Inspection·February 29, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess four of 14 sampled residents (Resident 4, Resident 234, Resident 235, and Resident 25), when the Minimum Data Set (MDS; an assessment tool) inaccurately indicated: Residents Affected - Few 1. The change in Resident 4's skin condition; 2. Resident 234's Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping); 3. Resident 235's urinary catheter; and, 4. Resident 25's MDS discharge assessment date. These failures decreased the facility's potential to identify residents' care needs. Findings: 1. A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including right upper arm fracture and readmitted on [DATE] with diagnoses including stage 4 sacral pressure ulcer (skin damage caused by constant pressure. Muscles, bones, and/or tendons may also be visible). A review of Resident 4's Progress Notes, dated 1/11/24, indicated Resident 4 had stage 4 sacral pressure injury. A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had an unstageable deep tissue injury. During an interview on 2/28/24 at 3:14 p.m. with MDS Coordinator (MDSC), MDSC confirmed Resident 4's MDS skin assessment, dated 1/25/24, was inaccurate and stated it should have been documented as stage 4 pressure ulcer exactly as the wound care nurse indicated in her progress note dated 1/11/24. During an interview on 2/28/24 at 3:30 p.m. with Interim Director of Nursing (IDON) and Executive Director for Quality and Compliance (EDQC), both IDON and EDQC confirmed Resident 4's MDS skin assessment was inaccurate and stated MDSC should have accurately documented what was indicated in the wound consultant's progress note. IDON and EDQC further stated inaccurate MDS skin assessment might have impacted Resident 4's assessment data, billing, and care areas. 2. A review of Resident 234's admission records indicated she was admitted [DATE] with diagnoses including aftercare following a hip replacement surgery with a wound vacuum (a device that helps reduce swelling and drainage from the wound) and bronchiectasis (tubes that carry air in and out of the lungs were damaged) requiring the use of a CPAP machine at bedtime. A review of Resident 234's Physician Order Report, dated 2/15/24, indicated an order for the use of a CPAP machine at bedtime. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 2 of 32 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 02/29/2024 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 In a review of Resident 234's Comprehensive MDS, dated [DATE], the use of a CPAP machine was not documented in Section O, but instead the oxygen use was incorrectly coded. 3. Resident 235 was admitted [DATE] with diagnoses including urinary tract infection and aftercare following a knee joint replacement surgery. Residents Affected - Few A review of Resident 235's Physician Order Report, dated 2/12/24, it indicated the physician ordered a urinary catheter to be inserted to Resident 235 due to urinary retention. During a concurrent interview and record review on 2/27/24 at 1:17 p.m. with the MDSC confirmed Resident 235's Comprehensive MDS, dated [DATE], was not accurately completed and she forgot to code the urinary catheter use. In an Interview on 2/27/24 at 3:51 p.m. with the EDQC, she acknowledged that the MDS completed for Resident 235, dated 2/15/24, was inaccurate and the urinary catheter should have been coded to reflect the resident's current status. 4. In a concurrent interview and record review on 2/27/23 at 1:04 p.m. with the MDS Coordinator (MDSC) the following were confirmed: Resident 25's Progress Notes, dated 9/24/23, indicated she was admitted on [DATE], complained of severe abdominal pain three hours after admission was picked up by the ambulance to be taken back to the hospital as ordered by the physician the same day at approximately 9:44 p.m. Resident 25's MDS discharged Assessment, was completed on 9/25/23. MDSC stated Resident 25's MDS Discharge Assessment date was incorrect and should have been dated 9/24/23. In a concurrent interview and record review on 2/27/24 at 1:30 p.m. with the the Business Office Manager (BOM), the BOM confirmed the Facility Census listed Resident 25's date of discharge as 9/25/23, will modify the census to reflect the right discharge of 9/24/23 A review of the facility's policy titled, [Resident Assessment Instrument] RAI Process, dated 2/28/24, indicated .all interdisciplinary team members (IDT) [are responsible] for correct completion of the MDS .The Community MDS Coordinator is responsible for coordinating the RAI process to assure assessments and care plans are completed timely and collaboratively with the resident, community staff, physician, and family/responsible parties. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 3 of 32 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 02/29/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview and record review, the facility failed to follow its own policy and procedure for Baseline Care Plan (BCP, a care plan that identifies resident's care needs upon admission) for one of 14 sampled residents (Resident 14) when Resident 14 was not provided a written summary of her BCP within 48 hours of admission. This failure had the potential to increase Resident 14's risk of not being aware of her plan of care. Findings: According to Resident 14's admission record she was admitted to the facility first week of February with diagnoses including,left ankle charcot (weakening of the bones in foot due to significant nerve damage) revision. With orders for non-weight bearing status due to pins and external fixators (devices used to keep fractured bones stabilized), attached to the left ankle/foot. Alert and oriented with no memory problems. She makes her own healthcare decisions. A review of Resident 14's BCP indicated it was completed on 2/1/24. In an interview on 2/26/24 at 4:33 p.m. with Resident 14, she stated she did not remember having a meeting to talk about the initial plan of care or receive a copy of a summary of her plan of care. During an interview on 2/27/24 at 2 p.m. with Licensed Nurse 7 (LN 7) she stated the BCP is completed only by the admitting nurse but she was not aware if residents receive a copy of it. In an interview on 2/28/24 at 3 p.m. with the Interim Director of Nursing (IDON) the IDON confirmed the BCP is done by the admitting nurses within 48 hours from admission and a copy should be given/explained to the resident or their representative. This should be followed so that there will be continuity of care for residents and maintain communication among the staff. A review of the facility's Policy and Procedure (P&P) titled Baseline Care Plan revised 11/12/21 the P&P indicated It is the policy of this community to develop a baseline care plan within 48 hours of admission. Along with the base line care plan is a summary of care plan that is provided to the resident and representative in a language that can be understood .Inform the residents and representatives if applicable of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 4 of 32 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 02/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and/or implement a person-centered care plan for three of 14 sampled residents (Resident 84, Resident 14, and Resident 234) when: Residents Affected - Few 1. There was no care plan for a coccyx (tail bone) wound for Resident 84; 2. There was no care plan for a wedge pillow for Resident 14; and, 3. There was no care plan for a continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping) machine for Resident 234. These failures had the potential for Resident 84, Resident 14, and Resident 234 to not receive the appropriate care, services, and treatment. Findings: 1. Review of the Resident Face Sheet, undated, indicated Resident 84 was admitted to the facility in 2024 with diagnoses that included falls. Review of the Minimum Data Set (MDS, an assessment tool), dated 2/17/24, indicated Resident 84 had no memory problems. Review of the Physician Order Report, dated 2/11/24 to 2/29/24, indicated Resident 84 had a treatment order for his coccyx wound, cleanse with normal saline, pat dry, apply triad (wound paste), cover with mepilex (a bordered foam dressing) and change dressing daily. During an interview on 2/27/24 at 4:28 p.m., the Health Information Coordinator (HIC) confirmed there was no documentation of having a coccyx wound care plan for Resident 84. During an interview on 2/29/24 at 8:23 a.m., the Interim Director of Nursing (IDON) confirmed there should have been a care plan for a coccyx wound. Review of the facility's policy titled, Interdisciplinary Team/Care Plan Process, dated 12/15/21, indicated, An interdisciplinary assessment team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. 2. A review of the clinical record for Resident 14 indicated the following: According to Resident 14's admission record she was admitted to the facility February 2024 with diagnoses including left ankle charcot (weakening of the bones in foot due to significant nerve damage) revision, and included a physician order for non-weight bearing status due to pins and external fixators (devices that stabilize fractured bones) attached to the left ankle/foot. A written order from the physician, dated 2/6/24, was found in Resident 14's chart for a left hip and ankle wedge pillow to be used to prevent the left leg from externally rotating. During a concurrent interview and record review on 2/29/24 at 10:57 a.m. with Licensed Nurse 1 (LN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 5 of 32 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 02/29/2024 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 0656 1), she confirmed there was no care plan developed for Resident 14's use of a left hip/ankle wedge pillow. Level of Harm - Minimal harm or potential for actual harm 3. A review of the clinical record for Resident 234 indicated the following: Residents Affected - Few According to Resident 234's admission records the facility admitted her February 2024 with diagnoses including bronchiectasis (tubes that carry air in and out of the lungs were damaged) requiring the use of a CPAP at bedtime. A physician order report, dated 2/15/24, included an order for a CPAP machine to be worn by Resident 234 at bedtime for bronchiectasis. During a concurrent interview and record review on 2/27/24 at 5 p.m. with Licensed Nurse (LN) 5, LN 5 confirmed she cannot find a care plan for Resident 234's CPAP machine and further added it should have been included to her record on the day she got admitted . In an interview on 2/28/24 at 3 p.m., the IDON stated he expected nurses to be able to develop/revise a resident's care plan, and they should be aware of the timeliness of its completion from admission. A review of the facility's Policy and Procedure (P&P) titled Interdisciplinary Team/Care Plan Process, revised 12/15/21 indicated, Each resident will have a care plan that is initiated upon admission and is complete no later than seven days after the completion of the resident assessment instrument . A preliminary care plan is developed upon admission to assure that the resident's immediate care needs are met and maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 6 of 32 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 02/29/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise in a timely manner the care plan interventions following a significant change assessment for one of 14 sampled residents (Resident 4), when Resident 4 developed a facility-acquired sacral pressure injury. This failure decreased the facility's potential to provide Resident 4 with a person-centered care plan and evaluate its effectiveness. Findings: A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including right humerus (long bone in upper arm) fracture and readmitted on [DATE] with diagnoses including stage 4 sacral pressure ulcer (skin damage caused by constant pressure) and pressure-induced deep tissue damage of sacral region. A review of Resident 4's Care Plan History, dated 10/17/23, indicated Resident 4 was at risk for impaired skin integrity related to right humerus fracture and limited mobility. A review of Resident 4's Minimum Data Set (MDS; an assessment tool), dated 10/22/23, indicated Resident 4 had no pressure ulcers/injuries. A review of an Event Report, dated 11/15/23, indicated Resident 4 had an abrasion on his buttock area. A review of Resident 4's Progress Notes, dated 11/24/23, indicated Resident 4 was noted with open wounds on buttocks area. A review of an Event Report, dated 11/30/23, indicated Resident 4 had redness and abrasion on his upper and mid back and a fluid filled blister on his low back near his upper left buttocks. A review of Resident 4's Progress Notes, dated 11/30/23, indicated Resident 4 developed an unstageable sacral pressure injury. A review of Resident 4's Progress Notes, dated 12/28/23, indicated Resident 4's wound deteriorated since last evaluation, was unstageable with dead tissue, and had foul odor and surrounding redness/warmth. The wound nurse performed a sharp debridement (removal of damaged tissue) procedure to Resident 4's sacral wound. A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had an unstageable deep tissue injury. A review of Resident 4's Progress Notes, dated 1/11/24, indicated Resident 4 had a stage 4 sacral pressure injury and wound still had a foul odor. A review of Resident 4's Care Plan History, dated 1/11/24, indicated Resident 4 had an alteration in skin integrity and acquired a pressure injury to sacrum. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 7 of 32 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 02/29/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 2/29/24 at 9 a.m. with Interim Director of Nursing (IDON), IDON confirmed Resident 4's care plan was not updated and revised to reflect his change in condition and stated it should have been revised/updated otherwise it could have prevented Resident 4 from developing a pressure injury and nurses could have followed new interventions. A review of the facility's policy titled, Interdisciplinary Team/Care Plan Process, dated 12/15/21, indicated Care plans are reviewed and revised as needed: Upon identification of a medical change in condition, when there has been a significant change in the resident's status .during the weekly summary process . Event ID: Facility ID: 555555 If continuation sheet Page 8 of 32 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 02/29/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 14 sampled residents (Resident 235), when Resident 235's omeprazole (medication used to treat excess stomach acid) was not administered as indicated in physician's order. Residents Affected - Few This failure decreased the facility's potential to safely follow the physician's orders. Findings: A review of Resident 235's Face Sheet, indicated she was admitted to the facility in February 2024. During an observation on 2/27/24 at 8:24 a.m. in Resident 235's room, Licensed Nurse 3 (LN 3) administered 40 milligrams (mg; a unit of measure) capsule of omeprazole to Resident 235. A review of Resident 235's Administration History, dated 2/28/24, indicated an order of 40 mg of omeprazole capsule to be administered to Resident 235 daily 30 minutes before a meal for excess acid build up in the stomach and LN 3 administered omeprazole on 2/27/24 at 8:37 a.m. During an interview on 2/27/24 at 9:09 a.m. with Resident 235, Resident 235 stated around 8:15 a.m. she had cheerios with honey for breakfast and that was before LN 3 administered her medications. During an interview on 2/27/24 at 9:16 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated around 8:10 a.m. Resident 235 had cheerios for her breakfast. During an interview on 2/27/24 at 9:20 a.m. with LN 3, LN 3 confirmed she administered omeprazole for Resident 235 after she had her breakfast and stated it should have been administered before meals as indicated in the physician's order. During an interview on 2/28/24 at 11:56 a.m. with Interim Director of Nursing (IDON), IDON stated LN 3 should have administered omeprazole medication before Resident 235 had her meal as indicated in physician's order because the medication was for stomach protection and if it was given after meals then this might have impacted its effectiveness. A review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated 11/17, indicated Review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medication. A review of the facility's P&P titled, Orders-Physician, dated 2/28/24, indicated The nursing staff shall note and verify orders when orders are received from provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 9 of 32 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 02/29/2024 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 follow and implement a physician's order for one of 14 sampled residents (Resident 14) when a prescribed hip-ankle wedge pillow was not provided as ordered for Resident 14. Residents Affected - Few This failure had the potential to delay the healing of Resident 14's ankle related to improper positioning and alignment. Findings: According to Resident 14's admission record she was admitted to the facility in February 2024 with diagnoses including left ankle charcot (weakening of the bones in foot due to significant nerve damage) revision, with orders for non-weight bearing status due to pins and external fixators (devices used to stabilize fractured bones) attached to the left ankle/foot. Resident 14 was alert and oriented with no memory problems. During a concurrent observation and interview on 2/26/24 at 2:24 p.m., observed Resident 14 lying in bed, with no wedge pillow in use. Resident 14 stated she was not using a wedge pillow because the facility did not have the right kind. The nurses just put pillows behind her hip but she prefers to have a wedge pillow to keep her leg straight and prevent it from rolling out to the side, especially at night while sleeping. A review of the clinical record for Resident 14 indicated the following: a. A written order from the physician, dated 2/6/24, was found in Resident 14's chart for a left hip and ankle wedge pillow to be used to prevent the left leg from externally rotating. b. The Physician Order Report, dated 2/17/24, included an order for a wedge pillow to left hip/ankle to be placed twice a day, afternoon and night, to prevent the left leg from externally rotating. c. The Medication Administration Record (MAR) revealed the Licensed Nurses (LN) signed the order without monitoring the placement of the wedge pillow from 2/26/24 to 2/29/24. During a concurrent observation, interview, and record review on 2/27/24 at 3:28 p.m. with a Physical Therapy Staff (PTS), PTS stated he was not aware that Resident 14 had an order for a hip/ankle wedge pillow not until he checked her orders. PTS confirmed while inside Resident 14's room, that she was not using a wedge pillow then acknowledged that she needed it for the proper alignment of her leg and pain management. In an interview on 2/28/24 at 10 a.m. with the Director of Rehab (DOR), DOR stated she was not made aware by the nursing staff of an order for a hip/ankle wedge pillow for Resident 14. In an interview on 2/28/24 at 10:28 a.m. with LN 4, LN 4 stated he was the nurse who got the order for Resident 14 to use a wedge pillow two times per day. He confirmed he did not talk to anybody in therapy for assistance on what kind of wedge pillow to order for Resident 14, he did not ask the Business Office Manager (BOM) to order a wedge pillow for the resident, and further added he did not check with Resident 14 if a wedge pillow was already available for her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 10 of 32 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 02/29/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 2/28/24 at 3 p.m. with the Interim Director of Nursing (IDON) the IDON stated he expected all nursing staff to be able to carry out physician orders accurately and efficiently making sure everything is coordinated within the interdisciplinary team (IDT) when necessary to avoid delays in the resident's delivery of care. A review of the facility's Policy and Procedure (P&P) titled Orders-Physician revised 2/28/24, stipulated the facility shall administer drugs and treatments upon the order of a licensed/ authorized person and it is the responsibility of the nurse to report and communicate new orders to staff. Event ID: Facility ID: 555555 If continuation sheet Page 11 of 32 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 02/29/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pressure injury preventative care plan interventions for one of 14 sampled residents (Resident 4), when: Residents Affected - Few 1. The certified nursing assistants (CNAs) did not consistently check Resident 4's skin during routine care for impairments; 2. Resident 4 was not frequently repositioned until 12/1/23; and, 3. A pressure reducing mattress was not applied until 11/27/23. These failures increased Resident 4's potential to develop a facility-acquired pressure injury. Findings: A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility in October 2023 with diagnoses including right humerus (long bone in upper arm) fracture and was readmitted in November 2023 with diagnoses including stage 4 sacral pressure ulcer (skin damage caused by constant pressure where muscle and bone may be exposed) and pressure-induced deep tissue damage of sacral region (between the right and left hip bones). A review of Resident 4's Care Plan History, dated 10/17/23, indicated Resident 4 was at risk for impaired skin integrity related to right humerus fracture and limited mobility. Care plan interventions included CNA to check Resident 4's skin during routine care for impairments, assist Resident 4 with turning and repositioning, and apply a pressure reducing mattress. A review of Resident 4's Minimum Data Set (MDS; an assessment tool), dated 10/22/23, indicated Resident 4 had no pressure ulcers/injuries. 1. A review of an Event Report, dated 11/15/23, indicated Resident 4 had an abrasion on his buttock area. During a concurrent interview and record review on 2/28/24 at 2:43 p.m. with Licensed Nurse 4 (LN 4), Resident 4's Transfer Referral Record, dated 11/22/23, was reviewed. LN 4 confirmed Resident 4 was transferred to acute for critical low hemoglobin (protein in red blood cells that carries oxygen) and transfer record did not indicate if Resident 4 had a pressure ulcer/injury before transfer. LN 4 stated Resident 4 was initially admitted to the facility with no pressure ulcers/injuries. A review of Resident 4's Progress Notes, dated 11/23/23, indicated Resident 4 returned back from acute to the facility on [DATE] at 6:05 a.m. During a concurrent interview and record review on 2/29/24 at 8:27 a.m. with LN 1, Resident 4's Shower Day Skin Inspection worksheets, dated 11/3/23, 11/14/23, and 11/17/23, were reviewed. LN 1 confirmed shower sheets indicated no skin assessment was performed by the CNAs on the reviewed dates. A review of Resident 4's Progress Notes, dated 11/24/23, indicated Resident 4 was noted with open wounds on buttocks area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 12 of 32 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 02/29/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of an Event Report, dated 11/30/23, indicated Resident 4 had redness and abrasion on his upper and mid back and a fluid filled blister on his low back near his upper left buttocks. A review of Resident 4's Progress Notes, dated 11/30/23, indicated Resident 4 developed an unstageable sacral pressure injury. Resident 4's etiology of wound appeared to be related to moisture-associated skin damage and pressure, and the onset of wounding occurred on/around November 2023. Progress notes further indicated no pressure relieving aids were in place. Pressure injury preventative recommendations included pressure relieving alternating low air loss mattress and initiating a frequent turning and repositioning schedule. 2. During a concurrent interview and record review on 2/29/24 at 8:27 a.m. with LN 1, Resident 4's Physician Order Report, was reviewed. LN 1 confirmed on 12/1/23, Resident 4's weight started to be adjusted every shift. LN 1 stated there was no physician order for repositioning until 12/1/23. 3. A review of Resident 4's Physician Order Report, indicated on 11/27/23, an alternating pressure (APP) mattress was to be checked every shift for functioning. During a concurrent interview and record review on 2/28/24 at 3:48 p.m. with LN 5, Resident 4's Physician Notification/Problem/Assessment, dated 11/24/23, was reviewed. LN 5 stated she notified the physician on 11/24/23 about Resident 4's open wounds on buttocks area and on 11/27/23 physician agreed with APP mattress and wound care. During an interview on 2/28/24 at 2:43 p.m. with LN 4, LN 4 stated Resident 4's APP mattress was applied on 11/27/23. A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had an unstageable deep tissue injury. A review of Resident 4's Care Plan History, dated 1/11/24, indicated Resident 4 had an alteration in skin integrity and acquired a pressure injury to sacrum. During an interview on 2/29/24 at 9 a.m. with Interim Director of Nursing (IDON), IDON confirmed Resident 4's shower sheets, dated 11/3/23, 11/14/23, and 11/17/23 indicated no skin assessment was done by CNAs and Resident 4's order history did not indicate a repositioning order until 12/1/23. IDON stated CNAs should have assessed skin on shower days, when providing care, and notified nurses if there was a change in condition. IDON added skin assessments should have also been performed before and after residents' transfer to hospital. IDON further stated Resident 4's care plan was not followed, positioning should have been documented and implemented as indicated in the care plan, and there was a potential that not following Resident 4's care plan interventions could have led Resident 4 to develop a pressure ulcer/injury. A review of the facility's policy titled, Routine Resident Checks, dated 10/27/99, indicated a resident check will be made every two (2) hours by nursing service personnel .routine resident check involves entering the resident's room to determine .if there has been a change in the resident's condition . A review of the facility's policy titled, Skin Integrity Protocol, dated 10/27/22, indicated All residents will have skin integrity evaluated by a licensed nurse on admission .A care plan will be implemented for each area .A CNA will observe for any skin issues during .the Shower Day and report any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 13 of 32 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 02/29/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm new areas of skin concerns to the licensed nurse using the Shower Day Skin Inspection worksheet .Resident's skin will be inspected using the shower sheet even if the shower is refused .The licensed nurse will document the status of each skin impairment and response to treatment in the Health Record and update the plan of care as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 14 of 32 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 02/29/2024 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 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 interview and record review, the facility failed to maintain a complete record of controlled drugs' receipt and disposition for a census of 21, when the Director of Nursing (DON) did not sign the facility's Discontinued Narcotic Drug and Disposition Log upon receiving controlled drugs. This failure decreased the facility's potential to safely destroy the residents'-controlled drugs. Findings: During an interview on 2/27/24 at 3:55 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated she's used to verbally counting the controlled drugs with the DON when delivering it for destruction without dating and signing any log. During a concurrent interview and record review on 2/27/24 at 3:45 p.m. with Interim DON (IDON), the facility's Discontinued Narcotic Drug and Disposition Log and untitled logs were reviewed. The untitled logs indicated the destruction dates for controlled substances with pharmacist and DON signatures. The Discontinued Narcotic Drug and Disposition Log indicated no documentation. IDON stated none of the logs indicated the DON's signature and the date she received the controlled drugs for destruction from the nurses. IDON further stated the DON should have used the facility's log for controlled drugs, documented the date she received the controlled drugs from nurses for destruction, and signed it upon receipt. A review of the facility's policy and procedure titled, Disposal of Medications, Syringes and Needles, dated 11/17, indicated A controlled medication disposition log, or equivalent form, shall be used for documentation .This log shall contain the following information .Date of disposition .Signatures of the required witnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 15 of 32 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 02/29/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 remove from use one expired medication for a census of 21, when miconazole nitrate cream (used to treat skin infections) was stored in the residents' treatment cart after its expiration date. This failure increased the facility's potential to administer expired medications to residents. Findings: During a concurrent observation and interview on 2/27/24 at 10:30 a.m., with Licensed Nurse 1 (LN 1), one household cream of miconazole nitrate was opened on 1/2/24 and stored in the treatment cart with expiration date 8/23. LN 1 confirmed miconazole cream was expired and stated it should have been removed from the cart. During an interview on 2/27/24 at 3:45 p.m. with Interim Director of Nursing (IDON), IDON stated expired medications should not have been stored in the treatment cart because there was a potential to administer it to residents which could have been unsafe. A review of the facility's policy and procedure titled, Medication Storage, dated 1/21, indicated Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .and reordered from the pharmacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 16 of 32 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 02/29/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm 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** The facility failed to ensure that recipes were used and followed during meal preparation. Residents Affected - Some This failure had the potential to alter the nutrient content of the meals and to affect the health status of the 3 residents (Resident 13, 14 and 185) out of 21 receiving the Consistent Carbohydrate diet to control blood sugar. Findings: During a return visit to the main kitchen on 2/27/24 at 8:48 a.m., the lunch meal was being prepared. The lunch meal was to include the following options: Chicken Tortilla Soup, Roasted Corn and Vegetable Succotash, Grilled Huli Huli Chicken, Cioppino with Garlic Toast, Quinoa [NAME], Citrus Basil Roast Veggie, Roasted Cauliflower, and Garlic Mashed Potatoes. During a walk through the food production area, no recipes were seen at the various workstations. Chef 1 (C1), who had worked for the facility for approximately 3 weeks, was making Cioppino (fish stew). He added onions, garlic, fennel, oil, and white wine to the tilt skillet to heat. After it boiled, he added tomato sauce and water. Once that boiled, more white wine (unmeasured), oil (unmeasured), and water were added and left to simmer for 1/2 hour. When questioned about how much of an ingredient was needed, C1 stated he knew based on his experience. After the sauce simmered, he added cod, shrimp, mussels, and squid, as well as previously cooked salmon that had been coated with a sauce. C1 stated it was leftover from a previous meal and wanted to make use the leftovers. Review of facility provided Cioppino recipe (Sodexo, 7/28/23) did not include salmon in the list of ingredients. During an interview with the Registered Dietitian (RD) on 2/28/24 at 11:18 a.m., her expectation was that the recipes were followed to ensure that meals provided the nutrients that were calculated and approved by the medical staff. During an interview with the Director of Culinary Experience (DCE) on 2/28/24 at 1:33 p.m., he expected the chefs to follow the recipes (which are kept in the cook's station) to ensure a consistent product. Review of facility provided policy titled Food Preparation and Safety revised 07/17/15, indicated that Food shall be prepared by methods that assure food safety while conserving nutritive value, flavor and appearance. The procedures further indicated, 1. Foods are prepared per the recipes which include portion yield, method of preparation, amounts of ingredients and time/temperature instructions . 11. Potentially hazardous foods are prepared per the time and temperature directed on the recipe . Review of the facility provided Sodexo Diet Manual for Healthcare Communities-2020, Chapter 7 on Consistent Carbohydrate diets indicated the following: 4. Modifications of the diet may be necessary for complications of diabetes and associated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 17 of 32 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 02/29/2024 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 0803 diseases: Level of Harm - Minimal harm or potential for actual harm a. Persons with diabetes have an increased risk of cardiovascular disease. Intake of saturated and trans fats should be limited and intake of unsaturated fatty acids . are recommended. Residents Affected - Some b. The intake of sodium should be considered in the treatment of persons with diabetes to prevent of delay complications resulting from hypertension and diabetic nephropathy. c. The caloric value of alcohol is approximately 7 calories per gram but provides no other nutritional value. The metabolism is like that of fat. d. Carbohydrates have the greatest effect on blood glucose, and therefore it is especially important to eat the same amount of carbohydrates at each meal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 18 of 32 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 02/29/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to serve food at a safe and appetizing temperature for five out of 21 residents (Residents 8, 9, 84, 186, and 236). Residents Affected - Some This failure had the potential of leading to poor food intake, nutrient deficits, and undesirable weight loss for residents eating facility prepared meals. Findings: During an interview on 2/27/24 at 8:37 a.m., in Resident 9's room, his wife stated that the food was served cold at times. She went on to state that this was particularly problematic when in the previous room that received food from the last meal cart. During an interview on 2/26/24 at 9:24 a.m., Resident 8 stated that the food is a little cold, not very warm. I like warm food to be warm. During an interview on 2/26/24 at 10:17 a.m., Resident 84 stated that sometimes the soup and hot cereal are not hot. During an interview on 2/26/24 at 12:26 p.m., Resident 236 was served lunch. She stated that the fish in the taco was not cooked thoroughly. Resident 236 further stated that this was not the first time and whenever she orders the fish it is always cooked incorrectly . Meals are always served at the wrong temperature, soup not hot or warm at least. I believe that hot foods should be hot and cold foods should be cold. She usually has the CNA warm up my food in the microwave. During the initial Assistive Living Unit (ALU) kitchen tour on at 2/26/24 at 8:10 a.m., the food warmer cabinet was observed with a sign on it indicating the right side was not working. The left side was opened and was being used to warm plates. During a follow up visit to the main kitchen on 2/27/24 at 10:55 a.m., Wait Staff 1 (WS1) was collecting the lunch items for the ALU kitchen. She took steam table pans from a warming oven and placed into an unheated cart. WS1 grabbed a pan of vegetables from a wire rack sitting by the kitchen door and started to place in her cart. Executive Chef (EC) noticed and stated that these still need to be heated and placed in the warming oven for approximately 10 minutes while other food items were left at room temperature in the cart. ALU food cart arrived at the ALU kitchen on 2/27/24 at 11:15 a.m. Food was moved from the cart to the steam table. Soup portions were transferred into paper bowls and left unheated next to serving area as there was no room for the soup containers (2) in the steam table, and plates were warming in the working side of the food warmer. The rest of the soup was brought to Assisted Living dining room and placed in a heated soup well. The food temperatures were taken at 11:37 a.m. The Quinoa [NAME] (one of entrée choices) was found to be at 122 degrees Fahrenheit (F, a unit of measurement), which was below the goal of 135 F or higher. It was pulled from steam table and staff was sent to main kitchen to get another pan which arrived at 11:58 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 19 of 32 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 02/29/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The meal service was started at 11:51 a.m. and the first of the two meal carts left the ALU kitchen at 12:28 p.m., over an hour after the soup was placed into paper bowls. During the 2/28/24 11:15 a.m. ALU kitchen observation and concurrent interview the Director of Culinary Experience (DCE) stated that his main concentration at this time is ensuring that the food complaints being brought by persons in Assisted Living are being taken care of since they are our long-term people. When we get complaints coming from the Skilled Nursing Facility, those people are not here long and by the time I get to them, they are already discharged from the facility. During an interview on 2/29/24 at 8:15 a.m., the Interim Director of Nursing (IDON) confirmed hot food should have been hot to the resident's preference. During an interview on 2/29/24 at 10:40 a.m. with the Skilled Nursing Dining Supervisor (SNDS), she stated food complaints are brought to her attention by nursing staff. There was not a system to follow residents after their initial screen unless there stay was long term. Review of facility provided invoice from 12/29/23 indicated that warmer cabinet was evaluated, and parts were on back order. Review of facility provided policy titled Food Preparation and Safety revised 07/17/15, indicated that Food shall be prepared by methods that assure food safety while conserving nutritive value, flavor and appearance. Procedures further indicated in bullet 7, At consumption, the food will be considered palatable by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 20 of 32 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 02/29/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide food storage and preparation in accordance with professional standards for food service safety when: 1) Hair and beard nets not used as required; 2) Kitchen surfaces found discolored or rusted; 3) Food products not labeled and/or dated; 4) Fans found with whitish/gray build-up; 5) Food packages left open and/or uncovered; 6) Floor in dry storage found with missing linoleum; 7) Worn equipment not discarded and replaced such as can opener, cutting boards, and fry pan; 8) Moldy bread was not discarded; 9) Kitchen floors, oven, heating element of large kettle, and wire rack found with dark build-up and/or debris; and, 10) Reach-in ice cream dipping cabinet found with ice build-up and discoloration on sides of cabinet. These concerns had the potential to lead to food borne illness for the 21 residents eating facility provided foods. Findings: 1) During initial Assisted Living Unit (ALU) kitchen tour on 2/26/24 at 8:10 a.m., Wait Staff 2 (WS2) was observed walking through the kitchen without wearing a hair net. Wait Staff 3 (WS3) walked in and out of the kitchen several times with front portion of hair not restrained in hair net. Review of facility provided policy titled Personnel-Sanitary and Dress Standards (Eskaton, revised 07/29/19) indicated in bullet 7, Hair nets or caps are to worn when in the food production, food storage and ware-washing areas of the Dining Services . During the initial ALU kitchen tour on 2/26/24 at 8:34 a.m., the Director of Culinary Experience (DCE) was observed with facial hair that was not covered. During a follow up visit to the main kitchen on 2/27/24 at 8:48 a.m., Chef 1 (C1) was making lunch. He was observed with facial hair that was not covered. At 10:18 a.m., Executive Chef (EC) was also observed with facial hair, not wearing a beard guard, while preparing lunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 21 of 32 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 02/29/2024 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 According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Hair Restraints 2-402.11: (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Residents Affected - Some 2) During the initial Assisted Living Unit (ALU) kitchen tour on 2/26/24 at 8:25 a.m., a metal ledge on left side of the food service area (by the cutting boards) was observed discolored with white and orange markings. The shelf (to the right, under cook's service area holding silver bowls) had food particles and dark markings on and under a mesh net. During the initial ALU kitchen tour on 2/26/24 at 8:33 a.m., rust was observed on the walk-in refrigerator wall by the light switch of approximately one foot long streak with a dotted pattern surrounding it, plus a 6-8 inch long streak on the left, back corner wall (near the iceberg lettuce). Review of facility provided policy titled Food Storage (Eskaton, 10/29/18) indicated that Food shall be stored in a clean, safe, and sanitary manner. Procedures included the following in bullet 1, Food storage areas shall be clean at all times. Review of the facility provided policy titled Sanitation and Cleaning (Eskaton, revised 10/29/18) indicated in bullet 2 that All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from . corrosions, . rust, and chipped areas. 3) During the initial ALU kitchen tour on 2/26/24 at 8:37 a.m. in the walk-in refrigerator, three cubes of butter were marked 2/26 to 3/1. A plastic container of chicken base was marked open 2/24 UB (use by) 3/2. In a subsequent interview with the DCE at 8:45 a.m., he stated that the labeling on these items did not include the year, which would make it difficult for staff to know when the food would no longer be safe. During the initial ALU kitchen tour on 2/26/24 at 8:48 a.m., a box of frozen supplements was observed without a use-by date. During an observation and concurrent interview in the main kitchen on 2/26/24 at 9:48 a.m., three 20-ounce spice containers (Ground Cinnamon, Onion Powder, and Caribbean Jerk Seasoning) were observed in the cook's area that were not labeled. The DCE confirmed the lack of labels and stated he was uncertain how old these products were. Food Safety Management System (Sodexo, revised 12/6/2022) indicated in the Receiving/Storing Rotation System that Date cartons, cases, boxes, etc., with date received. A First In, First Out (FIFO) system should be in place during storage. Food Storage (Eskaton, revised 10/29/18) indicated 2. All foods will be rotated by placing the new behind the old products . 4. Opened containers will be dated and labeled . 6. Frozen supplements placed in the refrigerator for thawing will be dated . Supplements can be held under refrigeration no longer than 14 days. During a 2/26/24 visit to the resident refrigerator at 3:24 p.m., Certified Nursing Assistant 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 22 of 32 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 02/29/2024 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 (CNA 3) discussed the process for family bringing outside food to a resident. The resident refrigerator was opened during the explanation. It contained a package of guacamole labeled with a room number (20 A) and no other resident identifiers or dating. When asked who the guacamole belonged to, CNA 3 was uncertain since that room was currently not occupied. She was unable to state how the facility would ensure it did not go to another resident if they were to move into room [ROOM NUMBER] A. Residents Affected - Some During an interview on 2/28/24 at 8:34 a.m., the Interim Director of Nursing (IDON) said that when labeling food, staff should put the room number and date received. He concurred that it could become confusing to staff if a resident were to discharge, and a new resident were placed in that same bed, as it could lead to the resident getting food that was not appropriate or safe for the new resident. Review of facility provided policy titled Foods Brought by Family/Friends (Eskaton, revised 07/17/15) indicated in bullet 2 that Perishable foods, kept in unit refrigerators (@ 41 degrees or less), must be dated, labeled and are removed within 3 days. 4) During the initial ALU kitchen tour on 2/26/24 at 8:33 a.m., in the walk-in refrigerator, three ceiling fans were observed covered in white/gray particles on the screen and fan blades. During the initial main kitchen tour on 2/26/24 at 10:02 a.m., a silver fan next to the hand washing sink was observed covered with white/gray particles on the wire screen and blades. A small black fan was observed in the dishwashing area covered in grease, dust and dirt. During an interview with the DCE on 2/28/24 at 1:49 p.m., he stated that dirty fans could be a food safety issue since they can blow dirt and bacteria onto food, clean dishes, and food preparation surfaces. Review of facility provided policy titled Food Storage (Eskaton, 10/29/18) indicated that Food shall be stored in a clean, safe, and sanitary manner. Procedures included the following in bullet 1 Food storage areas shall be clean at all times. 5) During the initial ALU kitchen tour on 2/26/24 at 8:44 a.m., an opened box of salt was observed in the dry storage area. During a subsequent interview with the DCE at 8:48 a.m., he confirmed that the box was left opened and stated that this not acceptable as it could allow dirt, bacteria and pests into the item. During the initial main kitchen tour on 2/26/24 at 9:57 a.m. in the dry storage area, 2 boxes of lentils, a box of barley, a box of pinto beans, a box of white beans, and a box of black-eyed peas were observed in uncovered boxes that were open to the environment. The DCE confirmed the open boxes and shook his head, indicating this was not an acceptable practice. During the initial main kitchen tour on 2/26/24 at 10:18 a.m., 2 uncovered containers of kosher salt (approximately 2 C) were found in the cook's station. The DCE confirmed the findings, noting the particles of food (green and black colored) were not acceptable and that the items should have been kept covered to prevent this. During a return visit to the ALU kitchen on 2/27/24 at 8:27 a.m., an ice cream dipping cabinet had four containers of ice cream, 2 with lids that partially covered the ice cream and 1 ice cream (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 23 of 32 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 02/29/2024 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 without a lid. During a concurrent interview with the DCE, he stated the ice cream needed to be covered and these would have to be thrown away. Review of the facility provided policy titled Food Storage (Eskaton, revised 10/29/18) indicated in bullet 3 that Opened packages of . food which are to be stored will be dated upon opening and tightly wrapped in plastic or placed in sealed (lidded) containers. 6) During the initial main kitchen tour on 2/26/24 at 9:53 a.m. in the dry storage, the linoleum floor was observed worn down in several areas, of up to a 4 inch by 4 inch section. Review of the FDA Food Code 2022, section 6-501.11 on Repairing indicated that Physical Facilities shall be maintained in good repair. Floors .: except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, . shall be designed, constructed, and installed so they are smooth and easily cleanable. 7) During the initial main kitchen tour on 2/26/24 at 10:25 a.m. in the cook's station, the can opener was observed dirty and with a chipped tip. During a concurrent interview with the DCE, he confirmed this and stated it was supposed to be washed daily. During a review of the 2022 Federal Food and Drug Administration Food Code, Section 4-501.11 on Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. During the initial main kitchen tour on 2/26/24 at 10:52 a.m. in the cook's station, a green cutting board and two white cutting boards were found discolored with orange and black markings as well as with deep gouges. During a concurrent interview with the DCE, he confirmed that they were dirty and asked that staff throw out and replace. Review of the facility provided policy titled Sanitation and Cleaning (Eskaton, revised 10/29/18) indicated the following: . 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from . corrosions, . rust, and chipped areas. 4. Plastic ware, . that cannot be sanitized or are hazardous because of chips, cracks, or loss of glaze shall be discarded. Review of the 2022 Federal Food and Drug Administration Food Code, Section 4-501.12 on Cutting Surfaces indicated that Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. 8) During the initial main kitchen tour on 2/26/24 at 10:26 a.m., a [NAME] of bread with a 3 inch by 6-inch area of mold was observed. During an interview on 2/28/24 at 1:51 p.m. with the DCE, he stated that all staff may discard obviously spoiled food such as moldy bread. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 24 of 32 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 02/29/2024 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 Review of the website askUSDA.gov indicated the following to the question How should you handle food with mold on it? If food is covered with mold, discard it. Put it into a small paper bag or wrap it in plastic and dispose in a covered trash can that children and animals can't get into. Residents Affected - Some Some molds cause allergic reactions and respiratory problems. And a few molds, in the right conditions, produce 'mycotoxins,' poisonous substances that can make people sick. 9) During the initial main kitchen tour on 2/26/24 at 10:37 a.m., an opened oven was observed dirty inside. The racks were covered with dried food residue, and the oven bottom was covered with food particles. During a concurrent interview with the DCE, he stated that the oven was not used (though appeared to be storing three fry pans), but that it still should be cleaned. During the initial main kitchen tour on 2/26/24 at 10:39 a.m., the cook's station floors were observed covered with dark markings, grime and various debris such as eggshells, a ball of foil, and food debris around the stove. During the initial main kitchen tour on 2/26/24 at 10:42 a.m., a pan hanging in the cook's station was observed covered with dark grime. During a concurrent interview with the DCE, he stated that it was no longer cleanable and threw it in the garbage can. During the initial main kitchen tour on 2/26/24 at 10:53 a.m. in the cook's station, a metal square box behind the steam kettle was observed discolored with black and brown markings. During a concurrent interview with the DCE, he confirmed that it was a dirty heating element. During the initial main kitchen tour on 2/26/24 at 10:59 a.m., a wire rack was observed covered with gray and white particles. The wire storage rack contained clean mixing bowls and other food preparation equipment. Review of facility provided policy titled Food Storage (Eskaton, 10/29/18) indicated that Food shall be stored in a clean, safe, and sanitary manner. Procedures included the following in bullet 1 Food storage areas shall be clean at all times. Review of facility provided policy titled Sanitation and Cleaning (Eskaton, revised 10/29/18) indicated the following: 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish . 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from . corrosions, . rust, and chipped areas. 4. All damaged cooking equipment and utensils should be discarded. 7. All floors in the food preparation and storage areas are washable . and cleaned daily. Review of the 2022 Federal Food and Drug Administration Food Code, Section 4-601.11 on Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment food-contact surfaces and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 25 of 32 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 02/29/2024 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 utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 10) During a return visit to the ALU kitchen on 2/27/24 at 8:27 a.m., an ice cream dipping cabinet was observed with ice buildup on all four walls (with an orange hue in some areas) and on the lids of the ice cream containers. During a concurrent interview with the DCE and Registered Dietitian (RD), the DCE stated this should not look like this. Review of facility provided policy title Food Storage (Eskaton, 10/29/18) indicated that Food shall be stored in a clean, safe, and sanitary manner. Procedures included the following in bullet 1 Food storage areas shall be clean at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 26 of 32 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 02/29/2024 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 follow infection control practices for four out of 14 sampled residents (Resident 14, Resident 234, Resident 235 and Resident 237) when: Residents Affected - Some 1. Staff did not disinfect vital sign equipment before and after use; 2. A Housekeeper (HK) did not apply the proper Personal Protective Equipment (PPE, gloves, gown, and/or goggles/face shield if risk of splash or spray) while cleaning Resident 234's room; and, 3. Resident 14, Resident 235 and Resident 237 were not assisted or offered to wash their hands before meals. These failures had the potential to spread infection in the facility. Findings: 1. During a concurrent observation and interview on 2/26/24 at 2:45 p.m. and 3:10 p.m., the Certified Nursing Assistant 2 (CNA 2) confirmed she was using the same vital sign equipment for multiples residents in different rooms. She confirmed she did not and should have disinfected the vital sign equipment before and after each use. During an interview on 2/29/24 at 8:24 a.m., the Interim Director of Nursing (IDON) confirmed vital sign equipment should be disinfected before and after use. 2. A review of Resident 234's admission records indicated she was admitted the second week of this month with diagnoses including aftercare following a hip replacement surgery with a wound vacuum (a device that helps reduce swelling and drainage from the wound) and bronchiectasis (tubes that carry air in and out of the lungs were damaged) requiring the use of a Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping) machine at bedtime. During the initial tour on 2/26/24 at 8:45 a.m. observed an Enhanced Barrier Precaution (EBP) Signage outside Resident 234's room. In a review of Resident 234's Physician Order Report, dated 2/15/24, it indicated an order for an EBP due to the presence of a medical device. During an observation on 2/26/24 at 11:24 a.m. observed an HK not wearing a gown while cleaning inside Resident 234's room. In a concurrent observation and interview on 2/26/24 at 11:28 a.m. with the Infection Preventionist (IP), the IP confirmed that the HK was not wearing the proper PPE while cleaning inside room [ROOM NUMBER] and stated the HK should have been wearing a gown to help prevent the spread of infection. In an interview on 2/26/24 at 11:35 a.m. with the HK she stated she doesn't know the meaning of the EBP sign outside room [ROOM NUMBER]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 27 of 32 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 02/29/2024 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 3. During a review of Resident 14, Resident 235, and Resident 237's clinical record indicated the following: Level of Harm - Minimal harm or potential for actual harm a. Resident 14 was admitted first week of February with diagnoses including left ankle charcot (weakening of the bones in foot due to significant nerve damage) revision, was non- weight bearing to left lower extremity requiring assistance getting in and out of bed, and alert and oriented with no memory problems. Residents Affected - Some b. The facility admitted Resident 235 second week of February with diagnoses that included aftercare following a knee joint replacement surgery, did not have the capacity to make own health care decisions, and required extensive assistance for transfers. c. Resident 237 came to the facility second week of February with diagnoses including cerebral infarction (also known as ischemic stroke, disruption of blood flow to the brain) and weakness, had moderate cognitive impairment, and required extensive assistance with activities of daily living (ADLS). d. All three residents preferred to eat all meals inside their rooms. During lunch observation on 2/26/24 at 12:12 p.m. observed staff serve a lunch tray to Resident 235. Staff did not assist Resident 235 to wash hands before eating. During lunch observation on 2/27/24 at 12:12 p.m. Resident 237 was served lunch by Certified Nurse Assistant 4 (CNA 4), CNA 4 did not offer to assist Resident 237 to wash her hands before eating. During lunch observation on 2/28/24 at 12:23 p.m. observed Resident 14 and Resident 237 were served lunch at the same time by CNA 4. Both were not assisted to do handwashing before eating. In an interview on 2/28/24 at 12:25 p.m. with Resident 14, she confirmed CNA 4 did not offer to wash her hands before eating lunch. During an interview on 2/28/24 at 12:27 p.m. with Resident 237 and a family member visiting, both confirmed CNA 4 did not offer to help clean Resident 237's hands before eating. In an interview on 2/28/24 at 12:50 p.m. with CNA 4 she stated she did not assist Resident 14 and Resident 237 wash their hands before eating and added she should have helped them but forgot. In an interview with the Infection Preventionist (IP) IP stated all staff serving meals to residents should wash their hands, residents who eat inside their rooms should be assisted/helped clean their hands before and after eating as part of their infection prevention practices. A review of the facility's Policy and Procedure (P&P) titled Hand Hygiene Program revised 6/6/20 the P&P indicated When being assisted by healthcare personnel, resident hand hygiene is performed .Before meals. During a review of the facility's P&P titled Isolation Precautions - Categories Of revised 10/24/22 it indicated Wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room . In-service training will be provided upon employment and at least annually for all staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 28 of 32 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 02/29/2024 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 on the categories of isolation precautions. 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 29 of 32 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 02/29/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm The facility failed to maintain equipment in safe operating condition when: Residents Affected - Some 1) ALU (assisted living unit) walk-in freezer found with ice build-up on ceiling and racks indicating potential temperature changes; 2) Ice machine filter found leaking clear fluid on to the main kitchen floor in cook's work area; and, 3) Sandwich bar not holding food temperature in safe food zone (below 41 degrees Fahrenheit-a unit of measurement). These issues had the potential of leading to food borne illness for the 21 residents eating facility prepared meals, as well as staff injury. Findings: 1) During the initial kitchen tour of the Assisted Living Unit (ALU) on 2/26/24 at 8:45 a.m., the walk-in freezer was observed to have ice buildup on the ceiling (areas of up to 1.5 inches across), as well as an ice drip in left rear corner with a collection of ice of up to 6 inches deep on the racks below. In a subsequent interview at 8:51 a.m. with the Director of Culinary Experience (DCE) he concurred that there was ice buildup. When shown that the freezer gasket was misshapen in the top corner, he stated that he believed the ice was due to the freezer door being left open, which caused temperature variation. Review of facility provided manual in the Trouble Shooting section, indicated that if Ice accumulating on ceiling around evaporator and/or on fan guards venturi or blades possible causes include: 1. Defrost duration is too long. 2. Fan delay not delaying fans after defrost period. 3. Defective defrost thermostat or timer. 4. Too many defrosts. The manual gave corrective steps for each of the possible causes. 2) During an concurrent observation and interview at the main kitchen on 2/26/24 at 10:12 a.m. a pool of clear liquid (approximately 2 feet by 3 feet) was seen on the floor near the door by the cook's station. The DCE confirmed the liquid and stated that it was coming from the filter on ice machine. During the observation, a larger pattern (outlined in white) was seen surrounding the pool. The DCE believed it to be mineral deposits which indicated the pool of water had been larger at some point. During a review of the 2022 Federal Food and Drug Administration Food Code, Section 4-501.11 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 30 of 32 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 02/29/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Good Repair and Proper Adjustment (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. 3) During the initial main kitchen tour on 2/26/24 at 10:40 a.m., a refrigerated sandwich bar was observed in the cook's station. The temperature was observed at 49.7 F (Fahrenheit a unit of measurement). The temperatures of several items were taken which included the following food items: Diced ham=49 F, Ham slices=52 F, Turkey slices=51 F. The DCE confirmed that the temperatures were above the safe range of safe cold holding of 41 F, and would be unsafe to eat. Review of the facility provided policy Food Storage (Eskaton, revised 10/29/18) indicated in bullet 4 that Refrigerated storage shall be maintained at temperatures of 41 degrees F or below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 31 of 32 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 02/29/2024 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 0943 Level of Harm - Minimal harm or potential for actual harm Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to complete its abuse and neglect training and dementia in-services (a professional training or staff development effort) for two out of five staff members. Residents Affected - Few This failure had the potential to place the residents at risk for elder abuse. Findings: Review of the personnel record for Licensed Nurse 6 (LN 6) revealed a hire date of 9/1/21. The record did not include any documentation of further dementia training received in 2023. Review of the personnel record for LN 7 revealed a hire date of 2/16/22. The record did not include any documentation of abuse and neglect training and dementia training received in 2023. During a concurrent interview and record review on 2/28/24 at 3:30 p.m., the Infection Preventionist (IP) confirmed there was no dementia care training in 2023 for LN 6. During a concurrent interview and record review on 2/28/24 at 3:49 p.m., the Infection Preventionist (IP) confirmed there was no dementia care training and abuse training in 2023 for LN 7. Review of the facility's policy titled, In-service Training - General Policies, dated 12/31/19, indicated, All personnel are required to attend scheduled, mandatory training classes. Review of the facility's policy titled, Elder and Dependent Adult Suspected Abuse and Reporting, dated 11/18/21, indicated, Community staff shall attend an in-service at least annually on reporting of suspected/alleged elder and dependent adult abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 32 of 32