Inspection·April 20, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures when a used Emergency Kit (E-Kit, a storage box that houses an emergency supply of medications) was not removed and replaced according to facility policy. This failure had the potential for an E-Kit to have an insufficient amount of an emergency supply of medication available for the facility's residents. Findings: During an observation on 4/18/2023 at 1:34 PM, the E-Kit at nurse's station two of the facility had an E-Kit opened on 4/13/2023 at 12:53 PM, for a ipratropium bromide and albuterol sulfate inhalation solution (a combination medication for helping with shortness of breath), 0.5mg/3mg (milligram, unit of measure for weight), and again opened on 4/18/2023 at 1:40 AM for another ipratropium bromide and albuterol sulfate inhalation solution 0.5mg/3mg. During an interview on 4/18/2023 at 2:07 PM with Licensed Nurse (LN) 1, it was stated and acknowledged that the E-Kit was accessed on 4/13/2023 and had not yet been renewed by the pharmacy within 72 hours. She stated the E-Kit was once again accessed on 4/18/2023 and the pharmacy was called for a renewal of the E-Kit. During an interview on 4/20/2023 at 8:23 AM with the Director of Nursing (DON), the DON stated the pharmacy that was used to supply medications comes to the facility two times in a day to refill medication prescriptions. The DON acknowledged that this would have given multiple opportunities for the facility and pharmacy to renew and replace the E-Kit that was opened and accessed on 4/13/2023. A record review of a policy titled, Emergency Pharmacy Service and Emergency Kits, dated June 2016, indicated, If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 2 of 38 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 04/20/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. Expired pharmaceutical products were not removed from the medication cart (a cart where resident medications are stored and dispensed from) 2. Several medications did not have open date labels This failure had the potential for the administration of expired and ineffective medications to residents. Findings: 1. During an observation on 4/18/2023 at 1:45 PM of the medication room at nurse's station two in the facility, several expired medications were found in medication cart three that was stored inside the medication room. These expired medications included: Insulin glargine (a medication used to lower blood sugar), 100 u/mL (units per millimeter, unit of measure) that expired 4/11/2023, Insulin aspart (a medication used to lower blood sugar), 100 u/mL that expired 4/14/2023, azelastine eye drops (a medication used to treat itching eyes) that expired 4/6/2023, and Azopt eye drops (a medication used to decrease the amount of fluid in the eye) that expired 4/13/2023. During an interview on 4/18/2023 at 2:07 PM, with Licensed Nurse (LN) 1, she acknowledged that the medications were expired. During an interview on 4/20/2023 at 8:23 AM, with the Director of Nursing (DON), it was acknowledged that these medications were expired and pulled out of medication cart three. It was also stated that these medications should have been pulled out of the medication cart upon expiration. During a review of the facility's policy titled, Resident Care - Medication Administration, with a revision date of 3/17/2023, this document indicated that, If medication is discontinued, or outdated, remove medication for proper disposal. During a review of the facility's policy titled, Medication Storage in the Facility, dated June 2016, this policy indicated, Drugs shall not be kept in stock after the expiration date on the label . 2. During an observation on 4/18/2023 at 1:50 PM of the medication room located at nurse's station two in the facility, several medications were found in medication cart three that did not have open date labels according to the facility policy. The medications that did not have an open date label included: Insulin glargine, two separate containers of Artificial Tears (eye drops that provide moisture to dry eyes), Azopt eye drops, and Tuberculin Purified Protein Derivative Tubersol (used to inject medication to test for Tuberculosis, a lung disease). During an interview on 4/18/2023 at 2:15 PM with LN1, she acknowledged that each of these medications did not have an open date label, therefore it would be difficult to know of the expiration date of the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 3 of 38 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 04/20/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 4/20/2023 at 8:23 AM with the DON, it was acknowledged that these medications did not have an open date label in accordance with the facility policy. During a review of the facility's policy and procedure titled, Dating of Containers when Opened, with no date provided, indicated that, . Medications require the container to be dated when opened and discarded a number of days after opening . Eye drops . will need to have the date opened noted on the container . Event ID: Facility ID: 555430 If continuation sheet Page 4 of 38 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 04/20/2023 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: Residents Affected - Many 1. The facility did not have a qualified food and nutrition professional working full time in the kitchen for approximately six months prior to survey when the Food Service Manager was on leave of absence. 2. The Registered Dietitian (RD) did not conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed. 3. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility. 4. There was not an adequate or effective system in place to ensure staff training and competency in skills and knowledge required for food safety and sanitation. These failures had to potential to result in non-compliance with physician ordered diets, inadequate provision of nutrients, promote foodborne illness, and to negatively affect overall health for residents living in the facility. Findings: During an interview with the Food Service Director (FSD) over all hospital affiliated food service entities on 4/17/23 at 9:45 am, he stated he was employed by the contracted food services company they had been responsible for the facility's food services for the past two years. Review of a document containing the food service contractor logo and titled Position Profile, Position Title: Registered Dietitian II, signed by the RD on 11/22/21 was provided by the Interim Food Service Manager (IFSM) and Clinical Nutrition Manager (CDM). It showed the RD was responsible for providing comprehensive nutrition assessments and care planning for patients and residents with special needs, upheld the company's business practices, mission and values, and contributed to account revenue and profit through implementation of services. Technical duties and responsibilities included individualized nutrition assessments and care planning for residents, directing dietary care of residents, collaborates and communicates with culinary and clinical departments on established processes, special diets and menu requests .Ensures compliance with all federal, state and local regulations as well as (food and nutrition services [FANS] contractor)/ client policies and procedures. The job description did not include the requirement for the facility RD's regular oversight of the Food and Nutrition Services if the Food Service Manager was not a full-time Registered Dietitian. Review of an untitled, undated document provided by the IFSM and CDM showed Job Title General Manager 3 - Food. Position summary showed Directs all contract management service operations at a single account/unit .Hires and trains personnel, provides team leadership, controls unit financials, directs daily food operations for quality and safety standards, supervises day to day activities .monitors operating standards .establishes a safe work environment. Qualifications included a bachelor's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 5 of 38 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 04/20/2023 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 0801 degree, management experience, with RD, CDM or DTR (Diet Technician Registered) required. Level of Harm - Minimal harm or potential for actual harm 1. The facility did not have a qualified food and nutrition professional working full time in the kitchen for approximately six months prior to survey when the Food Service Manager was on leave of absence. Residents Affected - Many During an interview with the Registered Dietitian (RD) and Interim Food Service Manager (IFSM) on 4/17/23 at 9:30 am, they stated all food service staff including the RD and IFSM were employees of the contracted food services company. The IFSM stated she was new to the job, had been there for about a month, but previously worked for the FANS contractor at the hospital in a different capacity. The RD stated she worked as the facility's RD for approximately 16 months. During an interview with the FSD on 04/17/23 at 10:30 am he stated the (FANS contractor) did have a general manager over the facility's food service, but he had been on leave of absence, just resigned, with last day 4/21/23. During an interview on 4/19/23 at 8:55 am, the CDM and IFSM stated the previous Food Service Manager had been on leave of absence and worked intermittently for 6 months prior to his April 2023 resignation, and they were unable to replace him sooner due to his protected status. They reported many documents including in-service training were missing from the FANS office after he left. Review of the State Operations Manual (SOM) §483.60(a) Staffing showed the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Review of the SOM §483.60(a)(2) showed if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. Review of the SOM §483.60(a)(1)-(2) showed Full-time meant working 35 or more hours a week. 2. The facility's Registered Dietitian did not provide adequate or effective oversight of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed (Cross Reference F812, F805, F802). During multiple observations between 4/17/23 at 9:30 am and 4/19/23 at 5:00 pm, multiple staff did not adequately restrain their hair, and did not practice hand hygiene or glove use according to facility policy and professional standards of practice. In addition, various food preparation areas and equipment in the kitchen and in nursing food pantries were not sanitary. Staff did not practice or document ambient food cooling, did not follow food storage guidelines, did not check chlorine or quat sanitizer concentration properly, and did not clean fixed equipment according to professional standards of practice. The dish machine rinse and final rinse temperatures for did not display on the machine and DW 2 confirmed they had not been visible on the screen for quite a while. On 4/18/23 at 9:45 am a review of documents titled Dishwashing/Ware washing Machine Temperature Log, dated April 2023 for breakfast, lunch and dinner meal periods showed temperature requirements for high temperature machines, but did not show the required temperatures for the low temperature machine the facility used. The logs showed staff continued to log temperatures on the dish machine temperature log. There was no indication the RD or ITSM had reviewed the logs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 6 of 38 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 04/20/2023 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the IFSM, RD and CNM on 4/19/23 at 3:30 pm the IFSM stated she had never run the dish machine and was unable to answer questions about it. She confirmed to clean fixed equipment staff should wash with soapy water, rinse with clean water, then sanitize and air dry. She stated she did not know how often the meal carts were cleaned but they should be sanitized between meals. In further interview, the RD stated she did quarterly kitchen audits. The IFSM stated she and the RD had completed one kitchen audit together, then the FSD reviewed it, saw what needed to be done, and determined what the action plan should be implemented. The surveyor requested the kitchen audits performed by the RD during the past year. Kitchen audits completed by the RD were provided by the CDM and showed the RD performed audits semi-annually (twice) instead of quarterly (four times) in the past year as previously stated. They were dated 4/18/22 and 9/29/22. The kitchen audit dated 4/18/22 was titled Kitchen Observation and showed deficiencies with food labeling and dating, tray line temperature logs, dishwasher temperatures, testing quat sanitizer need correct strips, appropriate chemical test strips - see notes, if the facility had and followed a cleaning schedule - Manley working on. The nursing unit refrigerators were not observed. It showed food preparation equipment was clean and there was no evidence of pests. It also showed the facility menus met the needs of the residents with note to see separate audit. The words see notes was written next to 14 topics of concern, yet no notes were provided with the audit to provide further explanation. The kitchen audit conducted 9/29/22 used a different format, was titled (Facility) Kitchen Sanitation/Food Storage Audit and included the RD's name. It cited deficiencies for a dusty refrigerator, and lack of documented corrective action when refrigerator temps were outside the acceptable range. The RD documented that all other aspects of the food services were acceptable including all hair is completely covered with hair net, dish machine temps were correct, equipment and work areas were clean, handwashing and glove use were correct. 3. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility (Cross Reference F803). Resident complaints and a review of lunch tray tickets dated 4/17/23 showed inconsistent practices in provision of fortified (high calorie, high protein) diets. Fortified diets are generally ordered for residents experiencing weight loss, or poor meal intakes, or with extra nutritional needs such as for wound healing. A review of the facility diet manual signed by the hospital CDM 1/25/22 (but not signed by the facility RD) showed it did not contain any guidance for fortified diets. The diet manual also showed unmodified consistent carbohydrate diets should receive 5 to 6 servings of carbohydrate each meal. The lunch meal on 4/17/23 contained approximately eight servings of carbohydrate (Cross Reference F803). During an interview on 4/19/23 at 3:30 pm regarding fortified diets, the RD agreed there was no tool or guide for cooks/staff to follow, to know if they were providing the correct food and portions for the fortified diet. She confirmed there were no guidelines for the fortified diet in the facility's diet manual. I am not making any adjustments for fortified diets, and I am not checking calories. When asked how they would know if a resident was getting the correct food and portions (for example with fortified diets) on their trays per doctor's orders, the CNM stated they would know by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 7 of 38 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 04/20/2023 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 0801 resident weight changes (Cross Reference F803). Level of Harm - Minimal harm or potential for actual harm Resident complaints regarding too much curry on the menu prompted a review of vegetarian tray tickets for the five-week cycle showed vegetarian residents were served the same three curry recipes for 37% of their lunch and dinner meals. There was no vegetarian menu available for vegetarian residents to review if desired. Residents Affected - Many 4. There was not an adequate or effective system in place to ensure staff training and competency in skills and knowledge required for food safety and sanitation (Cross Reference F802, F812, F805). During multiple observations, interviews and record reviews in the kitchen during the survey the kitchen areas and equipment were not sanitary, adequate hair restraint was not ensured, staff hand hygiene and glove use did not comply with professional standards of practice, risk of cross contamination was not minimized, food was not stored properly, staff did not know how to monitor the dish machine for proper function or how to test chlorine or quat sanitizer concentration, or clean fixed equipment correctly. They did not know what size texture modified foods should be, and they did not monitor food cooling for TCS foods (Cross Reference F802, F812, F805). . Review of training checklists showed some of these topics were listed in a broad sense such as HACCP System and Potentially Hazardous Foods in training, but it is unknown what details of those topics were taught, not taught, or if the staff was competent in those required skills. Other topics such as ambient food cooling was not covered in policy, training checklists, or staff practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 8 of 38 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 04/20/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review the facility failed to ensure its staff were trained and competent to perform their duties according to professional standards of practice when: Residents Affected - Many 1. There was no evidence training occurred for Food and Nutrition Services (FANS) staff with longevity at the facility, and there was no evidence of evaluation of competency for any FANS staff. 2. Staff did not perform hand hygiene or change gloves between tasks. 3. Staff did not adequately restrain hair or facial hair. 4. There was an overall lack of sanitation in the kitchen and nursing food pantries. 5. Equipment was not cleaned according to professional standards of practice. 6. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control for Food Safety) foods prepared at ambient temperature. 7. Staff did not recognize when the dish washer did not function correctly and did not describe or perform the correct process for checking chlorine concentration. 8. Staff did not describe or perform the correct process for checking quat sanitizer or its use in cleaning fixed equipment. 9. Staff did not chop meat according to diet manual standards. 10. Food was not stored, labeled, and dated correctly. These failures had the potential to result in foodborne illness for all residents receiving meals from the facility, and the potential to cause residents requiring chopped food to choke, have decreased meal intakes, or inability to self-feed. Findings: During an interview with the Registered Dietitian (RD) and Interim Food Service Manager (IFSM) on 4/17/23 at 9:30 am, they stated all food service staff including the RD and IFSM were employees of the contracted food services company. During an interview with the Food Service Director (FSD) over all hospital affiliated food service entities on 4/17/23 at 9:45 am, he stated he was employed by the contracted food services company they had been responsible for the facility's food services for the past two years. Review of a facility document titled Policy: Competencies of Food and Nutrition Support Staff, revised 12/5/22 showed support staff would be trained using on-the-job training and monthly in-services provided by the Food Service Manager or the RD. A competency checklist will be reviewed for each support staff member (cooks, food service workers, utility workers, etc.) to ensure they are competent in all required areas for the preparation and service of palatable, attractive meals and maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 9 of 38 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 04/20/2023 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 0802 of sanitary standards. Level of Harm - Minimal harm or potential for actual harm Review of a facility document titled Policy: In-service Training, revised 10/26/22 showed The Food & Nutrition Services Department conducts competency (in-service) training on an ongoing basis for all full-time and part-time employees for all shifts .A record of each class will be kept on file for a minimum of 3 years. A Competency Training Manual shall be established with current data on the schedule/frequency of classes, topics and lesson plans, records of participation and evaluation. Residents Affected - Many Review of an untitled Food and Nutrition Services (FANS) Staff Schedule dated 4/16/23 through 4/22/23 defined five positions in the kitchen: Manager, Lead Worker, Cooks, Diet Aids, Dishwashers. It identified 14 current staff, one staff as Manager, one staff as Lead Worker, five staff as Cooks, four as Diet Aids and three as Dishwashers. Seven documents provided by the IFSM titled Position Profile, March 2016 contained the food service contractor's logo and individual subtitles for positions [NAME] 1, Dietetic Clerk, Food Prep Helper, Trayline Attendant, Utility Worker, Healthcare Host/Hostess, and Cashier/Food Service Worker. Only one of seven position titles (Cook) aligned with the titles identified on the schedule or with how staff identified themselves when introducing themselves during survey. Only pages one and three were provided for 7 of 7 job descriptions, with the contents of page 2 unknown. Further review of the seven job descriptions showed they all required Complies with all (food service contractor) HACCP (Hazard Analysis Critical Control Points - Food safety practices) policies and procedures; clean and sanitize workstations and equipment following all (food service contractor), client and regulatory rules and procedures; attend allergy and foodborne illness in-service training. The Cook's Position Profile also showed Prepares food in accordance with current applicable federal, state and corporate standards, guidelines and regulations to ensure high-quality food service is provided .Prepares foods under direct supervision or instruction by operating a variety of equipment (in food preparation). 1. There was no evidence of training for Food and Nutrition Services (FANS) staff with longevity at the facility, and there was no evidence of evaluation of competency for any FANS staff. During an interview with the Food Service Director (FSD) over all hospital-affiliated food services on 4/19/23 at 8:55 PM he stated food safety, and health and safety were monthly in-service topics pre-determined by the food service contractor. New staff completed facility/Human Resources (HR) orientation requirements before starting to train in the kitchen. TOPS - Teach our People Safety was the food service contractor's in-service program. Orientation took about 4 hours. Staff sat down and received some verbal training and some video trainings. It included topics such as acknowledgement of the Employee Handbook, safety shoes requirement, uniforms. The HR portion was done in the first 30-45 minutes. Then staff started their kitchen training. They shadowed and trained with another staff for 1-2 weeks (depending on individual employee needs) and started participating in the work as they progressed. Then staff were put into their roles. The FSD stated managers knew staff competency by watching them. He further stated there were no staff competency forms or documentation of staff competency. On 4/20/23 at 9:14 am staff training and competency checklists were requested for seven FANS staff including four Cooks, one Diet Aide (DA), and two Dishwashers (DW). The Clinical Nutrition Manager (CNM) provided documents for four staff (Cook 2, [NAME] 4, DA 3, and DW 2), but stated they had no evidence of training or competency for the other three staff (Cook 1, [NAME] 3, DW 3) who had been at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 10 of 38 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 04/20/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the facility for a long time. There were no documents provided that indicated any staff in the FANS department were evaluated for competency. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster Include in every employee's file as of hire date showed places to insert the employee's name, hire date/position, and trainer(s), and an Employee Sign-off signature and date. All positions (Cook, Diet Aide, Dishwasher) had the same training checklists. The checklists showed handwashing, correct use of gloves, personal hygiene, HACCP system/potentially hazardous foods, critical control points, preventing cross contamination, thermometers use and calibration, food allergens, temperature logs, food temperatures, food cooling, hot and cold food holding must be covered during the first 10 days of starting a position. The showed handling service-ware and utensils, receiving and storing food, cleaning and sanitizing must be covered in training within 60 days of working in a food handling position. During an interview with the Clinical Nutrition Manager (CNM) and IFSM on 4/20/23 at 8:55 am they stated they had minimal in-service documentation available. They stated the previous Food Service Manager had been on leave of absence, was intermittently at work for six months prior to his resignation in April 2023, and they learned after he left that information was absent regarding in-services completed prior to 2023. 2. Staff did not perform hand hygiene or change gloves between tasks (Cross Reference F812). A review of the facility's policy titled Disposable Glove Use dated 10/26/22, the policy indicated, All personnel shall wash their hands each time before gloves are put on. Gloves shall be discarded after each use and if they are soiled, torn or contaminated. During multiple observations in the kitchen between 4/17/23 at 9:30 am and 4/19/23 at 5:00 pm, staff (Cook 2, [NAME] 3, DA 3, DA 4) were observed to touch multiple potentially contaminated surfaces (trash can, refrigerator handles, stove knobs, soiled dishes) with their gloves on, and return to food preparation activities without changing their gloves or washing their hands. During multiple observations in the kitchen between 4/17/23 at 9:30 am and 4/19/23 at 5:00 pm, multiple staff (Cook 2, [NAME] 4, DW 2, DA 3, DA 4) did not wash their hands before donning gloves, or between doffing soiled gloves and donning new gloves. During an observation in the kitchen on 4/17/23 at 11:44 am, five kitchen staff assembled resident's lunch trays on tray line. When a dietary aide rang a bell, five of five staff doffed (took off) their gloves, donned (put on) new gloves, and continued to prepare residents food trays. The did not wash their hands prior to donning new gloves. During an interview on 04/18/23 at 3:40 PM, with the Registered Dietitian (RD) and the Interim Food Service Manager (IFSM), the RD indicated that kitchen staff were to change their gloves every 30 minutes, and staff were supposed to wash their hands when they changed their gloves. During an interview on 4/19/23 at 2:05 PM, [NAME] 2 stated he did not always have time to wash his hands between glove changes. Review of a policy titled Food Safety revised 10/26/23 showed Employees must wash hands before beginning/returning to work or when necessary, during work .and maintain good hygienic practices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 11 of 38 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 04/20/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for [NAME] 2 (8/26/22), [NAME] 4 (9/6/22), DA 3 (5/31/22), and DW 2 (5/31/22) showed they were trained in handwashing procedures and correct use of gloves, but there was no evidence staff competency was evaluated, and staff practice did not follow food safety standards of practice. Residents Affected - Many 3. Staff did not adequately restrain hair or facial hair (Cross Reference F812). Review of a policy titled Food Safety revised 10/26/23 showed Employees wear approved hair restraints .Men with beards and/or mustaches must wear appropriate beard restraints. A review of the facility's kitchen audit tool titled Fountains Kitchen Sanitation/Food Storage Audit dated 9/22 and completed by the RD indicated Hair is covered completely with hair net. During multiple observations in the kitchen between 4/17/23 at 9:30 am and 4/19/23 at 5:00 pm, [NAME] 2 and [NAME] 3 did not wear beard nets to cover their beards and mustaches, but intermittently wore surgical masks with their mustaches still exposed. [NAME] 4 wore a hair net but had hair hanging out and the hairnet did not cover the lower two inches of her hair in the back. During an interview on 4/19/23 at 3:30 pm with the IFSM, CNM and RD, the IFSM stated their hairnets policy stated there should be no loose hair, and hair, including hair buns should be fully covered. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for [NAME] 2 (8/26/22), [NAME] 4 (9/6/22), DA 3 (5/31/22), and DW 2 (5/31/22) showed the topic personal hygiene and defined subtopics regarding jewelry, nail polish and fingernail hygiene, but did not list hair restraint requirements as part of training. 4. There was an overall lack of sanitation in the kitchen and nursing food pantries (Cross Reference F812). During multiple observations in the kitchen between 4/17/23 at 9:30 am and 4/19/23 at 5:00 pm the kitchen and its equipment were not sanitary. Multiple pieces of equipment had an accumulation of grime, food debris or food residue including the blender and food processor bases, knife rack, knives, food scale and serving utensils. The range and ovens had black grime and food debris on their surfaces and knobs. There was food splatter on the walls. The cook's white cutting boards on the steam table and in the corner near the oven had deep black knife cuts that could be a potential haven for microbial growth. The plate warmer was soiled with brown grime and food crumbs. The Coffee Room equipment storage and supply shelves dusty, the floor had black grime and food debris under the cabinet, and an ant crawling on the floor. The hood above the dish machine had a buildup of black grime and dust. There was further potential for cross contamination in relation to kitchen sanitation practices when cooks placed rinsed wet blender and food processor containers back on their bases, ready for use when they had not been washed and sanitized after use, and when cooks stacked soiled dishes in the food preparation sinks and counters where food was concurrently handled. During observations of the three, nursing unit resident food pantries on 4/18/23 at 4:20 pm, they contained soiled dishes in the sink, soiled refrigerators. Food and food supply cabinets were soiled with food debris, sticky substances, and dead ants. In concurrent interviews the RD confirmed these (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 12 of 38 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 04/20/2023 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 0802 spaces were dirty. Level of Harm - Minimal harm or potential for actual harm Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for [NAME] 2 (8/26/22), [NAME] 4 (9/6/22), DA 3 (5/31/22), and DW 2 (5/31/22) showed Within 60 Days they were trained on Cleaning and Sanitizing, and Cleaning and Sanitizing Food Contact Surfaces, Optional: Inspector HACCP video You Call That Clean? There was no evidence provided regarding staff competency in cleaning, and the kitchen and food pantries were found to be unsanitary. Residents Affected - Many 5. Equipment was not cleaned according to professional standards of practice (Cross Reference F812). Review of the 2022 FDA Food Code 4-603.15 and 4-603.16 showed a distinct 3-step process to clean fixed equipment including washing with detergent to remove all food residue and other contaminants, rinsing with clean water to remove abrasives and cleaning chemicals, and sanitizing to ensure microorganisms are reduced to a safe level. During an observation and concurrent interview with DA 3 on 4/19/23 at 10:00 am she used a rag to wipe down resident meal carts with sanitizer solution. In a concurrent interview she stated the process to clean the carts was to wipe them down with sanitizer, especially the top and bottom rungs the trays sit on because sometimes things spill on them. She stated I wish we could deep clean them better because some of the crevices and corners looked dirty. During an interview with [NAME] 4 on 4/18/23 at 10:08 am she stated she cleaned her area at the end of her shift including tray line. She stated she wiped off the food, wiped everything down with a sanitizer cloth, then dried off all the surfaces including inside of the wells with a clean new disposable cloth to ensure everything was dry and ready for the next shift. During an interview on 4/19/23 3:30 PM, the IFSM stated to clean fixed equipment, staff should wash with soapy water, rinse with clean water, then sanitize and air dry. She did not know how often the meal carts were cleaned but they should be sanitized between meals. A review of AM Dishwasher Cleaning Logs dated 4/9/23 - 4/15/23 included assignments to sweep and mop dry storage, carts area and coffee room daily; clean and sanitize meal carts after each meal; clean coffee room shelves on Monday, and wash hood in dish room on Friday. A review of their Kitchen Audit tool titled Kitchen sanitation/Food storage Audit dated 9/22, indicated the cook's work area, worktables and prep areas were to be clean, cutting boards clean with no deep knife marks, food processors clean, range, oven, grill clean and grease free, cutlery/rack clean and dry vegetable prep sink clean and work and prep tables clean and sanitized properly. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for [NAME] 2 (8/26/22), [NAME] 4 (9/6/22), DA 3 (5/31/22), and DW 2 (5/31/22) showed Within 60 Days they were trained on Cleaning and Sanitizing, and Cleaning and Sanitizing Food Contact Surfaces, Optional: Inspector HACCP video You Call That Clean? There was no evidence provided regarding staff competency in cleaning, and the kitchen and food pantries were found to be unsanitary. 6. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 13 of 38 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 04/20/2023 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 0802 for Food Safety) foods prepared at ambient temperature (Cross Reference F812). Level of Harm - Minimal harm or potential for actual harm The 2022 FDA Food Code 3-501.15(B) showed Time/temperature control for safety food shall be cooled within 4 hours to 41°F (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Residents Affected - Many Further review of the 2022 FDA Food Code Annex 3, 3-501.15 showed Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for food safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During an interview with Diet Aide 1 (DA 1) on 4/17/23 at 10:35 am she stated she worked at the facility for 16 years. In an additional interview with Diet Aide 1 (DA 1) on 4/19/23 at 9:45 am she stated she prepared sandwiches for residents, including egg salad, tuna salad, or chicken salad. She explained she made tuna salad using tuna from the dry storage room, added mayonnaise and pickle relish from the refrigerator. She made egg salad using purchased pre-cooked hard-boiled eggs, pickle relish, mustard, mayonnaise, and pepper. DA 1 added she preferred to put the ingredients together ahead of time and put it in the refrigerator so the flavors could meld. She stated she did not take the temperature when she made the egg/tuna/chicken salad but took the temperature before she made the sandwiches to make sure it was cold for the residents. DA 1 stated it should be less than 40°F, and she did not keep a temperature log. Review of a policy titled Food Safety revised 10/26/23 showed All TCS foods must meet the following temperature requirements during storage, preparation, display, service and transportation .HACCP temperature logs for potentially hazardous foods and for refrigerators and freezers are completed and kept on file for 12 months. The policy did not direct staff to monitor the temperature of TCS foods such as egg salad, tuna salad and chicken salad from ingredients at ambient temperature. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for DA 3 dated 5/31/22 showed she had been trained by DA 1. It included the topic cooling foods, but it did not identify monitoring food cooling for TCS foods made with ambient temperature ingredients. This presented a compounded problem when the facility's food cooling policy did not describe ambient food cooling, the training checklist did not include ambient food cooling, and the trainer, DA 1, did not monitor ambient food temperature cooling with foods such as tuna so was unlikely to teach that to new staff. 7. Staff did not recognize when the dishwasher was not functioning correctly, did not describe or perform the correct process for checking chlorine concentration (Cross Reference F812). The function of the dishwashing machine is vital in protection of residents from the spread of disease. If dishes aren't properly cleaned and sanitized microbes can spread from one person to the next through contaminated dishes. During an observation in the dish room on 4/19/23 at 10:20 am, the manufacturer's plate on the dish machine showed when used as a (low temperature) chemical sanitizing machine the wash temperature should be minimum 130°F (degrees Fahrenheit), the rinse temperature should be minimum 120°F, and the final rinse should be minimum 120°F. In a concurrent interview DW 2 stated the machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 14 of 38 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 04/20/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm used a chemical to sterilize the dishes. DW 2 stated the wash temperature should be 140 degrees or greater, however the Final Rinse temperature hasn't shown anything except XXX for a long time. In further observation, the Opti-Rinse screen on the dishwasher showed the wash temp was 140 degrees, the middle of the screen was blank, and the right side of the screen showed Final Rinse XXX °F. The screen did not show the first rinse temp at all. Residents Affected - Many In continued interview, DW 2 was asked how he knew the chlorine was working to sanitize the dishes. He explained and then demonstrated three times how they ran a chlorine sanitizer strip through the dish machine on a rack with result less than 10 ppm sanitizer when it should be 100 ppm. The FSD was asked to assist with the process. He confirmed the final rinse cycle did not register a temperature and that was a problem. He confirmed that one of the containers with test strips was expired. The FSD then tested the chemical concentration by putting a dish thought the dish machine then immediately touching the dish with the test strip when it came out. The strip color registered at 100 ppm. On 4/18/23 at 9:45 am a review of documents titled Dishwashing/Ware washing Machine Temperature Log, dated April 2023 for breakfast, lunch and dinner meal periods showed temperature requirements for high temperature machines, but did not show the required temperatures for the low temperature machine the facility used. The form defined desirable chemical sanitizer concentration as 50-100 ppm. Multiple staff documented wash, rinse, and final rinse dish machine temperatures on the logs despite the malfunctions identified above, as reported by staff, and confirmed by the FSD. Multiple staff documented sanitizer concentration values on the logs ranging 100 ppm to 140 ppm. There was no evidence the logs were being monitored by the IFSM or RD. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for DW 2 dated 5/31/22 showed training within the Completed within 60 days section, for the topic Cleaning and Sanitizing, washing pots and pans, and food contact surfaces. It did not indicate that training and competency on the dish machine use and care, or testing chlorine concentration had occurred. 8. Staff did not describe or perform the correct process for checking the concentration of quat sanitizer (Cross Reference F812). Review of a policy titled Food Safety revised 10/26/23 showed Clearly labeled sanitizer of the proper concentration must be available and used to sanitize all food-contact surfaces of stationary equipment, i.e., work counter/tables. Sanitizer test strips must be used to ensure proper concentration. During an observation in the kitchen near the three-compartment sink on 4/19/23 at 10:00 AM, a sign posted on the wall from the facility's chemical vendor showed (quaternary ammonia, Quat or QAC) sanitizer was an agent that killed bacteria, viruses, mold and fungi. DA 3 used a red bucket of solution and a rag to clean resident meal carts. In a concurrent interview DA 3 stated the red bucket contained sanitizer and demonstrated how test the sanitizer concentration using test strips. There was confusion among DA 3, [NAME] 1 and DW 2 regarding which of two bottles of test strips should be used and what the correct concentration should be. DW 2 and DA 3 thought 100 ppm was the correct concentration. A concurrent review of the test strip instructions indicated the proper range was 200-400 ppm. DA 3 tested a new bucket of sanitizer at 300 ppm and confirmed the correct ppm was 200-400 ppm, not 100 ppm as she previously thought. During an interview on 4/19/23 at 10:15 AM, the FSD explained that the facility had switched to Diversey from Ecolab in February 2023. He continued to explain the Ecolab strips had been left over (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 15 of 38 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 04/20/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many from the switch. The FSD confirmed that the quat sanitizer range should be 200-400 ppm. He stated, But they are both quat, so you would think you should be able to use either one. The two test strip packages were re-examined, and the FSD confirmed the Ecolab package had three color match choices, while the Diversey package had six. During an observation of the three-compartment sink and concurrent interview with DW 3 on 4/19/23 at 2:45 pm he explained how to test the quat sanitizer concentration in sink #3 and stated the goal was 100-200 ppm. He did the testing process. Test strip showed 300-400 ppm. He stated, So it's a little high? The test strip instructions indicated the proper range was 200-400 ppm. During an interview on 4/19/23 at 3:30 PM IFSM confirmed that the Quat test strips should be dipped for 10 seconds, and concentration color should be 200-400 ppm in sanitizing buckets and the final rinse sink. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for DA 3, dated 5/31/22 included topics Cleaning and Sanitizing, Washing Pots and Pans, and Food Contact Surfaces, Optional: Inspector HACCP video You Call That Clean? It did not show a topic for training or competency regarding checking sanitizer concentration and did not show the three-step process (wash, rinse, sanitize) that should be used for cleaning pots and pans and food contact surfaces. 9. Staff did not chop meat according to diet manual standards and were unclear regarding the correct size modified textures should be (Cross Reference F805). During an observation on 4/17/23 at 11:33 am, Resident 38's lunch tray arrived containing egg whole noodles, whole Swedish meatballs, and a half garlic bread stick. Her tray ticket indicated she was on a renal diet with regular texture, thin liquids, high protein, and chopped meats. Resident 38 required help with eating, and a staff member was in to assist. During an observation and concurrent interviews with [NAME] 2 and [NAME] 4 on 4/18/23 at 9:55 am, they modified textures of food for lunch using blenders and food processors. [NAME] 2 prepared mechanical soft textures. He stated he pulsed it until it was the right size. When asked what that size should be he stated he guessed that would be about 1/8 inch, and he pulled out any chunks that were too large. [NAME] 4 stated I was told they should be small enough to fall off the fork, but big enough to stay on the fork. A review of the policy titled Texture Modified Diets revised 10/26/22 showed Whole meats for mechanical soft diets will be chopped and served with gravy or sauce to promote ease of chewing/swallowing. Follow the (Food Service Contractor) Diet Manual for Health Care Communities instructions for mechanical soft diet. Review of the diet manual showed it contained the IDDSI 6 guidelines. During an interview on 4/19/23 at 3:30 pm, the Interim Food Service Manager (IFSM) and the Clinical Nutrition Manager (CNM) stated chopped food should follow IDDSI level 6 guidelines where small/bite size pieces would measure approximately 1.5 cm (about ½ inch). The surveyor shared a photo of Resident 38's lunch meal from 4/17/23. The RD and IFSM confirmed Resident 38's diet order was chopped meats and the Swedish meatballs served to her were too large and were not bite size. They confirmed the meatballs should have been chopped up and they were not. Review of a food service contractor document titled New Hire - Two Step Food Safety Training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 16 of 38 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 04/20/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Program Training Roster for [NAME] 2 (8/26/22) and [NAME] 4 (9/6/22) provided no evidence that staff training or competency occurred regarding the texture modification of food in regard to resident safety in chewing, swallowing and self-feeding. 10. Food was not stored, labeled, and dated correctly (Cross Reference F812). Residents Affected - Many Review of a policy titled Food Safety revised 10/26/23 showed All foods prepared in operation must be covered and labeled as to the contents and date of preparation prior to storage in refrigerators and freezers. Labels for TCS foods must also include time of storage. A use-by date should be specified. Review of a policy titled Labeling & Dating dated 10/26/22, showed All foods are labeled, dated, and securely covered, and use-by dates are monitored and followed. During observations of the walk-in refrigerator on 4/17/23 at 9:45 AM, bags of pre-cut butternut squash had a received-on date 3/20/23 and were mushy with a milky liquid around them. One bag of pre-cut onion/carrot/celery mix had translucent slimy onions. Portioned salads, with a prepared date of 4/16, use by date of 4/29, appeared like the lettuce had been frozen. [NAME] 1 stated the refrigerator got too cold for the salads and confirmed the diced squash and onion/carrot/celery were not in good shape and should be tossed. During an observation of the walk-in refrigerator and interview with the FSD on 4/17/23 at 9:48 the FSD confirmed the labeling/dating on the Lactaid milk in the walk-in refrigerator was incorrect. During an observation in the cold food preparation room on 4/17/23 10:35 AM, the refrigerator contained two frozen heads of iceberg lettuce. In a concurrent interview the FSD stated we will not be using this. In addition, a large plastic bin that contained a substance resembling rice had no label or date. The FSD stated it was brown rice and confirmed there was no date or label. During an interview on 4/19/23 at 8:55 AM, the FSD explained that short-dated or expired pre-cut produce should be caught and sent back at delivery. If product was expired, for example the squash and Mirepoix (carrot/celery/onion mix) it should have been discarded. During an observation in the walk-in refrigerator on 4/19/23 at 9:10 AM a plastic bag of diced potatoes was not closed and had no opened-on date. The FSD stated whenever staff opened a bag of produce, they were supposed to remove it from the bag and put it in a plastic storage container. The FSD confirmed the bag of diced potatoes was open, should not be like that, and should have been put in a Lexon (plastic container) for storage. Review of in-service documents titled Food Labeling and Dating, dated 10/27/22 showed [NAME] 1, [NAME] 1, [NAME] 2, [NAME] 4, DA 1, DA 3, DW 2, DW 3, and the RD attended. The lesson stated Labeling and dating items is an important step in preventing foodborne illness, and food waste. Proper labeling and dating will ensure spoiled items are discarded, not consumed, and can prevent errors with recipe ingredients. It did not show what information should be on the label or what the dating parameters should be. Staff performed a five-question quiz highlighting everyone was responsible to perform labeling and dating and that it was an important component in preventing foodborne illness. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for [NAME] 2 (8/26/22), [NAME] 4 (9/6/22), DA 3 (5/31/22), and DW 2 (5/31/22) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 17 of 38 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 04/20/2023 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 0802 showed Within 60 Days they were trained on receiving and storing food and chemicals, receiving temperatures, perishables storage, and dry storage, yet food was not stored properly in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 18 of 38 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 04/20/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure menus were in place to adhere to diet orders or meet residents needs when: 1. The facility-specific diet manual provided no indication that the Registered Dietitian responsible for nutrition care at the facility had reviewed and approved the diet manual. 2. The facility-specific diet manual did not contain guidelines and the facility did not have a consistent system in place for provision of fortified diets ordered by providers. 3. Consistent Carbohydrate Diet meals did not match the carbohydrate guidelines in the diet manual. 4. Meals planned for residents receiving Plant Based/Vegetarian diets had little variety and there was no menu posted or available for their use. 5. The facility did not have an effective tool or system in place to monitor or evaluate the accuracy of resident meal trays in relation to the diet order. These failures had the potential to result in meals that did not meet resident nutritional needs or comply with doctors' orders, leading to a decline in health status and quality of life. Findings: 1. The facility-specific diet manual provided no indication the facility's Registered Dietitian (RD) had reviewed and approved the diet manual. Review of a policy titled Long-Term Care Diet Manual revised 10/26/22 showed the diet manual Serves as a guide in meal planning for differing conditions and needs, aiding physicians in prescribing modified diets, and assisting health care staff to interpret and carry out diet orders .The manual should include a list and description of the standard and unit-specific diet orders that a physician may order .The manual is signed and approved by the medical director, administrator and qualified dietitian annually. State of California Facilities Letter (AFL) 14-32 reminds facilities that the nutritional needs of patients must be met through menu development in accordance with the physician's diet orders, as delineated in the facility diet manual. The analysis of the menu is the foundation of meal planning to assure that the menu meets the nutritional needs of the patient and are in accordance with the physician ordered diet. Review of the facility document titled (Food Service Contractor) Diet Manual for Health Care Communities revised 2020, showed it was evaluated and approved by members of the Patient Care Policy Committee including the administrator, medical director, Dietary Supervisor and the Clinical Nutrition Manager (CNM) from the Hospital, as well as other positions from housekeeping, marketing, maintenance, rehab and medical records in January 2022. It did not include the signature of the Registered Dietitian who, at time of survey, had been the facility's dietitian for 16 months and was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 19 of 38 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 04/20/2023 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 0803 the nutrition care of its residents. Level of Harm - Minimal harm or potential for actual harm During an interview with the RD, CNM and Interim Food Service Manager (IFSM) on 3/19/23 at 3:30 pm, the RD stated all diets ordered in the facility were in the Diet Manual. Residents Affected - Some 2. The facility-specific diet manual did not contain guidelines or have a consistent system in place for provision of fortified diets ordered at the facility. A review of lunch tray tickets on 4/17/23 at 11:05 am showed Resident 26 was on a consistent carbohydrate (CCHO), mechanical soft, thin liquids, vegetarian, no eggs, fortified diet. The foods listed on his tray ticket included Madras Vegetable Curry (1 cup), white rice (½ cup), banana cream pie (one slice), skim milk (8 oz), unsweetened apple juice (4 oz), and Buttery Spread (3 piece), with a note to add extra vegetables and butter. Review of ten fortified diet lunch tray tickets (Residents 17, 26, 52, 69, 84, 92, 103, 108 and 112), dated 04/17/23, showed 6 out of 9 residents (Residents 52, 69, 84, 92, 108 and 112) were provided with whole milk (160 calories) instead of skim (100 calories). One out of nine residents (Resident 26) were provided with three buttery spreads (90 calories) instead of one (30 calories) for extra calories. Ten out of ten residents on fortified diets received Banana Cream Pie. Review of the (Facility) Weekly Menu Week 4 showed the Banana Cream Pie was a standard menu item (not extra calories or protein) for Regular, CCHO, and Low Sodium Diets. Review of the facility's diet manual, titled (Contractor) Diet Manual for Health Care Communities revised 2020, showed these Guidelines for Diet Order Interpretation: If a High Calorie, High Protein diet was ordered, it would be provided as a Regular Diet (Fortified). The diet manual did not provide any further reference to the High Calorie, High Protein/ Fortified diet or how a diet would be modified to achieve it. During an interview with the RD, CNM and Interim Food Service Manager (IFSM) on 3/19/23 at 3:30 pm, the RD stated all diets ordered in the facility were in the Diet Manual. When asked about fortified diets she explained it included cheese, higher fat milks, extra sauces, gravy, and extra butters. The RD stated the facility had no specific guide or plan for fortified foods. I am not making any adjustments for fortified diets, and I am not checking calories. She stated she recommended fortified diets, and the doctors ordered them. The RD was asked why Resident 26 who was on a consistent carbohydrate (CCHO) fortified diet received skim milk instead of whole milk like other fortified diet residents. She checked his record, and it showed no preference for skim milk. She stated he probably received the skim milk because it was the default milk for the CCHO diet and was not caught. The RD agreed there was no tool or guide for cooks/staff to follow, to know if they were providing the correct food and portions for the fortified diet. She confirmed there were no guidelines for the fortified diet in the facility's diet manual. When asked how they would know if a resident was getting the correct food and portions (for example with fortified diets) on their trays per doctor's orders, the CNM stated they would know by resident weight changes. 3. Consistent Carbohydrate Diet meals did not match the carbohydrate guidelines in the diet manual. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 20 of 38 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 04/20/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm During an observation and concurrent interview on 4/17/23 at 12:37 pm, Resident 23 stated she received pie or cake every day on her meal tray but continuously told facility staff she didn't want it because she was diabetic. She received her lunch tray that included banana cream pie and again stated she did not want it because she was diabetic and couldn't eat that. She stated the dietician had never been in to see her that she could recall. Residents Affected - Some Review of Resident 23's medical record showed she was most recently admitted [DATE] following a stroke and had Type 2 diabetes. Her diet order was Consistent Carbohydrate, thin liquids, mechanical soft. During an interview with Resident 33 on 4/17/23 at 2:40 pm, she stated I'll eat pudding and cake, I don't know why they send it though. I'm diabetic. I'd rather have a baked potato and some butter with gravy and a piece of meat and a vegetable. That's how I'm accustomed to eating. Review of Resident 33's medical record showed she was admitted [DATE] had Type 2 Diabetes. Her diet order was Consistent Carbohydrate, thin liquids, mechanical soft, with special instructions for bite size, extra sauce/gravy, no straws, regular texture salads allowed. The American Diabetes Association website guidelines for healthy living with diabetes, accessed April 2023, encouraged a consistent carbohydrate diet to minimize spikes and drops in blood glucose (sugar) levels. To avoid blood sugar spikes, it helps to eat a consistent amount of carbs (carbohydrates) at meals throughout the day. Spikes or elevation in blood glucose damages blood vessels resulting in complications of diabetes. Spikes and drops in blood glucose can make a resident feel unwell, lack energy, and other negative symptoms. Review of the facility diet manual's Chapter 6 Consistent Carbohydrate Diet showed the goals of the diet were to provide a nutritionally adequate diet, maintain blood glucose and lipids (fats) as close to the resident's target goals as possible, and help prevent or treat complications associated with diabetes mellitus. It described the meal pattern as three meals and one snack each day, with consistent mealtimes and portion sizes to provide greater glycemic control and decrease the risk of malnutrition. Carbohydrate values are determined from the American Diabetic Association Exchange List for Meal Planning with 1 CHO (carbohydrate serving) = 15g (grams) and 5-6 CHO (carbohydrate servings) per meal dependent on the individual. Order as Consistent Carbohydrate Diet. Review of facility documents titled Nutrient/Cost Analysis Summary - Season's Harmony 2021 (Spring), printed 4/17/23, contained one page of nutrient analysis for each of the five weeks of the menu cycle. These documents also showed the consistent carbohydrate diet (CCD) contained 5-6 (servings) of carbohydrate each meal. Review of the (Facility) Weekly Menu, Week 4 Consistent Carbohydrate Diet showed that for lunch on Monday 4/17/23, residents on a consistent carbohydrate diet (CCHO) should receive Garden Salad, Penne Pesto Vegetables with Sausage, Garlic Knot (roll), and Banana Cream Pie. Review of the CCHO lunch tray tickets included the following carbohydrate (CHO) foods and serving sizes: Penne Pasta Vegetables with Sausage (1 each), Banana Cream Pie (1 slice), Garlic Knot (1/2 each), Skim Milk (8 oz), Sugar Free Apple Juice (4 oz). Review of a document titled, The (Facility) Production Counts, dated 4/17/23 showed portions available for Banana Cream Pie were 1 slice, ½ slice, and 1 ½ slice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 21 of 38 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 04/20/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Use of the facility diet manual's CCHO exchange lists and the manufacturer's nutrition label for Banana Cream Pie (provided by the IFSM) to evaluate this meal showed approximately eight servings /120 grams(g) of carbohydrate and was not aligned with facility's diet manual or American Diabetes Association guidelines for 5-6 servings per meal. Approximate CHO in this meal was: 1/3 cup Pasta = 15 g (but appeared greater than 1/3 cup pasta per serving during tray line), ½ each Garlic roll = 15 grams of CHO, Milk = 12 g, apple juice = 15 g. The manufacturer's nutrition label for the banana cream pie showed 1 slice contained 63 g CHO = 4 servings CHO. During an interview on 4/19/23 at 3:30 PM with the IFSM, RD, and CNM, they stated they did not know the goal for how many servings or grams of CHO should be on each consistent carbohydrate diet tray. The CNM stated We don't do exchanges here. They were unable to describe how they would know CCHO diets were appropriate to meet resident needs. 4. Meals planned for residents receiving Plant Based/Vegetarian diets had little variety and there was no menu posted or available for their use. During an interview with Resident 134 on 4/17/23 at 9:45 am she complained she received chickpea curry or tofu curry daily. Don't put curry in front of me. During an interview with the RD, IFSM and CNM on 4/17/23 at 3:15 pm, the RD stated meeting the cultural needs of their [NAME]/Indian residents was easy with their vegetarian diet, and There are quite a few curries on the vegetarian diet. The surveyor shared that nursing surveyors reported some of the vegetarian residents stated, All we get is curry. The RD stated she had heard that as well, visited those residents, and offered alternate choices if appropriate. A copy of the vegetarian menu was requested. The IFSM stated they did not have ability to create a vegetarian menu, but she could print out tray tickets for a fictitious resident to show what was served to a vegetarian diet during their five-week menu cycle. A review of breakfast, lunch and dinner tray tickets provided by the IFSM were dated 5/1/23 through 6/4/23 and were for a fictitious resident [NAME], with regular diet, regular texture, thin liquids Lacto-Vegetarian diet. The tray tickets showed a lack of variety for vegetarian residents when 11 out of 35 lunches and 14 out of 35 dinners contained curry. Curry was served 24 out of 35 days, and curry was served at both lunch and dinner on two days. Further review showed a theme of three curry recipes: Out of 70 possible lunch and dinner meals, Curry Sesame Tofu with Curry Sesame Vegetables were served 9 times, Madras Vegetable Curry was served 9 times, and Cauliflower Tofu Curry was served 8 times. 37% of vegetarian meals provided curry entrees. Review of the facility's Facility Assessment ethnicity/race information dated November 2022 showed seven out of 130 residents in the facility (5%) were [NAME]. Review of five documents titled Nutrient Analysis Summary - Season's Harmony 2021 (Spring), menu cycle weeks one through five, printed 4/27/23 showed nutrient analysis for Regular, Sodium Restricted, Cardiac, CCD (Consistent Carbohydrate Diets), Renal, Mechanical Soft, Dysphagia, and Pureed diets, but did not provide nutrient analysis to demonstrate the nutritional adequacy of vegetarian diets served at the facility. Review of the California Health and Safety Code 1265.10 showed a licensed health facility .shall make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 22 of 38 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 04/20/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. The facility did not have effective tools or systems in place to monitor or evaluate the accuracy of resident meal trays in relation to the diet order. During the initial tour of the kitchen on 4/17/23 at 9:30 am, the IFSM and RD were asked to provide copies of the menu for the week, the tray tickets for lunch that day, and the therapeutic diet spreadsheets (a tool that would indicate a standard for foods and portions to be provided on resident meal trays in relation to the diet order and diet manual). The IFSM provided the following documents: Review of the (Facility) Weekly Menu, dated 4/17/23 through 4/23/23 included separate pages for Regular, Consistent Carbohydrate (CCHO), two-gram Sodium, Heart Healthy, Renal, Full Liquid and Clear Liquid diet/menu foods, but they did not include the portions that should be provided. Review of the The (Facility) Production Counts Lunch-Combined Jobs, dated 4/17/23 through 4/20/23 showed they were a tool used by the cook and other food production staff. They provided a list of the foods and their quantities to prepare for each meal. They did not provide information regarding foods or portions to be served on individual trays related to the diet orders. Review of lunch meal tray tickets, dated 4/17/23, showed the diet order, food, and portions to be given to each resident, as well as many individualized menu notes. During an interview on 4/19/23 at 3:30 pm the RD agreed the facility had no cook's therapeutic diet sheet or other tool to help them quickly and easily evaluate if tray tickets and trays were correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 23 of 38 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 04/20/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prepare food in a manner to meet an individual's needs for one of one sampled resident (Resident 38) when she was served meat that was not chopped up as per her diet order. This failure had the potential for her nutritional status to decline. Findings: A review of The International Dysphagia (difficulty in swallowing) Diet Standardization Initiative (IDDSI, a global standard to describe texture modified foods for all care settings.) indicated chopped foods should be small/bite size, 1.5 cm (centimeters, or ½ inch). A review of Resident 38's admission record indicated, she was admitted to the facility on [DATE], with diagnoses of Lung disease, end stage kidney disease and on dialysis, and Gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). During an observation on 4/17/23 at 11:33 am, Resident 38's lunch tray arrived containing egg whole noodles, whole Swedish meatballs, and a half garlic bread stick. Her tray ticket indicated she was on a renal diet with regular texture, thin liquids, high protein, and chopped meats. Resident 38 required help with eating, and a staff member was assisting her. During a concurrent observation and interview on 4/18/23 at 9:56 am, [NAME] 2 indicated he was preparing the meat for the mechanical soft/chopped diets. He put some meat into the blender and pulsed the on button for a couple seconds, looked at the meat then pulsed it again and placed it in the serving dish. [NAME] 2 stated he did not know the exact measurements for the meat, and that he guessed. Then he said, What is the right size? During an observation of the tray line (assembly process for resident meal trays) on 4/18/23 at 11:18 pm, [NAME] 4 stated that the minced and moist meat had pieces that were to big. She took them out of the serving dish and blended them some more. During an interview on 4/19/23 at 3:30 pm, with the Interim Food Service Manager (IFSM) and the Clinical Nutrition Manager (CNM), they confirmed Resident 38's diet order was chopped meats and the Swedish meatballs served to her were too large and were not bite size. They confirmed that they should have been chopped up and they were not. A review of training and orientation checklists revealed there were no indication of training or competencies in texture modification for [NAME] 2, [NAME] 4, dietary aide (DA) 3, and dishwasher (DW) 2. The facility had no training competency documents for [NAME] 1 and [NAME] 3 who were long time employees. A review of the policy titled Texture Modified Diets revised 10/26/22 showed Whole meats for mechanical soft diets will be chopped and served with gravy or sauce to promote ease of chewing/swallowing. Follow the (Food Service Contractor) Diet Manual for Health Care Communities instructions for mechanical soft diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 24 of 38 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 04/20/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accommodate resident food preferences/dislikes when: 1. Resident 134 complained of having too much curry (a spice, mainly associated with South Asian cuisine) with her meals (Cross Reference F803 #4). 2. Resident 23 received pies and cakes when she continually refused them due to her diagnoses. (Cross Reference F803 #3) 3. Resident 69 and 38 refused their meal trays and the facility did not provide an alternative entrée of equal nutritive value. This failure had the potential to result in resident dissatisfaction with meal service, decrease meal intakes, nutritional status, and overall health decline. Findings: A review of a facility's policy titled Food Preferences dated 10/26/22, indicated Resident food and beverages preferences will be obtained upon admission and periodically as needed to assist the food and Nutrition Services department in providing preferred foods to enhance/maintain quality of life and nutritional status. 1. A review of Resident 134's medical record showed she was admitted on [DATE] with diagnoses of Iron deficiency anemia, cancer, and malnutrition. A review of Resident 134's admission Minimum Data Set (MDS, a clinical assessment tool) dated 4/9/23 indicated she required supervision with eating and her cognition was intact. A review of Resident's 134's lunch tray ticket dated 4/17/23 showed: Regular, Mechanical soft, thin liquids, Gluten-Free (GF), Lactose-Free, Low-Fiber diet Chef's Choice Entrée GF Lactose-Free, Chef's Choice Soup GF Lactose-Free, Soy milk, apple juice, condiments, Banana. During an interview with Resident 134 on 4//17/23 at 9:45 am, she stated I have trouble finding something to eat. The doctor wanted me to have lots of protein because of my Chemotherapy (Cancer medication). Resident 134 indicated she was gluten and dairy free and liked meat and potatoes, but the facility kept giving her tofu curry or chickpea curry and she could not eat it. She stated don't put curry in front of me, I had tilapia once which was wonderful. The dietician said she could not find anything else, so my husband brings in food. During an interview with the Interim Food service Manager (IFSD) on 4/17/23 at 3:15 pm, regarding Resident 134, she stated We don't do plain meat here very often. We always add flour (contains gluten) into foods, and she can't have gluten. IFSD indicated Resident 134's husband brought food in for her, especially meat. 2. A record review of Resident 23's quarterly MDS dated [DATE], revealed she was admitted on [DATE] with the diagnoses of diabetes (a group of diseases that affect how the body uses blood sugar), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 25 of 38 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 04/20/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some heart disease, and lung disease. She required supervision with eating and her cognition was moderately impaired. During a concurrent observation and interview with Resident 23 on 4/17/23 at 12:37 pm, her lunch tray contained a banana cream pie, pasta, and juice. Resident 23 indicated that she received dessert (pie and cake) every day but continued to tell them she did not want it and could not eat it because she was a diabetic. Resident 23 indicated the dietician had never been in to see her that she could recall. 3. During an observation of Resident 69 on 4/17/23 at 12:00 am, Resident 69 was in her room with her lunch tray. She had a plate of red and green pasta. She was yelling something in Spanish and pointing to her food. She pushed her food tray away and kept yelling. During an interview with Restorative Nursing Assistant RNA 1 (who spoke Spanish) on 4/17/23 at 12:02 pm, he indicated Resident 69 said her food was ugly, and that she did not like it. When asked if there was something else Resident 69 could have, RNA 1 stated feeding someone with a Hispanic culture was tough and I don't know how flexible the kitchen was. It's not often residents ask for alternatives Resident 69 did not receive an alternate for lunch that day. During an interview with Registered Dietitian (RD) on 4/17/23 at 3:12 pm, she indicated the staff can offer an alternative option if someone did not like something. She continued For the Hispanic culture we have tortillas now as a regular item and were looking at adding beans daily. During a concurrent observation and interview with Resident 38 on 4/17/23 at 11:33 am, her lunch tray arrived with egg whole noodles, and whole Swedish meatballs. Resident 38 stated she was not feeling very good and did not want to eat right now. She asked for some spaghetti and meatballs or Chinese food but was told by the Director of Staff Development (DSD) that they could not accommodate that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 26 of 38 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 04/20/2023 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: Residents Affected - Many 1. Eleven of 11 kitchen staff did not perform hand hygiene and glove use according to professional standards of practice which increased the likelihood of cross contamination. 2. Two of three hand washing areas used by kitchen staff had the potential to contaminate hands during the hand washing procedure when one sink area had drying towels that were contaminated due to dispensing onto the soiled sink and the second sink areas faucet dispensed water close to the sides of the sink which caused hands to touch the sides of the sink during the hand washing process. 3. Three of five kitchen staff did not have their hair, beards and mustaches completely covered while preparing and serving food. 4. Two of three refrigerators had frozen lettuce, undated open milk, slimy fruit and vegetables, and an undated open bag of diced potatoes 5. The kitchen, dish room, coffee room, and nursing station nourishment rooms had multiple unclean areas containing dust, dirty walls, black grime, crumbs, dried food on utensils, chipped and peeling paint, black spots, and a filter thick with dust in the dishwasher hood. 6. Sanitizing buckets used to clean and sanitize tray carts were being used at the wrong concentration and two of three staff were unaware how to test for the proper concentration of the sanitizer of the dish washing machine and cleaning buckets. 7. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control for Food Safety) foods prepared at ambient (room) temperature. These practices had the potential to result in foodborne illness for residents consuming food in the facility and could lead to negative clinical outcomes. Findings: 1. During a review of the facility's policy titled Disposable Glove Use dated 10/26/22, the policy indicated, All personnel shall wash their hands each time before gloves are put on. Gloves shall be discarded after each use and if they are soiled, torn or contaminated. During an observation on 4/17/23 at 11:30 am, in the kitchen, [NAME] 3 was observed cooking on the stove with gloves on. [NAME] 3 left the pot he was stirring and walked over to the garbage can, which had a push open lid, pushed the lid open with his gloved hand, and threw something away. [NAME] 3 did not change his gloves or wash his hands before resuming cooking at the stove with those same now soiled gloves. During an observation on 4/17/23 at 11:44 am, the tray line (assembly process for resident meal trays) was observed. Five kitchen staff were preparing resident's trays for their lunch meal. A dietary aide rang a bell, and five of five staff doffed (took off) their gloves, did not do hand hygiene, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 27 of 38 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 04/20/2023 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 donned (put on) new gloves, and continued to prepare residents food trays. Level of Harm - Minimal harm or potential for actual harm During an observation in the kitchen on 4/18/23 at 9:55 am, [NAME] 2 wore gloves while using the food processor. [NAME] 2 put the dirty dish into the sink, then used a sanitizer rag to wipe down the food processor base and the counter. [NAME] 2 doffed his gloves, pushed them against the contaminated push lid into the garbage can, then donned new gloves and went back to preparing food. No hand hygiene was done between glove use. Residents Affected - Many During an observation on 4/18/13 at 11:19 am, [NAME] 2 came into the kitchen to help with the tray line process, and without performing hand hygiene he donned gloves and assisted in preparation of resident's trays for lunch. During an observation on 4/18/23 at 11:35 am, [NAME] 2 was working on the tray line. He discarded one glove, and without washing hands he donned a new glove. [NAME] 2 proceeded to prepare residents food trays for lunch with one old and one new glove. [NAME] 2 had to push the soiled trash can lid open to throw the one glove away. During an observation on 4/18/23 at 11:38 am, [NAME] 4 was working on the tray line and stated, I just burned my finger. [NAME] 4 then doffed her gloves, blew on her finger, and without performing hand hygiene, she donned new gloves and went back to preparing residents food trays. During an observation on 04/18/23 11:47 am, dishwasher (DW) 2 was placing residents drinks on their lunch tray. DW 2 dropped one tray ticket (this displayed the resident's diet and tray contents) on the floor. He picked it up, changed gloves, did not wash hands, placed contaminated tray ticket on the tray. During an observation of tray line on 4/18/23 at 11:54 am, dietary aide (DA) 3 doffed her gloves, crumbled them in one hand, obtained a new set of gloves and crumbled them up in the other hand. DA 3 walked over to garbage, threw away old gloves and without performing hand hygiene donned new gloves and went back to work on the tray line. During an observation on 04/18/23 at 11:58 am, DA 4 was observed working on the tray line. She touched the cold food refrigerator handle with gloves on, and without changing gloves or washing hands DA 4 continued working on the tray line touching trays and other items on the resident's food tray. During an interview on 04/18/23 at 3:40 pm, with the Registered Dietitian (RD) and the Interim Food Service Manager (IFSM), the RD indicated that kitchen staff were to supposed to change gloves every 30 minutes. The RD stated staff were supposed to wash their hands when they changed their gloves. During an interview on 4/19/23 at 2:05 pm, with [NAME] 2, he confirmed he did not always have time to wash his hands between glove changes. 2. During multiple observations between 4/17/23 thru 4/18/23, the kitchen handwashing sink directly under the motion sensor towel dispenser was observed. On 4/17/23 at 9:40 am, a paper towel had been dispensed and hung down more than 12 inches into the sink, and about an inch from the faucet. On 4/18/23 at 9:30 am, and 9:40 am, the towels were observed dispensed and touching the handwashing sink faucet. On 4/18/23 at 3:00 pm, the kitchen handwashing sink was observed to have a towel hanging into the sink and touching the faucet. In a concurrent interview, DA 1 confirmed that the paper towels were contaminated due to them touching the dirty sink. She indicated that the towel dispenser should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 28 of 38 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 04/20/2023 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 be moved. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/17/23 at 10:35 am, in the cold food preparation room (separate from rest of kitchen) a hand washing sink was observed. The faucet water stream was about 1 inch from the back of the sink and the surveyor was unable to wash her hands without touching the back of the sink. In a concurrent interview, the FSM confirmed that it was hard to wash your hands in that sink. Residents Affected - Many 3. A review of the facility Audit tool titled Fountains Kitchen Sanitation/Food Storage Audit dated 9/22, the tool indicated Hair is covered completely with hair NET. During multiple observations on 4/17/23 between 10:00 am, and 3:15 pm, in the kitchen, the wearing of hair coverings was observed. At 10:00 am, [NAME] 2 wore a hat but no hair net or beard net. His hair was exposed below his hat and his beard and mustache were exposed. At 11:22 am, [NAME] 2 was observed with a yellow surgical mask over his chin but his mustache was exposed. At 11:43 am, [NAME] 3 was observed cooking soup, he had a yellow surgical mask on, but it was not covering his mustache. He had a hat on but no hair net. His hair was exposed below his hat line. At 3:15 pm, [NAME] 3 was observed in the cold food area and the kitchen area with his beard and mustache exposed. During multiple observations in the kitchen on 4/18/23 between 9:30 am and 3:00 pm, wearing of hair coverings was observed. At 9:30 AM, [NAME] 2 had no beard net on to cover his beard or mustache. At 9:50 am, [NAME] 4, was observed to have a hair net on but multiple hairs were not contained in the net. Her hair was straggling out the back and sides and the net was two inches higher than her hair line on the back of her head. At 11:00 am, [NAME] 3 had a surgical mask on that was not covering his mustache. During an observation of lunch tray line at 11:54 AM, [NAME] 4 had hair hanging out below his hair net, and [NAME] 2 wore a surgical mask that did not cover his mustache. During an interview on 4/19/23 at 3:30 pm, the IFSM indicated that the hair net policy states there should be no loose hair and hair should be fully covered. She was unaware that hair nets should be worn with hats and that all facial hair must be covered. 4. A review of a policy titled Labeling & Dating dated 10/26/22, indicated All foods are labeled, dated, and securely covered, and use-by dates are monitored and followed. During an observation of the walk-in refrigerator on 4/17/23 at 9:45 am, two of three plastic bags of pre-cut butternut squash showed received-on date 3/20/23 and were mushy with a milky liquid around them. One bag of pre-cut onion/carrot/celery mix had translucent slimy onions. Portioned salads, with a prepared date of 4/16, use by date of 4/29, appeared like the lettuce had been frozen. [NAME] 1 indicated the refrigerator got too cold for the salads and confirmed the diced squash and onion/carrot/celery were not in good shape and should be tossed. During a concurrent observation and interview on 4/17/23 at 9:48 am, with the Food Service Director over all facilities (FSD), an open Lactaid Milk carton was observed. A yellow sticker on the milk cap which showed a received-on date of 3/27/23. A facility label on the carton read Prepped or received dated 4/10/23, Use by 4/13/23. The Manufacturer's use-by date was 5/1/23. The Manufacturer's label showed: This milk is ultra-pasteurized to last longer unopened. Once opened, consume within 14 days. There was no opened-on date on the milk container. The FDS confirmed that the labeling/dating on the Lactaid milk in the walk-in refrigerator wasn't right. During a concurrent observation and interview on 4/17/23 10:35 am, in the cold food preparation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 29 of 38 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 04/20/2023 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 - Many room (where salads and sandwiches were made and stored), the sandwich refrigerator contained two frozen heads of iceberg lettuce. The FSD stated we will not be using this. There was a large plastic container filled with a rice looking substance that had no label or date on it. The FSD confirmed it was brown rice and that there was no date or label. During an interview on 4/19/23 at 8:55 am, the FSD explained that short-dated or expired pre-cut produce should be caught and sent back at delivery. If product was expired, for example the squash and Mirepoix (carrot/celery/onion mix) it should have been discarded. During a concurrent interview and observation on 4/19/23 at 9:10 am, in the walk-in refrigerator, a plastic bag of diced potatoes was observed lying open, not sealed and no opened-on date. The FSD indicated that whenever staff open a bag of produce, they are supposed to remove it from the bag and put it in a Lexon (plastic storage container). FSD confirmed that the open bag of diced potatoes should not be like that, and it should have been put in a Lexon for storage. 5. A review of their Kitchen Audit tool titled Kitchen sanitation/Food storage Audit dated 9/22, indicated the cook's work area, worktables and prep areas were to be clean, cutting boards clean with no deep knife marks, food processors clean, range, oven, grill clean and grease free, cutlery/rack clean and dry vegetable prep sink clean and work and prep tables clean and sanitized properly. During a concurrent observation and interview on 4/17/23 at 10:00 am, with [NAME] 1, the kitchen was observed. A large blender, a food processor, and small blenders, were noted to have buildup of grime, were wet inside, with their lids on, and were in place for use. [NAME] 1 indicated they were all used that morning and just rinsed out until they could be washed in the dish washing area. The knife rack that held 5 knives had dust and debris on it. One of five knives and one of five ready-to-use sampled spoodles (a type of serving spoon) were observed with dried food residue on them. The knife back splash, wall behind the mixing table, the range oven and behind the range oven had buildup of grime, food, debris, dust, crumbs, and food splatter. Two clean sauté pans were inside the oven which had a heavy buildup of black, burned residue and unknown white debris. [NAME] 1 indicated the clean pans were being stored in there so they did not get scratched. She confirmed that this area was not a clean storage area. During an observation on 4/17/23 at 10:15 am, a room identified as the Coffee Room by staff contained a microwave oven, hand sink, and a lemonade/iced tea dispensing machine. Shelves storing beverage pitchers and other supplies were dusty. The floor had black grime on it, crumbs under the counter and an ant crawling on the floor. During a concurrent observation and interview on 4/17/23 at 10:20 am, two of two glove boxes in the kitchen, were ripped with gloves hanging out of them touching the outside of the boxes which had red, black, and brown spots resembling food splashes. DTR confirmed the boxes were soiled and the gloves were contaminated by the soiled boxes. DA 4 indicated she had used these gloves to perform kitchen duties During an observation on 4/17/23 at 10:20 am, in the dish room and walkways near the dish room, there were uncleanable surface areas of peeling and chipped paint, and damaged drywall. The hood/vent above the dish machine was severely soiled with dark brown/black substance and the filter was thick with dust. During a concurrent observation and interview on 4/17/23 at 10:30 am, in the dry food storage room, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 30 of 38 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 04/20/2023 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 - Many walkway, and walk-in freezer. The dry food storage room had two bulging ceiling tiles located over stored food with brown stains on them. The FSD confirmed the facility had a condensation problem about 3 or 4 months ago and he believed they had worked on that issue. The freezer was cramped with green and yellow substances and food crumbs on the floor. There was ice condensation on the ceiling and frozen drips hanging down from the fan. The FSD confirmed the walk-in freezer was too small and that the ceiling condensation was from the freezer door being open when deliveries were being put away. During a concurrent observation and interview on 04/17/23 at 11:22 am, the cook's work area was observed: a. The tray line cutting board was severely scored with black knife marks. b. The lowerator (plate warmer) was soiled with brown grime and food crumbs and the suction cup used to handle the plates was sitting on top of the grime and food crumbs while serving up the plates. c. A food preparation sink (A two-compartment sink with an attached disposal sink) had a middle sink with food emersed in a container full of water with cool water running over it. The food was being defrosted for later use. In the attached sink to the left there was multiple soiled mixing utensils, plates, two bowls, and a strainer that were soiled with food debris. The attached area to the right had a disposal sink with water puddles and water leaking down into the middle sink. [NAME] 2 indicated the middle sink was used for food prep like draining pasta or vegetables, washing produce in a colander, and thawing meat. The right area (the disposal sink) was used to spray/rinse out blender containers, and the left sink they used to stack dirty dishes in. He confirmed that the clean sink was in the middle of the two dirty sinks. [NAME] 2 indicated that when they have time, they take their dirty dishes to the dish room and wash them, but he put them in there while he was preparing food. [NAME] 2 indicated the sinks got cleaned at the end of the day. During a concurrent observation and interview on 4/18/23 between 4:20 pm and 4:32 pm, with the RD, the nursing station nourishment rooms (where they stored the residents' nourishments) were observed: a. Nursing station 1 nourishment room had a coffee cup in the sink with brown stains around and in the cup. The RD indicated this was a staff members used cup. Three out of three drawers had food debris, one with an unknown sticky brown substance, all three with damage/uncleanable surfaces. The RD confirmed this room was dirty. b. Nursing station 2 nourishment room counter had two brown ring stain. The second drawer was soiled with food debris and stored unprotected plastic spoons used for the residents. The refrigerator door was dirty and had a hair in it. A cleaning log was hanging on the wall that indicated the room was last clean on the 13th (5 days ago). c. Nursing station 3 nourishment room had an open Styrofoam cup of water on top of regular size white refrigerator. Drawer containing paper cups had 2 dead ants. Three other drawers had multiple dead ants. There was damaged uncleanable surfaces. The RD confirmed that the cabinet and drawers were not clean and that they had had an ant problem During an interview on 4/19/23 3:30 pm, the IFSM stated to clean fixed equipment, staff should wash with soapy water, rinse with clean water, then sanitize and air dry. She did not know how often the meal carts were cleaned but they should be sanitized between meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 31 of 38 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 04/20/2023 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 - Many 6. During observation and interview on 4/19/23 at 10:00 am, DA 3 was observed sanitizing the meal carts. DA 3 was using a red bucket and wash rag to sanitize the carts. She indicated the red bucket had sanitizer in it. A sign on the wall next to the sanitizer containers read Diversey (a quaternary, [Quat or QAC], sanitizer, an agent that kills bacteria, virus, mold, and fungi). The sanitizer containers read Diversey. DA 3 proceeded to demonstrate how to assure that the right concentration of sanitizer was in her bucket. DA 3 reached for test strips that were stored over the three-compartment sink. The container read Ecolab (a brand of quaternary sanitizer) QAC test papers The instructions read Dip about one inch of a test paper into the solution about to be tested and hold there for 90 seconds. Then compare the test paper color to the color standards shown. The container showed a 3 color comparisons range (100 ppm [parts per million], 200 ppm, 400 ppm). While reading this container, [NAME] 1 walked by and stated those were the wrong test strips and then handed DA 3 a different container of test strips that were titled Diversey. Those instructions were to Immerse for 10 seconds. Compare when wet. Parts Per Million. Proper range was 200-400 ppm The Diversey test papers showed 6 color comparisons ranging zero to 500 ppm. [NAME] 1 stated the Ecolab QAC papers on the shelf were the same thing as the Diversey test papers, but she had never used them before, and called DW 2 over. DW 2 indicated that he thought 100 ppm was the correct concentration for the quat sanitizer. DA 3 then put a piece of the test strip into the sanitizer bucket for 8-10 seconds. She matched the color of the test strip to the Diversey color scale. The test strip was orangish which matched the 100-ppm color scale. According to the instructions the proper range should be 200-400 ppm. DW 3 confirmed that the correct ppm was 200-400 and not 100 as she thought, she confirmed that her sanitizing bucket was not within the right range to properly sanitize. She dumped the bucket and made a fresh bucket of sanitizer which tested at 300 ppm, the right range. During an interview on 4/19/23 at 10:15 am, the FSD explained that the facility had switched to Diversey from Ecolab in February 2023. He continued to explain the Ecolab strips had been left over from the switch. The FSD confirmed that the quat sanitizer range should be 200-400 ppm. He stated, But they are both quat, so you would think you should be able to use either one. The two test strip packages were re-examined, and the FSD confirmed the Ecolab package had three color match choices, while the Diversey package had six. During a concurrent observation and interview on 4/19/23 at 10:20 am, with DW 2, the dish washing machine was observed. DW 2 indicated it was a low temp rinse cycle and it used a chemical to sterilize the dishes and the dispenser will beep if the chemicals were empty or weren't going through. He stated the chlorine dispenser did not beep if the chlorine was empty. The wash temperature should be 140 degrees or greater. DW 2 stated the Final Rinse temperature hasn't shown anything for temperature except XXX for a long time. Observation of the dishwashing process revealed the wash temperature was 140, and there was no rinse temp at all, the final rinse digital display read XXX °F (degrees Fahrenheit). DW 2 explained that each morning they were supposed to run a chlorine sanitizer strip through the dish machine on a rack to verify adequate chlorine was in the final rinse. Four containers of test strips were observed. One container had an expiration date of 5/22 the other three were 3/24. The labels had four ppm color comparisons ranging from light lavender (10 ppm) to purplish black (200 ppm). DW 2 demonstrated this process three times by putting a strip on a dish rack and sending it through the dishwasher. The first time the strip was white (less than 10 ppm sanitizer), the second time the strip was lost in the dish machine, the third time the strip was white again. The FSD was asked to assist with the process. He confirmed the final rinse cycle did not register a temperature and that was a problem. He confirmed that one of the containers with test strips was expired. The FSD then tested the chemical concentration by putting a dish thought the dish machine then immediately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 32 of 38 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 04/20/2023 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 touching the dish with the test strip when it came out. The strip color registered at 100 ppm. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 4/19/23 at 2:45 pm, with DW 3, the three-compartment dishwashing sink was observed. DW 3 demonstrated how to correctly test the chemical in sink #3 which was the final rinse sink. He stated the goal was 100-200 ppm. He did the testing process. Test strip showed 300-400 ppm. He stated, So it's a little high? Residents Affected - Many During an interview on 4/19/23 at 3:30 pm, IFSM confirmed that the Quat test strips should be dipped for 10 seconds, and concentration color should be 200-400 ppm in sanitizing buckets and the final rinse sink. She stated she did not know about the dish machine testing. 7. During a concurrent observation and interview on 4/18/23 at 4:10 pm, in the cool preparation room where sandwiches and salads were made, the room temperature was 84.2 degrees. DA 1 stated that some days it was hard to breath in here because it was so hot. During an interview with DA 1 on 4/19/23 at 9:45 am, she stated she made sandwiches for residents, and the types of sandwiches she made depended on what residents requested, or what was on the food production tally for the day. DA 1 stated she mostly made turkey with cheese, egg salad, tuna salad, or chicken salad sandwiches, and they were made from scratch (not an item purchased already prepared). She explained the egg/tuna/chicken salads were good for two days, she made it in small amounts, and sometimes she made it every day. She added she was making four egg salad sandwiches that day. DA 1 was asked to describe how she made tuna salad. She stated she used a small can of tuna and made only enough for two days even though it's good for four days. She obtained the tuna from the dry storage room (ambient temperature), added mayonnaise and pickle relish from the refrigerator, and used a #12 scoop to make the sandwich. DA 1 was asked to describe how she made egg salad. She stated they purchased pre-cooked hard-boiled eggs, added pickle relish, mustard, mayonnaise and pepper. She stated they should have a recipe, but she had been here too long, and they had changed companies (so she just made it as she always had). She stated she knew what to put in it and preferred to make it ahead of time and put it in the refrigerator so the flavors could meld. DA 1 stated she did not take the temperature when she made egg, tuna, or chicken salad, but she took the temperature before she gave the items to the residents to make sure they were cold for the residents, adding they should be less than 40 degrees. DA 1 stated she did not keep a temperature log for that. During an interview with the IFSM on 4/19/23 at 3:30 PM she was asked what process staff used to prepare tuna salad from room temperature ingredients? She replied, I'm not really sure. A review of their policy titled Taste and Temperature Control/Food Holding dated 10/26/22, the policy indicated that food is maintained at proper temperatures during service to meet resident expectations for palatability and to ensure that food safety principles are maintained to prevent foodborne illness. All cold foods must be held at 40 degrees Fahrenheit or below. Any cold foods that have been held at greater than 40 degrees for 2 hours must be discarded. A review of the facility's recipe for egg salad, and tuna salad, undated, did not specify to use prechilled ingredients and did not guide to check the temperature and to perform a cooling log if greater that 41 degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 33 of 38 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 04/20/2023 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 Review of the 2022 FDA Food Code 3-501.14 showed Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as .canned tuna. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 34 of 38 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 04/20/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some 1. The washing machine final rinse cycle was rinsing at the right temperature to maintain sanitation when the machine rinse cycle temperature display showed only XXX. This had the potential to cause the dish sanitation to be ineffective and cause foodborne illness and negative clinical outcomes to residents in the facility. 2. The walk-in freezer was free of condensation on the celling and fan which could result in the failure of the freezer over time. Findings: A review of the facility's undated policy titled Preventative Maintenance, the policy indicated Department managers participate in and administer a preventive maintenance program in the facility to control equipment maintenance and repair expenses by avoiding repetitive maintenance and excessive parts replacement. 1. During an observation and interview in the dish room on 4/19/23 10:20 am, the dish washing machine had a digital temperature screen displaying the wash temperature at 140 °F (degrees Fahrenheit) and the final rinse temperature at XXX °F. Dishwasher (DW) 2 indicated it was a cool final rinse dish machine, meaning it needed chemicals to sterilize the dishes instead of hot water. DW 2 indicated the wash temperature should be 140 degrees or greater. He stated the final rinse temperature hadn't shown anything except XXX for a long time. During an interview with the Food Service Director (FSD) and [NAME] 1 on 4/19/23 at 10:25 am, FSD indicated that he thought the staff ran temperature strips through the machine to record the final rinse temperature. In a concurrent record review of the dish machine temp logs there was no indication of that. FSD asked [NAME] 1 if they were used. FSD stated they had never used temp strips, but there used to be a digital temperature gauge on top of the dish machine, but it disappeared when the new company took over. FSD confirmed that there was a problem with the final rinse temperature not showing. 2.During an observation and interview in the walk-in freezer with FSD, on 4/17/23 at 10:30 am, the shelves were full, and the freezer was cramped with standing room only for one person due to a cart (full of items) in the middle of the freezer. There was ice condensation on the ceiling and the fan. FSD agreed the walk-in freezer and walk-in refrigerator were too small for this facility and its population. He confirmed that there was ice on the ceiling and fan due to condensation from the freezer door being open when deliveries were being put away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 35 of 38 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 04/20/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review the facility failed to provide regular maintenance to the facility kitchen to ensure a safe and sanitary environment when: Residents Affected - Some 1. The temperature in the cold prep room was not maintained at a safe level. 2. The walls, floor trim, floor drains, and ceiling tiles were not maintained in good repair. These failures had the potential to negatively impact the food safety and sanitation of food services areas and can be a safety issue for staff. (Reference F812) Findings: 1. During a concurrent observation and interview, with the Food Service Director (FSD), and dietary aide (DA) 1, on 4/17/23 at 10:35 am, the cold food prep room contained rice, flour and other dried food, a refrigerator that contained individual salads, sandwiches, and other snacks. DA 1 stated she had worked there for 16 years prepping snacks for residents. She confirmed that she made the sandwiches, salads, and snacks in this room. The room temperature felt very warm and stuffy during the whole observation. The FSD confirmed that this room felt very warm. During a concurrent observation and interview, in the cool prep room, on 4/18/23 at 3:40 pm, The Registered Dietitian (RD) and the Interim Food Service Manager (IFSM) agreed the cold food prep room was warm. Surveyor temperature of the room was 84.2 degrees Fahrenheit. DA 1 stated It's always warm in here. I always complained it's hard to breath in here. We're not allowed to open doors. They told me it (the hot air) couldn't be fixed because it's connected to patients. A review of the All Facilities Letter 16-06 Dated October 6th, 2017, Pursuant to Title 42 of the coded of Federal Regulations section 483.159(h) (6), skilled nursing facilities must have comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81°F. A review of the facility's undated policy titled. Building Maintenance Program indicated It was important that an effective preventive maintenance program be carried out for all hospital equipment to ensure a safe and comfortable environment for all patients, visitors, and employees. A review of kitchen work orders dated 1/8/23 to 4/19/23, were reviewed and there were no requests for the cool prep room temperature to be checked. There were no documents provided by the facility indicating when the cool prep room was last inspected for a safe temperature. 2. During a concurrent observation and interview on 4/17/23 at 10:20 am, there were multiple areas in dish room and walkways near dish room with peeling paint, chipped paint, and damaged drywall. The coffee room had partially detached floor trim sticking out with thick black grime exposed. The floor drain under the sink was grimy, uncovered, and had a cup of milky white water sitting in it. An ant was noted to be crawling towards it. FSD indicated the general manager of the Fountains food service had been off since 4/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 36 of 38 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 04/20/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with the FSD on 4/17/23 at 10:30 am, the main dry storage area had bulging ceiling tiles with some brown stains on them directly over some dried food. FSD indicated they had a leak in that area from some pipes about 3-4 months ago. He stated, I think it needs to be fixed. During an interview with the Quality Compliance Analyst (MAINT. 1) on 4/18/23 at 3:13 pm, when asked if Plant Services did regular inspections of the kitchen, she replied they did at least quarterly EOC (Environment of Care) rounds. During a concurrent observation and interview in the dry storage room on 4/18/2023 at 3:40 pm, the registered dietitian (RD)and the IFSM confirmed that the ceiling tiles were damaged due to a roof leak. They indicated the facility needed a new roof and they had to use buckets in the hallways because of the heavy rains this year. Maintenance replaced the ceiling tiles many times for 6 years. They did not repair/replace the ceiling over the dry storage room when other roof areas were replaced/repaired. RD stated they have never had to replace the food. During an interview with the Administrator on 4/19/23 at 8:05 am, he stated the damaged ceiling in the kitchen dry storage room was due to a roof leak and they plan to have it repaired this summer. During an interview with the Director of Facility's (DOF) on 4/19/23 at 8:43 am, he confirmed there was some ripped wallpaper, bulging ceiling tiles and some drains uncovered. Surveyor asked how often he inspected, and he said he did not and that the staff would normally bring it to his attention of things that needed to be fixed. He did rounds before Covid but post Covid not so much anymore. The DOF indicated that the kitchen staff that work in the various areas would communicate any problems they noticed and would put in a work request. He would do rounds in the kitchen and look for low hanging fruit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 37 of 38 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 04/20/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure an effective pest control system was in place when a live ant was found in the kitchen's coffee room, and multiple dead ants were found in a nursing unit food storage and preparation pantry for resident food. Residents Affected - Few This had the potential to result in foodborne illness for residents consuming food from the kitchen and nursing unit pantry. Findings: During an observation of the room identified by staff as the Coffee Shop or Coffee Room on 04/17/23 at 10:15 AM, one live ant crawled on the floor near the floor drain. The floor drain was half covered by a grate. The drain itself had nothing over it. The floor drain had a clear cup full of a milky colored liquid sitting in it. During an observation and concurrent interview with the Facilities Analyst (Maint1) and Facilities staff (Maint 2), and Registered Dietitian (RD) in the coffee room on 4/18/23 at 3:20 pm they confirmed that the floor under the cabinet had black grime and food crumbs, and the interior of the cabinet under the sink had debris and grime. The RD confirmed they had had issues with ants. During an observation and concurrent interview with the Registered Dietitian (RD) in the Nursing Unit 3 Pantry (food storage for residents) on 04/18/23 at 3:58 PM, three drawers had damaged, uncleanable surfaces and contained dead ants while also storing food service supplies. The RD stated housekeeping was responsible to clean the food pantry areas. In an additional concurrent observation, an unwashed yellow plastic food storage container containing oily food debris was a potential attractant for vermin and microbial growth. It was stored on the top shelf of a cabinet in the Nursing Unit 3 dining room with food and food service supplies. In an interview with the Food Service Manager (FSM) on 04/19/23 at 3:30 PM she stated the facility had a monthly pest service. She thought housekeeping cleaned the nursing pantries but wasn't sure. During an interview on 4/20/23 at 11:00 AM, with the head of Housekeeping for the facility (HHSK), the HHSK indicated housekeeping personnel was not responsible for cleaning inside the drawers or cabinets for the nursing unit pantries. Review of a policy titled Pest Control, revised 10/26/22 showed It is the Food & Nutrition Services Department's responsibility to ensure an environment that is sanitary, and which presents no hazard to the well-being of the residents, staff, or visitors. An ongoing program to control rodent, pests, and insects must be evident. Review of invoices from the pest service company showed on service date 4/12/23 the kitchen was sprayed for ants and bait was applied to the exterior of the facility. On service date 4/19/23 the facility was baited on the exterior of the building for ants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 38 of 38