Inspection·April 14, 2022

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the confidentiality of medical records for two residents (Resident 136 and Resident 137) of 21 sampled residents, when a facility activity report was left unattended on a medication cart. Residents Affected - Few This failure decreased the facility's potential to protect residents' personal information from being accessible to unauthorized staff, residents and visitors. Findings: In an observation on 4/11/22 at 8:27 a.m., an unattended facility activity report was observed lying face-up on top of a medication cart outside a resident room. The activity report indicated Resident 136 and Resident 137s' names and medical diagnoses and was accessible to anyone who walked past the medication cart. In an observation and concurrent interview on 4/11/22 at 8:41 a.m., the Licensed Nurse 2 (LN 2) exited a resident's room. The LN 2 confirmed the facility activity report contained resident names, diagnoses, change in condition and significant events. The LN 2 also confirmed the information was accessible to anyone who walked past the the document as it was lying face-up. The LN 2 stated she was supposed to keep it with her or place it upside down so no one could see it. In an interview on 4/14/22 at 11:06 a.m., the Director of Nursing (DON) stated any document containing resident information was confidential and the activity report should have been protected. The DON stated this was a violation of residents' rights and HIPAA (Health Insurance Portability and Accountability Act). A review of the facility's policy titled, Confidentiality of Information, revised on 3/22/10, indicated, .Resident information and records, whether medical, financial, or social in nature will be safeguarded to protect the confidentiality of the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 2 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure written notice before transfer was provided for one resident (Resident 35) for a census of 31. Residents Affected - Few This failure reduced the facility's potential to provide documented notification before transfer of Resident 35. Findings: A review of an admission record indicated Resident 35 was admitted to the facility in early 2022 with diagnoses which included dementia (memory loss), repeated falls, and failure to thrive. A review of Resident 35's progress notes, dated 3/14/22, showed no documented evidence a written notice of transfer was provided to Resident 35, his resident representative (RP), or the Ombudsman (a community representative who acts in the resident's best interest). During an interview on 4/14/22 at 8:50 a.m., the Director of Nursing (DON) stated staff was to provide a written notice of transfer to the resident or the RP and the Ombudsman in an emergency transfer situation (transfer to a hospital). The DON also stated the transfer should be documented in the progress notes to verify these things were done. The DON further stated, [If it was] not documented [then it was] not done. A review of a notice of proposed transfer/ discharge was conducted with the Medical Record Coordinator (MRC) on 4/14/22 at 9:05 a.m. A review of Resident 35's notice of proposed transfer/discharge and transfer and referral record indicated no location to which the resident was transferred or discharged . Neither document contained signatures from Resident 35, the RP, and a facility representative. The MRC confirmed there was no documented evidence a written notice of transfer was provided to Resident 35, his RP, or to the Ombudsman. The MRC acknowledged the facility should have provided Resident 35 or the RP written notice of transfer prior to the transfer/discharge. A review of the facility's policy titled, Notice of Proposed Transfer/Discharge, revised January 2018, indicated, Our community shall provide a resident and/or the resident's representative written notice of an impending transfer or discharge .with the following information .The location to which the resident is being transferred to or discharged .In the event of a transfer or discharge of a resident to acute care, the written Notice of Proposed Transfer/Discharge will be .completed by nursing staff and a copy sent with the resident .or copied for the resident's representative at the time of transfer .The community will send a copy of the Notice of Proposed Transfer/Discharge of all facility-initiated transfers and discharges to the LTC [Long Term Care] Ombudsman . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 3 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to ensure written notice of the facility's bed-hold policy was given to one resident (Resident 35) for a census of 31 before or upon transfer of the resident. Residents Affected - Few This failure reduced the facility's potential to notify residents' of their right for their placement to be saved for a limited amount of time before it is given to another resident for admission. Findings: A review of an admission record indicated Resident 35 was admitted to the facility in early 2022 with diagnoses which included dementia (memory loss), repeated falls, and failure to thrive. During an interview and concurrent record review on 4/12/22, at 2:35 p.m., the Business Office Assistant (BOA) and the Medical Records Coordinator (MRC) confirmed Resident 35 was transferred or discharged to a hospital on 3/14/22. The BOA and MRC stated and confirmed there was no documented evidence Resident 35 or the resident representative was notified in writing of the facility's bed-hold policy prior to transfer to the hospital. During an interview on 4/14/22, at 8:50 a.m., the Director of Nursing stated it should be documented to verify these things were done. The DON further stated, [If] not documented [then it was] not done. A review of facility's policy titled, Bed Holds, revised February 2012, indicated, Our facility informs residents .prior to a transfer for hospitalization .of our bed-hold policy .by providing the resident with written information concerning the bed-hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 4 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate assessments were conducted and documented for two sampled residents (Resident 7 and Resident 24) for a census of 31. Residents Affected - Few This failure decreased the facility's potential to identify residents' care needs and well-being. Findings: A review of an admission record indicated Resident 7 was admitted to the facility in early 2021 with diagnoses which included a history of falling and weakness. A review of a Minimum Data Set (MDS, a comprehensive assessment tool), dated 2/4/22, indicated Resident 7 needed extensive assistance from two or more staff to: move in bed, transfer between the bed and wheelchair, get into standing position, use the toilet, get dressed, and was totally dependent on staff to bathe. A review of an assessment of functional limitations for range of motion (ROM), dated 2/4/22, indicated Resident 7 had an impairment on one of her arms and one of her legs. During an observation and concurrent interview on 4/11/22 at 9:20 a.m., Resident 7 was sitting up in a wheelchair. Resident 7 stated both her arms and both her legs were weak and she was unable to walk. During an interview on 4/13/22 at 2:21 p.m., the Licensed Nurse (LN) 1 confirmed Resident 7 required total care from staff, needed assistance with feeding, and was unable to walk. The LN 1 stated staff conduct ROM exercises in both arms and legs five times a week. The LN 1 also stated a functional assessment should capture both sides of arms and legs. A review of an admission record indicated Resident 24 was admitted to the facility in early 2021 with diagnoses which included right-side sciatica (nerve pain which runs from your lower back through your hips and buttocks and down each leg) and generalized osteoarthritis (pain caused by wearing down of the protective tissue at the ends of bones). During an observation on 4/11/22 at 11 a.m., Resident 24 required two staff to reposition her because she was unable to turn her body by herself. During an observation on 4/11/22 at 12:20 p.m., a staff member fed Resident 24 her lunch meal because Resident 24 was unable to feed herself. During an interview on 4/13/22 at 11:38 a.m., the LN 1 stated Resident 24 was unable to walk and unable to support her legs. The LN 1 confirmed two staff members are required to reposition Resident 24. The LN 1 also confirmed the MDS assessment dated [DATE] did not indicate Resident 24's impairment on both arms and legs. A concurrent interview and record review was conducted with the Medical Records Coordinator (MRC) and the Director of Nursing (DON) on 4/13/22 at 11:40 a.m. A review of an MDS, dated [DATE], indicated Resident 24 was impaired in one arm only. The DON and MRC confirmed the MDS assessment was inaccurate. The DON said documentation and medical record should be accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 5 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/14/22 at 8:41 a.m., the DON confirmed all charting and documentation were part of resident's medical record. The DON stated all documentation and medical records were expected to be accurate and consistent. A review of the facility's policy titled, Nursing Progress Notes, revised February 2016, indicated, Licensed Nurses will .ensure that all documentation remains consistent. A review of facility's policy titled, Closure of the Medical Record, revised July 2015 indicated, Resident medical records are maintained .in a complete and accurate manner. A review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Version 3.0 Manual dated, October 2019, indicated, A resident's potential for maximum function is .based on accurate assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 6 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide resident centered care and services for one of 12 sampled residents (Resident 187) when, on two separate occasions, her call light was not within reach. Residents Affected - Some These failures decreased the potential for the resident to receive effective treatment and necessary personal care. Findings: According to the resident's face sheet, Resident 1 was admitted to the facility in mid 2022 with diagnoses including fracture of the left humerus (the bone of upper arm). A review of Resident's 187's clinical records included the following documents: An MDS (Minimum Data Sheet, an assessment tool), dated 4/15/22, indicated Resident 187 was cognitively intact. In an observation on 4/11/22 at 8:45 a.m., Resident 187 was observed calling out for the nurse. In an observation on 4/11/22 at 9:03 a.m., Resident 187 was calling out for the nurse and Certified Nursing Assistant (CNA) 5 passed by Resident 187's room and failed to acknowledge the resident's calls. In an observation on 4/11/22 at 9:05 a.m., Licensed Nurse (LN) 4 instructed CNA 5 to check on which resident was calling, Nurse. In an observation and concurrent interview with CNA 5 on 4/11/22 at 9:07 a.m., Resident 187 was seen lying in bed with sling on her left arm. The call light and bedside remote control were hanging on the far end of the right side of the bed. Resident 187 stated she was uncomfortable and needed assistance to position herself. She further stated she was unable to reach the call light as she had only one functional arm. In an interview on 4/11/22 at 9:10 a.m., CNA 5 stated this resident is at risk for falls and needed supervision for safety. She further stated the expectation was the resident should have the call light next to them at all the times. In an observation and interview on 4/13/22 at 9:53 a.m., Resident 187 was lying in bed and stated she could not reach her call light. The resident's call light was observed hanging on the headboard of the bed behind her. Resident 187 stated she could not reach her call light. In a concurrent observation and interview on 4/13/22 at 9:55 a.m., the Director of Nursing (DON) came into Resident 187's room and confirmed the call light was on the headboard behind the resident. The DON moved the call light and clipped it to the resident's gown. The DON stated call lights should be always available to residents, otherwise residents could not reach staff and their needs would not be met. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 7 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0684 A review of the facility's policy titled, Call Light System, last revised 3/5/2002, stated, .Each Resident will have call light system within reach while in the room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 8 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review, the facility failed to provide treatment per physician's order for one resident (Resident 28) of 12 sampled residents, when Resident 28 was not gotten out of bed daily. This failure had the potential to decrease Resident 28's strength in both upper and lower extremities. Findings: According to the resident's face sheet, Resident 28 was admitted in mid-2017 with multiple diagnoses including paraplegia (paralysis of the lower body and legs). A review of Resident 28's clinical record includes the following documents: An MDS (Minimum Data Set, an assessment tool), dated 3/13/22, indicated resident 28 had severe cognitive impairment (the ability to remember, learn, concentrate or make decisions) and required extensive assistance with bed mobility, transfers, dressing and personal hygiene. A physician's order report, dated 7/26/12, indicated, Up in chair QD (once a day) as tolerated. A point of care history report, dated 4/1/22 to 4/14/22, indicated staff did not get Resident 28 out of bed on 4/7/22, 4/9/22, 4/11/22 and 4/12/22. In an interview on 4/14/22 at 9:35 a.m., the DON (Director of Nurses) confirmed Resident 28 had a physician's order to get out of bed daily and she expected staff to follow the order. The DON stated if Resident 28 was not gotten out of bed it could affect her functionality and muscle strength. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 9 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than 5 percent (%) when two medication errors occurred out of 25 opportunities during medication administration for two residents (Resident 86 and Resident 87) for a census of 31. Residents Affected - Some As a result of these failures, the facility's medication administration error rate was 8%. Findings: A review of an admission record indicated Resident 87 was admitted to the facility in early 2022 with multiple diagnoses which included multiple fractures of the left ribs and opioid (a substance used to treat moderate to severe pain) drug induced constipation. A review of Resident 87's physician order, dated 3/31/22, indicated, polyethylene glycol 3350 powder [medication for constipation] 17 gram/dose .administer 2 dose[s] .mix 34 GM(S)[grams - weight measurement]with 8 to 16 OZ [ounce - liquid volume][8 OZ/dose] of liquid . During a concurrent medication administration observation and interview on 4/11/22 at 7:55 a.m., the Licensed Nurse 1 (LN 1) poured the medication powder in a cup and poured water into the same cup. The LN 1 did not measure the amount of water added to the medication powder. The LN 1 stated, I eyeballed the water. A review of an admission record indicated Resident 86 was admitted to the facility in early 2022 with multiple diagnoses which included diarrhea and a history of urinary tract infections. A review of Resident 87's physician order, dated 3/31/22, indicated, Lactobacillus acidoph-L.bulgar granules in packet[pkt] [medication for bowel problems] .mix 1 packet in 8 OZ of fluids . During a concurrent medication administration observation and interview on 4/11/22 at 8:23 am, the LN 1 poured the medication contents in a medication cup, poured apple sauce in the same cup, and mixed the medication with the applesauce. The LN 1 then administered the medication to Resident 87. The LN 1 stated the order was confusing and she should have clarified the order with the physician before giving the medication. During an interview on 4/13/22 at 8:36 a.m., the LN 3 stated it was expected for Licensed Nurses to follow the physician's orders. The LN 3 further stated, Clarify [the order] with .[the] MD [Medical Doctor]. During an interview on 4/13/22 at 8:52 a.m., the Director of Nursing (DON) stated, [It] was expected [for LNs] to follow MD orders. The DON stated if the order is confusing, confirm and clarify it with the DON or MD. During an interview on 4/13/22 at 10 a.m., the MD stated, It [Lactobacillus acidoph-L.bulgar granules] should be [mixed with] water .it [Lactobacillus acidoph-L.bulgar granules] affects the [medication] absorption if not mixed with water. A review of the facility's policy titled, Medication Administration: General Guidelines, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 10 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 2007, indicated, .Medications are administered as prescribed .and .in accordance with written orders . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 11 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to preserve the nutritive value of a meal for one resident of a census of 31, when kitchen staff did not follow the recipe for carrot and country steak. Residents Affected - Few This failure decreased the facility's potential to provide essential nutrients to residents with a pureed textured diet. Findings: During an observation and interview on 4/13/22 at 10:35 a.m., the Lead [NAME] (LC) used measuring cups that were supposed to be used to measure fluid ounces to measure cooked carrots. The LC stated he measured, two cups of cooked carrots. The LC then poured the cooked carrots into the food processor and added two ladles of milk to make pureed carrots. The LC stated two ladles were equal to eight ounces. The LC stated he mixed the carrots with sugar, cinnamon, salt, and oil before cooking the carrots. The LC confirmed he did not use thickener like the recipe had indicated. The LC then placed two slices of cooked steak and five tablespoons (tbsp) of beef base into the food processor to make country steak puree. The LC stated the steak equaled four ounces. The LC confirmed he did not use hot water and thickener as the recipe indicated to make the country steak puree. A review of the facility's recipe titled .Cinnamon Glazed Carrots, Puree revision date 7/31/21, indicated, Instant Food & Beverage Thickener 2 [tablespoons] .Whole Milk 4 oz [ounces] .Carrots, fresh, bias cut 12 oz .Place finished product in food processor with milk and puree until smooth . A review of the facility's document titled .Diet Spread Report, indicated ½ cup of glazed carrots was equal to 4 oz and 1 ladle was 6 oz. A review of the facility's recipe, titled .Country Style Steak, Simply puree, revision date 7/31/21, indicated, .Country Steak, Signature Item 4 servings, hot water 1-1/3 cup, 1 [tablespoon, tbsp], shape and serve thickener 1/3 cup, 1 tbsp, beef base 1-1/4 [teaspoon] .Place the steak into a food processor, and process to a fine consistency. Add base mixed with hot water and .Thickener and process until smooth . During an interview on 4/14/22 at 9:10 a.m., the Dining Director confirmed the LC should have used the right measuring tool to measure the carrots and should have used four slices of beef. During an interview on 4/14/22 at 11:11 a.m., the Registered Dietician confirmed the cook should have followed the puree recipe to maintain the food's nutritional value. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 12 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe food storage when opened food packages were not labeled with open and use by dates and when food items were expired and kept in storage in the kitchen. These failures decreased the facility's potential to prevent food borne infections (illness caused by consuming contaminated food) among 31 residents. Findings: During a concurrent observation and interview of the kitchen pantry on 4/11/22 at 9:39 a.m., an opened package of low sodium white bread with four slices left was not labeled with an open date and use-by date. The Lead [NAME] (LC) confirmed all open food items should be labeled and dated. During a concurrent observation and interview of the kitchen on 4/13/22 at 8:51 a.m., the following items were found in the pantry: -an opened package of 9.5 pound (lb, a unit of measure) sweet and sour sauce with a use by date of 2/2/22, -an opened bottle of 3.79 liter of molasses with a use by date of 3/5/22, -an opened bottle of 1 lb and 12 ounces (oz, a unit of measure) chili hot sauce with a use by date of 3/23/22, -an opened package of 1 lb 8 oz grits Quick-5-Minute with a best before date of 1/1/22, -an opened package of 11 lb vanilla crème icing with a use by date 4/3/22, -an opened bottle of 1 gallon extra virgin olive oil, unlabeled with an opened and use by date, -an opened 12.9 fluid oz balsamic vinegar, unlabeled with an opened and use by date, and -an opened package of bread with 11 slices in it, unlabeled with an opened and use by date. The Assistant Dining Director (ADD) confirmed condiments should be discarded after the use by date. During a concurrent observation and interview of the kitchen on 4/13/22, at 9:26 a.m., the following items were found in the two walk-in refrigerators: -a box of more than 20 yellow bell peppers with gray, fuzzy substance, -a package of pre-cut Brussels sprouts with a use by date of 4/12/22, -four bags (2 lbs each) of chopped romaine lettuce with a use by date of 4/12/22, -four bags (5 lbs each) of cabbage slaw with a use by date of 4/12/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 13 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 -two big chunks (6 lbs each) of cooked beef with a discard date of 4/11/22, Level of Harm - Minimal harm or potential for actual harm -an unlabeled pan of cooked rice, and -a package of smoked salmon with use by date 4/12/22. Residents Affected - Some The Regional Director stated, it is molded when referred to the yellow bell peppers. The Regional Director confirmed the food items were past their use by dates and should have been discarded. A review of the facility's policy titled, Food and Supply Storage revised date 1/21, indicated, .Foods past the use by, sell-by, best-by, or enjoy by date should be discarded .Cover, label and date unused portions and open packages. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 14 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the garbage waste was properly contained with lids or covered. Residents Affected - Few This failure had the potential for foul odors and pest infestation for a census of 31. Findings: During a concurrent observation and interview on 4/11/22 at 4:14 p.m., the large outside garbage dumpsters were left wide open and uncovered. No staff were observed throwing garbage away in the bins. The Assistant Dining Director (ADD) confirmed the garbage bins should always be closed with lids when they were not in use. The ADD and another staff member closed the lids. The ADD stated she will conduct in-services for the staff. A review of the facility's policy titled, Solid Waste Disposal, revised 1/21, indicated, Garbage containers are .covered at all times .Keep lids closed on all outside trash receptacles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 15 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for two residents (Resident 28 and Resident 35) of twelve sampled residents when: Residents Affected - Some 1. Resident 28's point of care history was documented inaccurately; and 2. Resident 35's transfer and referral record and physician discharge summary was incomplete. These failures decreased the facility's potential to provide necessary care and services to Resident 28 and Resident 35. Findings: 1. According to the resident's face sheet, Resident 28 was admitted in July 2017 with multiple diagnoses including paraplegia (paralysis of the legs and lower body). A review of Resident 28 clinical record includes the following documents: A Minimum Data Set (MDS, an assessment tool), dated 3/13/22, indicated Resident 28 had severe memory problems and required extensive assistance by at least two staff members with transfers from bed to chair. A physician's order report, dated 7/26/17, indicated, Up in chair QD (once a day) as tolerated. In a series of observations on 4/11/22 at 8:30 a.m., 9:51 a.m., 10:49 a.m., Resident 28 was in bed. A review of a point of care history report, dated 4/1/22 to 4/14/22, indicated on 4/11/22 at 10:59 a.m. the Certified Nursing Assistant 6 (CNA 6) clicked the following documentation options in Resident 28's chart: Total Dependence, 2+ persons physical assist, and Lifted mechanically. These options indicated CNA 6 and at least one other staff member used a mechanical lift to transfer Resident 28 from the bed to the chair on 4/11/22 at 10:59 a.m. In a series of observations on 4/11/22 at 11:01 a.m., 11:41 a.m., 1:10 p.m., and 2:10 p.m., Resident 28 was in bed. In an interview on 4/11/22 at 2:10 p.m., the Certified Nursing Assistant 6 (CNA 6) stated, I did not get her up. In an interview and concurrent record review on 4/12/22 at 4:20 p.m., the Director of Nursing (DON) confirmed the point of care history report indicated Resident 28 was up in the chair. A review of Resident 28's progress note, dated 4/13/22 at 10:14 a.m. indicated, Note for CNA charting from 4/11/22 .Charting for transfer is invalid. Per CNA, Resident refused to be transferred from bed- Activity did not occur Per CNA she clicked wrong option . In an interview on 4/13/22 at 2:30 p.m., the Administrator (ADM) stated the CNA 6 documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 16 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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 0842 Resident 28 was up in the chair in error. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/14/22 at 9:37 a.m., the DON stated resident's muscle strength and functionality could be negatively affected if they do not receive care as documented. The DON also stated she expected her staff to document accurately and consistently. Residents Affected - Some A review of the facility's policy titled, Nursing Progress Notes, revised February 2016, indicated, Licensed Nurses will .ensure that all documentation remains consistent. 2. A review of an admission record indicated Resident 35 was admitted to the facility in early 2022 with multiple diagnoses, which included dementia (memory loss), repeated falls and failure to thrive. During an interview on 4/14/22, at 8:41 a.m., the Director of Nursing (DON) stated, Yes. [I] expect all documentation and medical records accurate .consistent. A review and concurrent interview with the Medical Record Coordinator (MRC) on 4/14/22, at 9:05 a.m., Resident 35's medical record indicated the following: -No destination information and no signatures of transfer and referral record, -No destination information, no signatures of resident or resident representative and facility representative of notice of proposed transfer/discharge, and -No admitting diagnosis on physician discharge summary. The MRC confirmed Resident 35's medical record was inaccurate and incomplete. The MRC stated it was expected all documentation and records should be accurate and complete. A review of the facility's policy titled, Notice of Proposed Transfer/Discharge, revised January 2018, indicated, Our community shall provide a resident and/or resident's representative written notice of an impending transfer or discharge .and .will be .completed by nursing staff .with the following information .the location to which the resident is being transferred or discharged .date and signature .from the community representative and the resident or resident representative. A review of the facility's policy titled, Nursing Progress Notes, revised February 2016, indicated, Licensed Nurses will .ensure that all documentation remains consistent. A review of facility's policy titled, Closure of the Medical Record, revised July 2015, indicated, Resident medical records are maintained .in a complete and accurate manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 17 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were implemented and maintained when staff members did not perform hand hygiene upon entering and exiting resident rooms and before putting on gloves and removing gloves. Residents Affected - Some These failures decreased the facility's potential to limit the spread germs and prevent illness for a census of 31 residents. Findings: During an observation on 4/11/22 at 9:15 a.m., the Occupational Therapy (OT) donned (put on) gloves and entered a resident's room. The OT did not perform hand hygiene prior to entering the resident's room or donning gloves. During an observation on 4/11/22 at 9:23 a.m., the OT removed the gloves and exited the resident's room. The OT quickly returned to the room, immediately put on gloves, and assisted the resident in walking. The OT did not perform hand hygiene after removing the gloves and exiting the resident's room nor prior to donning the gloves or entering the resident's room. During an interview on 4/11/22 at 9:37 a.m., the OT confirmed he did not sanitize his hands before donning gloves and after removing gloves. During an observation on 4/11/22 at 9:44 a.m., the Certified Nursing Assistant 1 (CNA 1) entered a resident's room and touched the resident's wheelchair. The CNA 1 did not perform hand hygiene performed before touching the resident's wheelchair. During an interview on 4/11/22 at 9:46 a.m., the CNA 1 confirmed she should have washed or sanitized her hands before assisting the resident. During an observation on 4/11/22 at 10:32 a.m., the CNA 2 donned gloves and walked into the resident's room to assist the resident to bed. The CNA 2 then removed her gloves and exited the resident's room to get a clean linen from the linen cart. The CNA 2 went back to the room to put the pillow under the resident's back and then exited the room. The CNA 2 did not perform hand hygiene before putting on gloves, after removing gloves, or upon exiting the room after touching the resident. During a concurrent observation and interview on 4/11/22 at 10:34 a.m., the CNA 2 had a red, open wound on the left hand. The CNA 2 also confirmed she should have used hand sanitizer before and after performing care the resident. During an observation on 4/13/22 at 12:13 p.m., the CNA 3 opened the clean food cart, removed a food tray, and delivered it to room [ROOM NUMBER]. The CNA 3 removed the lids of the food and set up the resident's tray. The CNA 3 then immediately returned to the food cart, removed a second tray, and delivered it to room [ROOM NUMBER]. The CNA 3 did not perform hand hygiene prior to touching the clean food cart, upon exiting the resident room, nor between providing care to each resident. During an interview on 4/14/22 at 8:56 a.m., the Director of Nursing (DON) confirmed hand hygiene should be performed before and after providing care. The DON also confirmed staff should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 18 of 19 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 performed hand hygiene before donning gloves, passing meal trays, and in between residents. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/14/22 at 10:34 a.m., the Infection Preventionist (IP) confirmed hand hygiene should be performed before and after: providing care for each resident, entering and exiting a room, and donning and removing gloves. Residents Affected - Some During a review of the Centers for Disease Control and Prevention's document titled, Clean Hands Count for Healthcare Providers, revised 1/8/21, indicated, Use an Alcohol-Based Hand Sanitizer .Immediately before touching a patient .After touching a patient or the patient's immediate environment .Immediately after glove removal. The document further stipulated, If your task requires gloves, perform hand hygiene prior to donning gloves .perform hand hygiene immediately after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 19 of 19