five sampled residents (Residents 20, 27, 31, 64 and 276) did not receive routine dental services. This resulted in pain, potential for choking, and potential for residents remaining on therapeutic diets (e.g., nectar thin liquids) unnecessarily. Residents Affected - Some Findings: A review of the facility's document titled, Policy & Procedure, Dental Services, dated 2/08/17, indicated, The facility will assist residents in obtaining routine and 24-hour emergency dental care. Procedure: A) Social services staff/nursing staff will assist in making appointments and notify the activities department of transportation needs to the dental services office. B) Staff will promptly within 3 days, refer residents with lost or damaged dentures for dental services. A review of the facility's document titled, Social Services--Hearing, Dental, Vision & Podiatry Evals dated 7/10/13 indicated that Social Services will maintain a current list, which is coordinated with nursing, to ensure that all residents with any dental, vision, hearing, or podiatry needs are seen by the consultant in this area. A physician's order is needed prior to any consultations. Resident 20 was admitted to the facility on [DATE] with diagnoses including high cholesterol and heart failure. In a concurrent observation and interview on 5/4/2021 at 9:03 AM, Resident 20 was observed with no dentures in his mouth. Resident 20 stated, I lost my dentures about a month ago. They have not been replaced. It makes it hard for me to eat. In an interview on 5/4/21 at 9:48 AM, RN C stated, I am not seeing [his dentures] listed on his inventory. In a concurrent record review of Resident 20's (admitting) inventory sheet titled, Personal belongings dated 2/9/21, RN C confirmed that the document was blank (no checkbox) in the selection dentures. A review of the Resident 20's admission notes dated 1/26/21 indicated, no dentures. In an interview on 5/4/2021 at 9:56 a.m., Social Worker (SS) stated, We're going to try to get things covered, but unfortunately some things are out of our hands. If someone is suffering, we will try to get them seen in 3 days. In an interview on 5/4/21 at 9:56 AM, RN C stated, I made a note that his top dentures are with his friend, he came in with no bottom dentures. In an interview on 5/4/21 at 3:54 PM, Registered Dietitian (RDV) stated, [Resident 20] has no problem with swallowing that I know of. I do assess their teeth and their ability to swallow. I did note on my assessment that he doesn't have a ton of teeth. Resident 27 was admitted on [DATE] with high blood pressure, diabetes and partial paralysis. In a concurrent observation and interview on 5/3/2021 at 11:51 AM, resident 27 was observed to be missing an upper tooth. Resident 27 stated, I am missing a tooth. They looked into it. Three teeth hurt me a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 20 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0790 lot. I can't chew my food well enough. Resident 27 further stated, I get stomach aches. Level of Harm - Minimal harm or potential for actual harm In a concurrent interview and record review on 5/3/2021 at 3:08 PM, SS reviewed Resident 27's dental record dated 7/14/2020 and stated, He was seen by a dentist in July, 2020 for an initial exam. The dentist indicated he needed FMX, or full mouth x-ray. There was no follow up. Initially insurance was saying he had no coverage. They were supposed to get back to us. It was never followed up on. If a resident doesn't have coverage, we will work with them. Looks like we didn't have a system for follow up. A review of Resident 27's dental visit dated 7/2/2020 indicated that the resident required a full-mouth x-rays and further follow up. Residents Affected - Some In an interview on 5/4/2021 at 03:51 PM, RDV stated, We base residents' diets on their medical needs and dentition and ability to swallow. We look at diet textures if I feel it's a concern, go to speech language pathologist to assess their swallow. If someone comes in with missing teeth or dentures we assess them. Patients without teeth are taking bigger bites and can result in aspiration (choking) and stomach problems. RDV acknowledged that Resident 27's dentition and lack of attention to dental care could be contributing to his taking larger bites. A review of the facility's document titled, Speech Therapy Discharge Summary dated 10/28/2019 indicated, Consequences if services are not provided include possible aspiration (choking) .and continued dependence on modified diet (e.g. nectar thick, mechanical soft.). A review of resident 27's physician telephone order dated 3/2/20 indicated, Mechanical soft texture and nectar thick liquids. and that resident was to eat small bites. A review of a physician order dated 2/3/2021 for Resident 27, signed by Medical Director, indicated, Aspiration Risk Care Plan: [Resident 27] is at risk for aspiration [due to having had a stroke] and behavior of shoveling food instead of small bites and small sips. A review of a physician visit summary dated 2/15/2021 signed by Medical Director (MD), indicated, [Resident 27 ] has intermittent complaints of stomach ache, indigestion, gas and bloating A review of the facility's admission assessment for Resident 27 dated 8/4/2019, included an oral health evaluation that allowed the choice Poor dental/oral health, but that box was not checked. The evaluator's response of Resident 27's dental health indicated, None of the above. A review of a physician order for Resident 27, dated 2/15/2021 indicated, At risk for complications and discomfort related to indigestion. 12/27/2020 Pantoprozole [Prilosec, an a prescription antacid] 40 mg q (every) a.m. (morning) before breakfast. A review of the facility's care plan for Resident 27, dated 2/15/2021, indicated, Aspiration Risk Care Plan: [Resident 27] is at risk for aspiration [due to stroke] and behavior of shoveling food instead of small bites and small sips. In an interview on 5/5/2021 at 10:44 AM, Speech Therapist (ST 1) stated that Resident 27 had completed speech therapy care by a previous speech therapist after evaluating the resident's dentition (dental health) and placing him on a thin liquids/mechanical soft diet. From what I understand, he had a stroke so dysphagia (problems swallowing) must be from a stroke. His oral prep phase (chewing, moistening) took longer than usual. Our Social worker arranges dentist visits about once a month. ST 1 further stated that not being able to chew food properly can result in choking, stomach pain, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 21 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gastroesophageal reflux (stomach acid coming up in the throat) and a prolonged oral phase, or food remaining in the mouth longer than necessary and presenting a choking hazard. ST 1 stated, Maybe we should have followed up. ST 1 indicated that Resident 27's dentition may have contributed to his limited ability to manage food in his mouth. A review of Resident 27's Speech Therapy Evaluation and Plan of Treatment dated 8/5/2019 indicated, Initially patient reportedly coughing on nectar and puree with pocketing [storing food in cheeks] bilaterally [both sides]. Poor bolus formation (ability to manage food into pieces that can be swallowed safely). Resident 31 was admitted on [DATE] with diagnoses that included high blood pressure, anxiety and depression. In an interview on 5/4/2021 at 9:15 AM, Resident 31 stated that his bottom dentures were broken and the top dentures were not fitting correctly. In an interview on 5/4/21 at 9:38 AM, SS stated, [Resident 31] hasn't asked for a dental consult. If he wanted one we would take him to the dentist. The dentist makes the schedule. The dentist was last here on 4/16/2021 but just saw one resident. Normally the resident would let someone know that teeth are bothering them. A review of a physician order dated 2/3/2021 for Resident 31, signed by the medical director (MD) indicated: [Resident 31]: Tums chewable 500 mg PO three times daily as needed for heartburn, indigestion. A review of a physician order dated 2/3/2021 for Resident 31, signed by MD, indicated: [Resident 31]: Resident may be seen by dentist or hygienist while at facility Resident 64 was admitted to the facility on [DATE] with diagnoses that included heart failure, coronary artery disease and diabetes. In an interview on 5/4/2021 at 8:42 AM, Resident 64 stated that he needs his bottom dentures, when he eats he can't chew properly. He stated he doesn't remember when he last went to the dentist. Resident 64 stated that his bottom teeth hurt and he can't chew. He's been waiting for an appointment. He has a lower bridge but the adjacent teeth hurt him when he chews. Resident 276 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, heart failure and high blood pressure. In a concurrent observation and interview on 5/4/2021 at 9:00 AM, Resident 48 was observed to to have what appeared to be a large accumulation of soft white matter between his teeth, which were stained and dirty. Resident 48 stated, I was getting dental cleanings, but they're not taking me to the dentist. I got a 'cleaning' here, which amounted to some solution being put in my mouth and brushing my teeth. They don't do the scraping part. I don't want to lose my teeth. They're getting to where the gums are going down because they're not being cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 22 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety when 1) one of four ice machines was not maintained in a sanitary condition, 2) expired food was available for use in a refrigerator in the kitchen, and 3) food was not covered during transport to residents. These failures put the residents at risk for food borne illness and physical contamination of food. Findings: 1. During a concurrent observation of the [NAME] brand ice machine on Station 2 and interview on 5/5/21 at 10:25 AM with Facility [NAME] (PN) and Engineer (EN), the ice machine was opened and a white towel was used by PN around the inside of the ice chute within the machine. The white towel was noted to have a black substance on it. PN agreed that there was a black substance on the white towel. During a concurrent interview with Facility Manager (FM) on 5/5/21 at 11:04 AM, FM was shown the photo taken of the white towel. He agreed there was a black substance on the towel and that it should not have been there. During a concurrent interview and record review on 5/5/21 at 2:30 PM with FM and Maintenance Mechanic (MM), MM provided documentation from [NAME] that indicated the ice machine is to be cleaned at least semi-annually. MM also provided documentation that indicated he last sanitized the machine on 3/22/21. A review of the 2017 Food and Drug Administration (FDA) Food Code section 4-204.16 indicated that because of the high moisture environment, mold and algae may form on the surface of the ice bins. A record review of [NAME] ice machine manufacturer's instructions with unknown date, read, Cleaning and Sanitizing .Periodic cleaning of [NAME]'s ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate. 2. During the initial observation on 5/3/21 at 10:30 AM of the kitchen, a small refrigerator was noted next to the tray line. In this refrigerator, two turkey sandwiches were noted to have use by dates of 4/30/21. During a concurrent observation and interview on 5/3/21 at 10:30 AM, [NAME] (CC) agreed that the two turkey sandwiches had use by dates of 4/30/21. CC stated that they put sandwiches and other items that may need to be used during the plating of the meals and that the dietary staff was responsible for monitoring the dates and that food past the use by date should not be available for use. During an interview on 5/5/21 at 10 AM with Dietary Services Manager (DSM), she stated that the small refrigerator in the kitchen should be checked daily by the dietary aide. DSM stated that CC informed her of the outdated sandwiches that were found 5/3/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 23 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 A review of the facility policy titled Procedure for Refrigerated Storage, dated 2018, read, Food items should be arranged so that older items will be used first. A review of the facility's Refrigerated Storage Guide dated 2018, indicated that luncheon meats had a maximum refrigeration time of 5 days. Residents Affected - Some 3. During a concurrent observation on 5/5/21 at 12:09 PM and interview with the DSM, dietary aides were noted putting cut pieces of a custard pie on resident trays that were being taken to the residents for the noon meal. Some of these trays were placed on a food cart and the pie was partially covered with a hard plastic cover. DSM stated the cover was placed on the pie as those trays were on a cart that was not enclosed, so the pie needed to be covered as it was taken to the nursing floor to be served to the residents. A record review of the 2017 FDA Food Code read, Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 24 of 25 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent interview and record review, on 5/6/2021, at 7:00 AM, with Infection Preventionist (IP) and Minimum Data Set Infection Preventionist Nurse (MDS/IP), the general orientation checklist (GOC) for LVN K dated 5/14/2015 was reviewed. The IP and MDS/IP confirmed LVN K was oriented to infection control procedures including handwashing. Residents Affected - Few An interview on 5/6/2021, at 8:00 AM, with Administrator (ADM) and Director of Nursing (DON), confirmed, the facility policy and expectation for employees was to perform hand hygiene (hand washing or hand sanitizing), between the change of soiled to clean gloves while performing resident wound treatments. Based on observation, interview, and policy review, the facility failed to ensure a licensed vocational nurse (LVN) K perform hand hygiene while preformed wound care. This failure had the potential to spread infection from one resident to another, and cause an infection to a wound. Findings: During a concurrent observation and interview on 5/4/21, at 11:43 AM, with LVN K, in room [ROOM NUMBER]A, LVN K was performing wound care on Resident 66. LVN K removed a soiled dressing from Resident 66's stage 4 pressure ulcer(an open area with full-thickness skin and tissue loss). LVN K cleaned the wound then removed her soiled gloves. Without performing hand hygiene, she reached into her pocket and donned(put on) new gloves. LVN K indicated that she normally did not do hand hygiene between changing from soiled to clean gloves when she was working with the same resident. She was unaware that she should do hand hygiene between the change of soiled to clean gloves, while performing resident wound treatments A review of the facility's policy and procedure (P&P) titled, Infection Control-Handwashing-FTNS, reviewed 12/18/2019, indicated hand hygiene is required after removing gloves, and between contact with different patients. A review of the facility's (undated) policy and procedure (P&P) titled, Resident Care-Wound and Skin Management-FTNS, indicated that any resident who has a pressure sore will receive the necessary treatment and services to promote healing, prevent infections, prevent new ulcers/sores from development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 25 of 25