Inspection·January 9, 2025

F 0584 . adequate levels of illumination suitable for tasks the resident chooses to perform . maintain all mechanical, electrical . equipment . in safe operating condition. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 2 of 15 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 01/09/2025 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of 22 sampled residents (Resident 148), when Resident 148's care plan did not indicate he was receiving oxygen therapy. This failure decreased the facility's potential to meet Resident 148's care needs. Findings: A review of Resident 148's Resident Face Sheet indicated he was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dependence on supplemental oxygen. During an observation on 1/6/25 at 2:35 p.m. in Resident 148's room, Resident 148 was observed receiving oxygen at two liters per minute via nasal cannula (a device that gives you additional oxygen through your nose). A review of Resident 148's General Order, dated 1/3/25, indicated Resident 148 was on oxygen at two liters per minute every shift. During concurrent interview and record review on 1/8/25 at 12:16 p.m. with Licensed Nurse 4 (LN 4), Resident 148's care plan was reviewed. LN 4 confirmed there was no oxygen care plan in the clinical record and stated a care plan was needed so staff would know Resident 148's care needs. During an interview on 1/8/25 at 1:06 p.m. with the Interim Director of Nursing (IDON), IDON stated his expectations were all residents should have care plans; otherwise, there was a potential for nurses not to be able to provide the residents' care needs. A review of the facility's policy titled, Care Plan Process, revised 12/15/21, indicated, Each resident will have a care plan that is initiated 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 3 of 15 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 01/09/2025 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 22 sampled residents (Resident 198), when Licensed Nurse 1 (LN 1) prepared a medication for Resident 198 taken from another resident's medication supply. Residents Affected - Few This failure decreased the facility's potential to safely administer medications to residents. Findings: A review of Resident 198's Resident Face Sheet indicated Resident 198 was admitted to the facility in December 2024 with diagnoses including right hip fracture and chronic constipation. A review of Resident 198's Prescription Order, dated 12/22/2024, indicated an order for polyethylene glycol (medication used to treat constipation) once a day. During a concurrent observation and interview on 1/6/25 at 9:17 a.m. with LN 1, LN 1 was observed preparing polyethylene glycol for Resident 198. LN 1 removed the medication from a plastic bag and the bag's label indicated a different resident's name. LN 1 confirmed she prepared Resident 198's medication after taking it from another resident's bag and stated she should have taken it from the facility's medications stock; otherwise, the medication might have the wrong dose and Resident 198 might have an adverse effect. During an interview on 1/8/25 at 12:38 p.m. with the Interim Director of Nursing (IDON), IDON stated his expectations were nurses should have followed the five rights of medication administration (right patient, right medication, right time, right dose, and right route); otherwise, there was a potential for residents experiencing adverse effects if given medications that did not belong to them. A review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 1/21, indicated, Read medication label three times before preparing medication, when pulling medication package from med cart, when dose is prepared and before dose is administered. P&P further indicated, Medications supplied for one resident are never administered to another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 4 of 15 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 01/09/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide adequate assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) for one of 22 sampled residents (Resident 248), when Resident 248 was not offered or given showers as scheduled. Residents Affected - Few This failure had the potential to negatively impact Resident 248's cleanliness, discomfort, and psychosocial well-being. Findings: A review of Resident 248's Resident Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of right femur (the large bone in the upper part of your leg) fracture. A review of Resident 248's Physician Order Report, dated 12/1/24-12/31/24, indicated she had the capacity to understand choices and make health care decisions. The report further indicated Resident 248 should have showered twice a week on Monday and Friday. During a concurrent observation and interview on 1/6/25 at 10:57 a.m. with Resident 248 in her room, Resident 248 was lying in bed and wearing a hospital gown with a large brown area on the upper chest site. Resident 248's hair was unkempt and matted on the back of her head. Resident 248 stated she did not have a shower since her accident and would love to have a shower and her hair to be washed. Resident 248 further stated she asked staff on several occasions for a shower and none of them discussed a shower schedule with her. A review of Resident 248's Care Plan, dated 12/29/24, indicated Resident 248 needed assistance with bathing and personal hygiene and to be showered/bathed two times a week as scheduled. During a concurrent interview and record review on 1/7/25 at 2:28 p.m. with Certified Nursing Assistant 1 (CNA 1), Resident 248's shower sheets and clinical record were reviewed. CNA 1 stated she did not recall offering a shower or bath to Resident 248 during her stay and could not find a documentation in the clinical record that a shower or bath was offered, refused, or given on the shower's scheduled dates 12/30/24, 1/3/25, and 1/6/25. CNA 1 stated it was the CNA's responsibility to check Resident 248's shower schedule, to offer her a shower or bath and assist her as needed. During a concurrent interview and record review on 1/7/25 at 2:33 p.m. with Licensed Nurse 1 (LN 1), Resident 248's shower sheets and clinical record were reviewed. LN 1 could not find a documentation in the clinical record that a shower or bath was offered, refused, or given on the shower's scheduled dates 12/30/24, 1/3/25, and 1/6/25. LN 1 stated CNAs should have offered Resident 248 a shower or bath according to the shower calendar and documented on the Shower Day Skin Inspection Sheet whether it was given or refused. LN 1 further stated Resident 248 might become depressed or might develop skin issues because of uncleanliness and not been offered a shower. A review of the facility's policy titled, Necessary Care and Services: Activities of Daily Living, dated 11/2024, indicated, The facility will ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good . grooming . and personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 5 of 15 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 01/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safety measures were in place for one of 22 sampled residents (Resident 15), when Resident 15 fell to the floor during transfer and sustained a blunt head injury (when the head hit a hard object or surface without breaking the skull) and a scalp abrasion (cut of the scalp). This failure decreased the facility's potential to prevent Resident 15's fall and injury. Findings: A review of Resident 15's Resident Face Sheet indicated Resident 15 was admitted to the facility in 2019 with a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 15's Physician Order Report, dated [DATE] to [DATE], indicated Resident 15 had no capacity to understand choices and make health care decisions due to dementia (a progressive state of decline in mental abilities). Resident 15 had an order to be up in chair daily as tolerated. A review of Resident 15's John Hopkins Fall Risk Assessment Tool, dated [DATE], indicated Resident 15 had moderate fall risk. During an interview on [DATE] at 11:56 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 confirmed witnessing one of the loops from the head of the sling broke during Resident 15's transfer and as a result, Resident 15 fell to the floor and hit his head. CNA 4 stated there was no written expiration date on the sling during inspection. A review of Resident 15's Observation Detail List Report, dated [DATE], indicated Resident 15 had a fall on the morning of [DATE] during a mechanical lift from bed and sustained a bleeding from head. A review of Resident 15's Resident Progress Notes, dated [DATE], indicated, . [Resident 15] fell during transfer from [mechanical lift's] sling . The sling from [mechanical lift] malfunctioned and [Resident 15] fell landed on the floor . hit his head and is bleeding. A review of Resident 15's hospital Discharge Instructions Document, dated [DATE], indicated Resident 15 was in the hospital for fall, scalp abrasion, and blunt head injury. A review of Resident 15's Care Plan History, dated [DATE], indicated Resident 15 had a witnessed fall with head injury. During an interview on [DATE] at 9:59 a.m. with the Director of Staff Development (DSD) and Interim Director of Nursing (IDON), DSD confirmed Resident 15 fell during transfer due to a broken sling. IDON stated the expectations were staff should have inspected Resident 15's sling to make sure it was intact, had no damage, no break, and was not expired. A review of the facility's policy titled, Mechanical Lift Policy, dated [DATE], indicated, Slings will be maintained in appropriate condition for use with residents. Slings will be documented with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 6 of 15 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 01/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (in use start date) upon initial use by community. Slings will be inspected prior to each use for compromised material including frayed sling loops, frayed/loose seams, and weakness in fabric. A review of the facility's policy titled, Fall Prevention Program, dated [DATE], indicated, Residents will be provided an environment which will reasonably maximize safety while maintaining an optimal level of independence. Event ID: Facility ID: 555555 If continuation sheet Page 7 of 15 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 01/09/2025 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly store medications for three residents (Resident 14, Resident 148, and Resident 149) of a census of 33, when three opened inhalers were not dated with open and discard dates. This failure decreased the facility's potential to properly store residents' medications and ensure medication potency. Findings: A review of Resident 14's Resident Face Sheet indicated Resident 14 was admitted to the facility in October 2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and asthma (chronic disease of the lungs that makes it difficult to breathe). A review of Resident 148's Resident Face Sheet indicated Resident 148 was admitted to the facility in December 2024 with a diagnosis of COPD. A review of Resident 149's Resident Face Sheet indicated Resident 149 was admitted to the facility in January 2025 with a diagnosis of COPD. During a concurrent observation and interview on 1/7/25 at 1:01 p.m. with Licensed Nurse 4 (LN 4), LN 4 confirmed the following opened medications were stored in medication cart three without open or discard dates: - Resident 14's fluticasone furoate, umeclidinium, and vilanterol inhaler (treats asthma and COPD) indicated to discard six weeks after opening the foil tray; - Resident 148's fluticasone and salmeterol inhaler (treats asthma and COPD), indicated to discard one month after opening the foil pouch; and - Resident 149's fluticasone furoate inhaler (treats asthma and COPD), indicated to discard six weeks after opening the foil tray. LN 4 stated opened medications might not be effective if given past the discard date and might not treat the respiratory condition. LN 4 further stated open and discard dates should have been written on the medications according to manufacturer's recommendations. During an interview on 1/8/25 at 12:40 p.m. with the Interim Director of Nursing (IDON), IDON stated medications should have open and discard dates to ensure been given for the maximum effect. IDON further stated residents might not get the maximum effect of medications if given past discard date. A review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 1/21, indicated, The nurse shall place a 'date opened' sticker on the medication . and certain products have specified shortened end-of- use dating, once opened, to ensure medication purity and potency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 8 of 15 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 01/09/2025 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** Based on observation, interview, and record review, the facility failed to ensure the nutritive values of food were conserved during preparation for a census of 33 residents, when [NAME] 1 prepared quiche (an entrée for lunch) without measuring the ingredients and following the recipe. Residents Affected - Some This failure decreased the facility's potential to meet the residents' nutritional needs. Findings: During a concurrent observation and interview on 1/8/25 at 9:45 a.m. with [NAME] 1 in the main kitchen, [NAME] 1 was observed mixing the ingredients when cooking quiche. [NAME] 1 did not follow the recipe and poured unmeasured amounts of liquid eggs and heavy cream in a pot. [NAME] 1 confirmed she did not follow the recipe to cook quiche and stated she did not need to measure the amounts of liquid eggs and heavy cream. [NAME] 1 also stated she was unable to tell the exact numbers of servings to be prepared. A review of the facility's recipe titled, Quiche [NAME] Jour, dated 2024, indicated, one gallon (a unit of measure) plus three and quarter of a quart (a unit of measure) of liquid eggs, and three quarts plus three cups (a unit of measure) of heavy cream should be used to prepare 180 servings of quiche. During an interview on 1/8/25 at 10 a.m. with Executive Chef (EC), EC stated [NAME] 1 should have followed the quiche recipe with correct measured amounts of both ingredients. EC also stated the unmeasured amounts of ingredients might have altered the nutritive values of food. During an interview on 1/9/25 at 8:29 a.m. with the Administrator (ADM), ADM stated the expectation was [NAME] 1 should have followed the recipe and measured the amounts of ingredients to maintain the nutritive values of quiche cooked for the residents. ADM further stated foods with altered nutritive values might not meet the residents' nutritional needs. A review of the facility's policy titled, Menus and Recipes, revised in 2017, indicated, . Standardized recipes will be used in preparation of the menu . A review of the facility's policy titled, Food Preparation and safety, revised in 2015, indicated, . Foods are prepared per the recipes which include . amounts of ingredients . based on the diet counts which are available from the computerized tray card system . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 9 of 15 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 01/09/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure food preferences were accommodated to one of 22 sampled residents (Resident 15), when Resident 15's meal ticket did not match with lunch's meal tray. This failure had the potential to negatively impact the resident's nutritional status. Findings: A review of Resident 15's Resident Face Sheet indicated Resident 15 was admitted to the facility in 2019 with a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 15's Physician Order Report, dated 1/1/25 to 1/31/25, indicated Resident 15 had no capacity to understand choices and make health care decisions due to dementia (a progressive state of decline in mental abilities). The report further indicated Resident 15 had fortified diet (food that have nutrients added to them), mechanical soft (food that is easy to eat and does require lots of chewing) chopped, and bit size texture. During a concurrent observation and interview on 1/6/25 at 12:38 p.m. with Certified Nursing Assistant 2 (CNA 2) in the dining room, CNA 2 confirmed Resident 15's meal tray had chicken tamales with green sauce, refried beans, extra sauce, orange juice, milk, and water. CNA 2 also confirmed the meal tray had different food choices compared to the meal ticket. A review of Resident 15's lunch meal ticket, dated 1/6/25, indicated the noon meal was potato soup, chicken supreme, herbed quinoa, green peas, garlic bread, coffee, whole milk, orange juice, apple juice, cranberry juice, and margarine with extra gravy sauce. During an interview on 1/9/25 at 2:01 p.m. with the Interim Director of Nursing (IDON), IDON stated the expectation was Resident 15's meal ticket should have reflected the food choices in the meal tray. A review of the facility's policy titled, Nutritional Care, Screening and Assessment, dated 2/9/2017, indicated, Food Preference will be maintained in the tray card system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 10 of 15 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 01/09/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for a census of 33 residents, when; Residents Affected - Some 1. Unlabeled, expired, incorrectly dated, and soiled food items were found stored in the ready-to-cook area in the main kitchen; 2. Wet, dirty, and damaged cooking pans were found stored on the ready-to-use rack next to cooking area in the main kitchen; 3. A can-opener was found dirty, ready-to-use, and attached to the kitchen counter in the main kitchen; 4. The interior dispenser of ice machine had black, brown, and white substances on its surfaces in Skilled Nursing Facility (SNF) kitchen; 5. One kitchen staff touched the clean cutting board and knife with soiled gloved hands after touching multiple surfaces in the main kitchen; and 6. Ice buildup was found on the edges and frames of entry doors and on food boxes inside the walk-in freezers in the SNF and main kitchens. These failures decreased the facility's potential to provide sanitary conditions to store and prepare food for its residents. Findings: 1. During a concurrent observation and interview on 1/6/25 at 9:54 a.m. with Executive Chef (EC), foods and spices were observed in the main kitchen's cooking area. A bottle of citrus seasoned dressing and sauce was found partially used but unlabeled for open and expiry dates. A fish sauce bottle was found expired in 2024. A dark chili powder container was found with two labels indicating two different open and expiry dates. A box of kosher salt was found crumbled with moistened salt inside it. EC confirmed there were unlabeled, expired, incorrectly labeled, and soiled food items stored in the ready-to-cook area in the main kitchen. During an interview on 1/9/25 at 8:29 a.m. with Administrator (ADM), ADM stated any unlabeled, expired, incorrectly labeled, and soiled food items stored in the ready-to-cook area were unsafe. ADM also stated unsafe food items might cause food born illnesses and kitchen staff should have labeled all food items correctly once been opened. A review of the facility's policy titled, Food Storage, dated 10/29/18, indicated, . Opened packages of dry food which are to be stored will be dated upon opening . 2. During a concurrent observation and interview on 1/6/25 at 10:05 a.m. with EC, cooking pans were observed on the ready-to-use rack next to the main kitchen's cooking area. Fifteen hotel pans size six and 20 hotel pans size three were found stored wet. Seven frying pans were found stored dirty with interior surfaces covered with oil and food crumbs. Twenty nonstick frying pans were found stored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 11 of 15 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 01/09/2025 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 with eroded interior surfaces. One big cooking pan was found stored with interior surface covered with yellowish-orange colored substance. EC confirmed wet, dirty, and damaged pans were stored on the ready-to-use rack next to the main kitchen's cooking area. During an interview on 1/9/25 at 8:29 a.m. with ADM, ADM stated staff should have not stored wet, dirty, and damaged cooking pans. ADM also stated wet, dirty, and damaged pans might become sources of food contamination and all cooking pans stored on the ready-to-use rack should have been undamaged, clean, and dry. A review of the facility's policy titled, Ware Washing, dated 7/17/15, indicated, . pans . washed . rinsed . sanitized . inverted on drain board. Let air dry . 3. During a concurrent observation and interview on 1/6/25 at 9:37 a.m. with EC, a can-opener was observed attached to the kitchen counter and ready to be used in the main kitchen. The can-opener tip and other parts were found covered with brownish-black substance. EC confirmed the can-opener was dirty and needed to be cleaned. During an interview on 1/9/25 at 8:29 a.m. with ADM, ADM stated a dirty can-opener should have not been placed for ready to use. ADM further stated dirty equipment might cause food contamination and food born illnesses among residents and expected all equipment to be kept clean for food safety. A review of the facility's policy titled, Sanitation and Cleaning, dated 10/29/18, indicated, . All equipment shall be kept clean . 4. During a concurrent observation and interview on 1/6/25 at 10:21 a.m. with Dietary Manager (DM) and Director of Environmental Services (DES), the interior dispenser of ice machine in SNF kitchen was observed. The surfaces of interior dispenser were found covered with black, brown, and white substances. Both DM and DES confirmed the interior dispenser of ice machine was dirty and ice was exposed to its dirty surfaces. DM stated the interior of ice machine needed immediate cleaning. During an interview on 1/9/25 at 8:29 a.m. with ADM, ADM stated dirty interior of ice machine might cause contamination of the ice. ADM also stated contaminated ice could cause food borne illnesses among residents and expected the interior of ice machine to be maintained clean at all times A review of the facility's policy titled, Ice, dated 10/29/18, indicated, . Maintenance is responsible for thoroughly cleaning the ice machine . and will keep a cleaning log . 5. During a concurrent observation and interview on 1/08/25 at 8:35 a.m. with [NAME] 2 and EC in the main kitchen, [NAME] 2 was observed wearing single use gloves in the cooking area. [NAME] 2 touched the clean cutting board and knife with soiled gloves after touching multiple surfaces. [NAME] 2 confirmed he cleaned the kitchen counter, touched his apron and face with same pair of gloves, did not change the soiled gloves and then touched the clean cutting board and knife. [NAME] 2 stated he was getting ready to use that cutting board and knife to chop the sausage. EC confirmed [NAME] 2 touched the clean cutting board and knife with soiled gloves and the food preparation surfaces might have been contaminated. During an interview on 1/9/25 at 8:29 a.m. with ADM, ADM stated [NAME] 2 should have not touched the food preparation utensils and surfaces with soiled gloves because touching food preparation areas and surfaces might have caused cross contamination to the food cooked in the main kitchen. ADM also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 12 of 15 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 01/09/2025 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 stated [NAME] 2 should have changed his single-use gloves after each task. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled, Personal-Sanitary and Dress Standards, dated 3/24/24, indicated, . Gloves are not to be used as a replacement for frequent, proper hand washing and gloves must be changed when going from dirty to clean operations . Residents Affected - Some 6. During a concurrent observation and interview on 1/6/25 at 8:45 a.m. with DM in SNF kitchen, the walk-in freezer was observed. Ice built-up was found on the door edges and frame of walk-in freezer. Big chunks of ice were also found on boxes containing food. DM confirmed the door edges and frame of walk-in freezer were covered with ice built-up and ice chunks were found on top of food boxes inside the freezer. During a concurrent observation and interview on 1/6/25 at 3:07 p.m. with EC in main kitchen, the walk-in freezer was observed. The door edges and frame of walk-in freezer were found covered with ice built-up. Ice was also found accumulated on the food boxes inside the freezer. EC confirmed the walk-in freezer door in main kitchen was not closing properly due to ice built-up and ice accumulated on food boxes. During an interview on 1/9/25 at 8:29 a.m. with ADM, ADM stated no built-up ice should have been on the doors, frames, or food boxes inside the walk-in freezers in the SNF and main kitchens. ADM expected kitchen staff to report this issue to the maintenance staff on a routine basis and stated ice built-up on the edges and frames of walk-in freezer doors interfere with door closing and might affect the quality of food stored inside. A review of the facility's policy titled, Sanitation and Cleaning, dated 10/29/18, indicated, All kitchens, kitchen areas . shall be kept clean, maintained in good repairs . and freezers to be cleaned monthly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 13 of 15 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 01/09/2025 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 Based on observation, interview, and record review, the facility failed to maintain infection control practices for a census of 33 residents, when Certified Nursing Assistant 3 (CNA 3) did not use gown and gloves in an isolation (separation of residents with an infection from residents without an infection) room. Residents Affected - Few This failure had the potential to increase the spread of infection among residents. Findings: A review of Resident 31's Resident Face Sheet, indicated Resident 31 was admitted to the facility in 2023 with a diagnosis of pneumonia (an infection/inflammation in the lungs). During a concurrent observation and interview on 1/6/25 at 9:30 a.m. with CNA 3, Resident 31's room had a contact isolation sign on the door. The sign indicated staff to use gown and gloves when entering the room. CNA 3 went inside Resident 31's room and collected the meal tray from the bedside without using gown and gloves. CNA 3 confirmed she should have used gown and gloves while providing care in an isolation room. During an interview on 1/8/25 at 10:46 a.m. with the Infection Preventionist (IP), IP stated the expectation was staff to wear gown and gloves when providing care to residents in isolated precaution rooms. IP further stated there could have been a chance for cross contamination to other residents when not using gown and gloves. During an interview on 1/9/25 at 2:01 p.m. with the Interim Director of Nursing (IDON), IDON stated staff should have used gown, gloves, and/or face shield when providing care to residents in contact isolation rooms. IDON further stated there could have been cross contamination of infection among other residents when staff did not use gown and gloves. A review of the facility's policy titled, Categories of Isolation Precautions, dated 6/24/2024, indicated, . All staff must wear appropriate Personal Protective Equipment (PPE) to include glove (clean, nonsterile) when entering the room, regardless of tasks being performed . Wear a gown (clean, nonsterile) when entering the room . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 14 of 15 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 01/09/2025 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 Based on observation, interview, and record review, the facility failed to safely operate the dryer for a census of 33 residents, when the dryer's lint compartment was not cleaned accordingly. Residents Affected - Some This failure decreased the facility's potential to prevent a fire hazard. Findings: During a concurrent observation and interview on 1/8/25 at 11:04 a.m. with Laundry Staff (LS) in the laundry room, the three lint compartments of the dryers were inspected. LS opened the lint compartment, rolled up two thick layers of lint, and discarded it. LS confirmed she did not clean the lint compartment at the beginning of her shift. During a concurrent interview and record review on 1/9/25 at 8:41 a.m. with the Housekeeping Supervisor (HS), the lint compartment log was reviewed. HS expected staff to clean the lint compartment every two hours and stated it would have been a fire hazard if staff did not clean the lint compartment frequently. A review of the facility's Cleaning the Lint Compartments Log for January 2025, indicated morning and evening laundry staff should have cleaned the lint trap every two hours and documented it. The log further indicated there was missing documentation of removing lint every two hours on seven occasions at evenings during the month of January 2025. A review of the facility's policy titled, Supplies and Equipment, dated 12/29/18, indicated, Housekeeping/Laundry/Nursing department supplies, and equipment shall be readily available so that department personnel can perform necessary tasks. Equipment must be ready for use at all times of the day and night to serve the residents' needs. Care should be exercised in the handling and in the use of equipment to prevent damage or breakage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555555 If continuation sheet Page 15 of 15