Health inspection·October 20, 2023

F 0580 go listen to [Resident 43]'s lungs, and do an assessment before I call the doctor. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 43's clinical record, Resident 43's records titled, Active Orders, dated 10/17/23, indicated Mucinex DM Oral Tablet Extended Release 12 hour, 30/600 milligrams, give one tablet by mouth every 12 hours as needed for cough for 14 days. Residents Affected - Few During a concurent record review and interview on 10/18/23 at 3:15 PM, the Assistant Director of Nursing (ADON) confirmed Resident 43 should have been on alert charting for new onset of cough, new symptoms keeping Resident 43 up at night, as soon as Resident 43 complained of a new cough. ADON also confirmed alert charting was not completed in the record for Resident 43 until 10/17/23 when DSD was updated, and [Resident 43] should have had an assessment completed including listening to lungs, and the medical doctor called for advisement. 2. During a review of Resident 276's clinical record, Resident 276 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of the second cervical vertebrae (broken neck bone), heart disease, high blood pressure and muscle weakness. During an interview on 10/18/23 at 8:05 AM, Resident 276 stated, Can you find out about my urine results, I have been waiting to hear if I have an infection. They took a urine sample on 10/15/23. During a review of Resident 276's Clinical Laboratory Urinalysis (U/A), dated 10/16/23, the clinical laboratory indicated a routine U/A was received on 10/16/23, and indicated Resident 276's urine was positive for white blood cells (wbc), red blood cells (rbc), and nitrates 2 + (bacteria found in urine). These results indicated Resident 276 did have a Urinary Tract Infection (UTI). During an interview with DSD on 10/18/23 at 9:00 AM, DSD stated, We are waiting on [Resident 276]'s urine culture results. DSD confirmed Resident 276 was not on alert charting for signs and symptoms of a UTI, and they had collected a urine sample on 10/15/23 for dysuria (difficulty urinating). DSD also confirmed Resident 276 did have a history of UTIs requiring antibiotic therapy on 10/5/23. During a follow up interview on 10/18/23 at 11:35 AM, DSD confirmed Resident 276 had a positive U/A for infection and the urine culture was called to the Nurse Practioner, new orders were received to start antibiotic therapy effective 10/18/23 for five days for a new UTI. During an interview on 10/18/23 at 3:30 PM, the ADON confirmed Resident 276 should have been on alert charting since urinary complaints, vital signs should have been obtained every shift since 10/15/23. ADON stated, I will make sure and educate the staff to add to alert charting before we get the labs back. I agree we should have also updated Resident 276 with the urine results in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 2 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, a standardized resident assessment) within 14 calendar days of admission for two of 17 sampled residents (Resident 275 and Resident 276.) This failure had the potential to delay the development of a comprehensive care plan necessary to provide appropriate individualized care and services for each resident related to the care areas that would have been identified on the Comprehensive MDS. Findings: During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS)/Resident Assessment Instrument (RAI), revised 1/3/2022, the P&P indicated, All comprehensive assessments should be completed and signed (Z0500) within seven days of the Assessment Reference Date (ARD), but no later than thirteen days after the ARD or by the fourteenth day of resident's admission. During a review of Resident 275's clinical record, Resident 275 was admitted to the facility on [DATE] with diagnoses that included a stroke, high blood pressure, dysphasia (difficulty swallowing), and Chondrocostal junction syndrome (inflammation and pain to the upper ribs). During a review of Resident 276's clinical record, Resident 276 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of the second cervical vertebrae (broken neck bone), heart disease, high blood pressure and muscle weakness. During a concurrent record review and interview on 10/19/23 at 1:10 PM, the Assistant Director of Nursing (ADON) confirmed [Resident 275 and Resident 276] MDS admission assessments were not completed and were late. ADON confirmed [Resident 275] assessment was eight days late and [Resident 276] assessment was two days late. ADON stated, We are behind, and I am helping to get the MDS' caught up. We have 14 days to complete after their admission. The MDS nurse is new, and I am helping to get them all done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 3 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one of 17 residents (Resident 53). This resulted in Resident 53 did not have a care plan to address her fluid restriction. Findings: During a review of the facility's policy and procedure (P&P) titled, Care Plans, revised 1/31/22, the P&P indicated that it is the policy of this facility that a comprehensive care plan is to be developed for each resident within seven days of the resident's comprehensive Minimum Data Set (MDS) assessment. During a review of Resident 53's clinical record, Resident 53 was admitted to the facility on [DATE] for diagnoses that included dementia (general term for impaired thinking, remembering, reasoning, and functional ability), seizures (uncontrolled signals between brain cells), and urinary tract infections (bladder infections). During a review of Resident 53's Active Orders, dated 8/28/23, indicated fluid restriction of 1200 cubic centimeter (cc, a unit of measurement) in 24 hours. During a review of Resident 53's Care Plan, revised on 8/28/23 no problem or interventions were listed for current Medical Doctors' (MD) orders for fluid restriction of 1200 cc daily. During a concurrent record review and interview on 10/19/23 at 3:45 pm, the Assistant Director of Nursing stated, The care plan is 11 days late for [Resident 53]. During a concurrent interview with the Interim Director of Nursing (IDON) and (ADON) on 10/20/23 at 12:38 PM, both confirmed fluid restrictions were not added to the care plan for [Resident 53] and interventions were not implemented to follow MD orders on 8/28/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 4 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 25 was initiated on 10/18/23. Resident 25 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), mild protein-calorie malnutrition (the condition of lack of energy due to the deficiency of all the macronutrients and many micronutrients), hyperlipidemia (elevated fat in the blood), hypertension (high blood pressure) and major depressive disorder. Review of the facility document titled Weights and Vitals Summary from 9/11/23 through 10/11/23, showed the following weights and comparisons for Resident 25: * On 9/11/23 = 130.6 pounds (lbs.), * On 9/30/23 = 121.4 lbs. -9.2 lbs., a 7% severe weight loss since 9/11/23, less than one month [comparison weight on 9/11/23, 130.6 lbs.], * On 10/6/23 = 117.6 lbs., -13 lbs., a 10% severe weight loss since 9/11/23 [comparison weight on 9/11/23, 130.6 lbs.]. On 10/19/23 at 10:33 AM a review of Resident 25's electronic medical record and concurrent interview was conducted with the ADON. The ADON confirmed when a resident experiences a significant weight change, the resident centered plan or care should be updated to reflect the weight change. The ADON confirmed the care plan for Resident 25 had not been updated to reflect the -9.2 lbs., 7% unplanned severe weight loss on 9/30/23 or the -13 lbs., a 10% unplanned severe weight loss on 10/6/23. The ADON added it was the RD's responsibility to update the resident care plan with any significant weight changes. On 10/20/23 at 9:02 AM, a phone interview was conducted with the RD. The RD confirmed she was responsible to update resident care plans with significant weight changes. The RD confirmed she had not updated the care plan for Resident 25 to reflect the unplanned severe weight loss of -9.2 lbs., 7% on 9/30/23 or the -13 lbs., 10% unplanned severe weight loss on 10/6/23. Based on observation, interview, and record review, the facility failed to ensure that care plans for three of 17 sampled residents (Resident 25, 62, and Resident 275) were revised and updated to identify resident specific needs. This failure had the potential for residents individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status related to weight loss, communication needs, and proper transfers required to for pain management. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Care Plans, revised 1/31/22, the P&P indicated that it is the policy of this facility that the care plan is to be reviewed and revised after the resident's initial assessment, quarterly, and more often as warranted by the changes in a resident's condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 5 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 9/15/17, the P&P indicated that the licensed nurse is to update the care plan to reflect any change in condition. During a review of Resident 62's clinical record, Resident 62 was admitted to the facility on [DATE] for diagnoses that included fracture of the left femur (broken thigh bone), diabetes, high blood pressure, and Dementia (a general term for impaired thinking, remembering, reasoning and fucntional ability). During a review of 62's clinical record, Resident 62's Care Plan, dated 9/27/23, indicated a problem [Resident 62]'s preferred language was Spanish with no interventions for communication or translation line needed for specific resident needs to be met. During a concurent observation and interview on 10/17/23 at 11:00 AM, Resident 62 stated, No English, shaking her head no, and unable to answer any questions. During an interview on 10/17/23 at 11:12 AM, the Family Member (FM) of Resident 62 stated, I interpret English and my other family members do when they are here, [Resident 62] does not speak any English. During an interview on 10/20/23 at 11:55 am, the Assistant Director of Nursing (ADON) confirmed Resident 62 only spoke Spanish, and stated, I am bilingual, but I will change this immediately. I know [Resident 62] only speaks Spanish, and I will add the interpretor line to the care plan for the staff to use if needed. I have interpreted for [Resident 62], but we need access to the language line if there is a medical problem. [Resident 62]'s family can interpret also, she is not her own responsible party (RP). 2. During a review of Resident 275's clinical record, Resident 275 was admitted to the facility on [DATE] with diagnoses that included a stroke, high blood pressure, dysphasia (difficulty swallowing), and Chondrocostal junction syndrome (inflammation and pain to the upper ribs). During a review of Resident 275's clinical record, an assessment titled Brief Interview for Mental Status, dated 10/11/23, indicated Resident 275 was alert and oriented, scored 15 out of 15 (able to think and reason), and Resident 275 was her own RP for decisions. During a review of Resident 275's clinical record, Resident 275's Care Plan, dated 10/5/23, indicated a problem Resident 275 had a functional decline, needed one person assistance for activities of daily living (ADLs) such as toileting, bathing, grooming, and bed mobility. During a review of Resident 275's clinical record, Resident 275's Care Plan, dated 10/19/23, indicated a problem Resident 275 is at risk for pain with no interventions added to assist all transfers with one person, avoiding the rib area as needed for the diagnosis of Chondrocostal junction syndrome. During an interview on 10/18/23 at 8:50 AM, Resident 275 stated, I wish the staff knew how to help me transfer, it is painful if I am not helped correctly. I have to remind all the staff when they come in and help me in the bathroom or anytime they help me in and out of the bed. During an interview on 10/19/23 at 8:30 AM, the ADON confirmed Resident 275 needed new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 6 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 interventions for proper transfers related to chronic pain, disease process, and to not exacerbate Resident 275's pain in her rib area to update all staff providing direct care. 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: 555625 If continuation sheet Page 7 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility Policy and Procedure review, the facility failed to ensure one of 17 final sampled residents (Resident 25) maintained acceptable parameters of nutritional status when: Residents Affected - Few 1. The facility failed to provide documentation which showed the physician was notified of Resident 25's unplanned severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% unplanned severe weight loss from 9/11/23 to 10/6/23, 2. The facility failed to reweigh Resident 25 per the facility policy when he experienced a severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% severe weight loss from 9/11/23 to 10/6/23. 3. The facility failed to ensure the IDT (Interdisciplinary team) evaluated and monitored the effectiveness of the intervention implemented for Resident 25's unplanned severe weight loss on 10/12/23. 4. The facility failed to revise the resident centered plan of care for Resident 25 to reflect the unplanned severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% unplanned severe weight loss from 9/11/23 to 10/6/23. As a result of these failures, Resident 25's compromised nutritional status was not monitored effectively which could lead to further medical complications. Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. 1. Review of the facility's Policy and Procedure titled Weight revised on 1/31/22 showed in part, Significant changes in a resident's weight are to be reported to the physician and the resident's representative .11. The physician is to be notified of significant weight changes by the licensed nurse .12. The resident's care plan is to be updated with recommendations made by the dietitian and IDT upon review. Medical record review for Resident 25 was initiated on 10/18/23. Resident 25 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), mild protein-calorie malnutrition (the condition of lack of energy due to the deficiency of all the macronutrients and many micronutrients), hyperlipidemia (elevated fat in the blood), hypertension (high blood pressure) and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 8 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0692 Review of Resident 25's Physician's Order dated 10/19/23, showed the following orders: Level of Harm - Minimal harm or potential for actual harm - 5/16/23, Regular Health Shake (nutritional supplement) two times a day. Residents Affected - Few - 5/27/23, a mechanical soft diet, thin liquids consistency. No corn, rice, lettuce. Regular texture cheeseburger acceptable per ST (Speech Therapist), - 10/12/23, Magic cup (nutritional supplement) two times a day. Review of the facility document titled Weights and Vitals Summary from 9/11/23 through 10/11/23, showed the following weights and comparisons for Resident 25: * On 9/11/23 = 130.6 pounds (lbs.), * On 9/30/23 = 121.4 lbs. -9.2 lbs., a 7% severe weight loss since 9/11/23, less than one month [comparison weight on 9/11/23, 130.6 lbs.], * On 10/6/23 = 117.6 lbs., -13 lbs., a 10% severe weight loss since 9/11/23 [comparison weight on 9/11/23, 130.6 lbs.]. Review of Resident 25's quarterly MDS dated [DATE], showed under Section K, Resident 25 weighed 126 pounds and had not experienced a 5% weight loss or gain in the last month or 10% weight loss or gain in the past six months. Resident 25 was not on a physician-prescribed weight loss or weight gain regimen. Review of the physician progress notes for Resident 25 signed and dated on 8/1/23 by Physician 1 showed, no loss in appetite, stable on current treatment plan at this time. Resident 25's weight or weight change was not documented on the physician progress note dated 8/1/23. Review of the physician progress notes for Resident 25 signed and dated on 9/21/23 by Physician 1 showed, no loss of appetite, stable on current treatment plan at this time. Resident 25's weight or weight change was not documented on the physician progress note dated 9/21/23. Review of the physician progress notes for Resident 25 signed and dated on 10/12/23 by Physician 1 showed, no loss of appetite, patient health status appropriate for current age, follow monthly and PRN (as needed). Resident 25's weight or weight change was not documented on the physician progress note dated 10/12/23. On 10/18/2 at 4:00 PM a review of Resident 25's electronic medical record and concurrent interview was conducted with the DSD. The DSD confirmed Resident 25 experienced an unplanned severe weight loss of 9.2 lbs., 7% from 9/11/23 to 9/30/23 and an unplanned severe weight loss of 13 lbs., 10% between 9/11/23 and 10/6/23. The DSD stated the physician must be notified of any resident significant weight changes. The DSD was not able to confirm documentation Resident 25's physician was notified of the unplanned severe weight loss of 9.2 lbs., 7% from 9/11/23 to 9/30/23 or the unplanned severe weight loss of 13 lbs., 10% between 9/11/23 and 10/6/23. On 10/19/23 at 10:33 AM a review of Resident 25's electronic medical record and concurrent interview was conducted with the ADON. The ADON confirmed Resident 25 experienced an unplanned severe weight loss of 9.2 lbs., 7% from 9/11/23 to 9/30/23 and an unplanned severe weight loss of 13 lbs., 10% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 9 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few between 9/11/23 and 10/6/23. The ADON stated the cart nurse was responsible to notify the physician of any significant weight loss. The ADON stated the cart nurse had notified Resident 25's physician but did not document such in the electronic medical record. The ADON added nursing should have done something and documented the weight loss. 2. Review of the facility's Policy and Procedure titled Weight revised on 1/31/22 showed in part, 7. Gross weight gains or losses should trigger an immediate reweighing of the resident. a. Re-weighs are to be completed the day after the original weight, b. Re-weighs are to be done on any resident who has a five-pound weight difference, whether it is a gain or loss . During an interview with the ADON on 10/19/23 at 10:33 AM, the ADON stated residents with significant weight changes were reweighed per the facility policy. On 10/20/23 at 9:00 AM a review of Resident 25's electronic medical record and concurrent phone interview was conducted with the Registered Dietitian (RD). The RD confirmed Resident 25 experienced an unplanned severe weight loss of 9.2 lbs., 7% from 9/11/23 to 9/30/23 and an unplanned severe weight loss of 13 lbs., 10% between 9/11/23 and 10/6/23. The RD was asked if she recommended Resident 25 be reweighed. The RD stated she had not recommended Resident 25 be reweighed because nursing had informed her the weight taken on 9/30/23 for Resident 25 was inaccurate. The RD stated Resident 25 was reweighed on 10/6/23, a week after the initial severe weight loss of 9.2 lbs., 7% on 9/30/23. Resident 25 had experienced an additional 3.8 lbs. weight loss on 10/6/23 for a total of 13 lbs., 10% since 9/11/23, less than one month. On 10/20/23 at 10:58 AM a review of Resident 25's electronic medical record review and concurrent interview was conducted with the DSD. The DSD confirmed Resident 25 had not been reweighed on 9/30/23 when he experienced a severe weight loss of 9.2 lbs., 7%. 3. Review of the facility progress note for Resident 25 written and signed by the RD on 10/4/23 showed in part, Resident 25 experienced a 9.2 lbs., 7% weight loss in one month. BMI (body mass index, a measurement of weight in comparison to a person's height) was 17.9 which indicated Resident 25 was underweight. Intake average was 67% in past seven days which was equivalent to 1340 kcal (kilocalories), health shake BID (twice a day) 100%. Weight loss possibly r/t (related to) weights with O2 (oxygen) tank on. CBW (current body weight) 121.4 lbs. Recommend: continue with (POC) plan of care. Monitor weight, skin, PO (oral) intake. Goals are for no further significant weight changes, good nutrient intake. RD to follow. Review of the facility progress note titled IDT weight variance review dated 10/4/23 showed in part, weight variance: 9.2lbs, 7% weight loss in one month. Current weight 121.4 lbs. (9/30/23), previous weight 130.6 lbs. (9/11/23). Goal: IBW (ideal body weight) 160 lbs. Average intake 67% x seven days. Supplements ordered: health shake BID 100%. Contributing factors: previous weight possible with oxygen tank. MD notified of weight change was blank. New intervention or recommendation: continue POC (plan of care). Review of the facility progress note for Resident 25 written and signed by the RD on 10/11/23 showed in part, Resident 25 experienced a 3.8 lbs., 3.1% weight loss in one week. BMI was 17.4 which indicated Resident 25 was underweight. Intake average was 68% in past seven days which was equivalent to 1360 kcals, health shake BID (twice a day) 100%. Weight loss likely r/t inadequate energy intake. CBW (current body weight) 117.8 lbs (10/6/23). Recommend: add magic cup BID (twice a day) at lunch and dinner. Goals are for no further significant weight changes, good nutrient intake. RD to follow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 10 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of the facility progress note titled IDT weight variance review dated 10/11/23 showed in part, weight variance: 3.8 lbs., 3.1% in one week. Current weight 117.6 lbs. (10/6/23), previous weight 121.4 lbs. (9/30/23). Goal: IBW 160 lbs. Average intake 68% x seven days. Supplements ordered: health shake BID 100%. Contributing factors: suboptimal PO intake. New intervention or recommendation: add magic cup BID at lunch and dinner. Residents Affected - Few On 10/19/23 at 12:36 PM an observation of Resident 25's lunch meal and concurrent interview was conducted with the RNA. Resident 25 was alert and able to answer questions. The RNA was feeding Resident 25 his lunch meal which consisted of ground meat, a roll, green beans, lemonade, one four-ounce health shake and a magic cup. The RNA stated Resident 25 usually ate 50% of meals, sometimes 75%. The RNA stated Resident 25 preferred meat and potatoes and did not like sweet foods. The RNA stated Resident 25 would drink the health shake when it was mixed with milk. The RNA stated Resident 25 did not like lemonade or the magic cup nutritional supplement. The RNA added he usually weighed Resident 25 and noticed he was losing weight, so he encouraged Resident 25 to eat. Upon completion of the lunch meal, Resident 25 consumed 50% of the roll, 75% of the meat, 0% green beans, 0% magic cup, and 75% of the health shake supplement. The RNA confirmed Resident 25 does not receive snacks between meals but could ask for something if he wanted a snack. The RNA stated Resident 25 did not ask for snacks between meals. On 10/20/23 at 9:00 AM a review of Resident 25's electronic medical record and concurrent interview was conducted via the phone with the RD. The progress note written and signed by the RD on 10/4/23 was reviewed with the RD. The RD confirmed she assessed Resident 25's intake average to be 67% in the past seven days which was equivalent to 1340 kcals. The RD was asked if she determined 1340 kcals was meeting Resident 25's kcal needs. The RD confirmed she had not assessed if 1340 kcals was meeting Resident 25's kcal needs and agreed that should be included in her assessment. The RD confirmed no interventions were recommended or implemented when Resident 25 experienced a severe unplanned weight loss of 9.2 lbs., 7% from 9/11/23 to 9/30/23. The progress note written and signed by the RD on 10/11/23 was reviewed with the RD. The RD confirmed Resident 25 experienced an additional 3.8 lbs., 3.1% in one week for a total of 13 pounds, 10% severe weight loss from 9/11/23 to 10/6/23. The RD confirmed she recommended magic cup be added BID to Resident 25's lunch and dinner meals for additional kcals. The RD was asked if she visited Resident 25 to discuss the recommended intervention of magic cup BID. The RD stated she tried to visit the residents but could not verify if she had seen Resident 25. The RD stated she was not aware Resident 25 did not like the magic cup. The RD stated nursing should notify the CDM if a resident did not like a particular food. When asked how the IDT determined if an intervention was effective, the RD stated if the resident did not continue to lose weight the intervention was working. On 10/20/23 at 10:31 AM an interview was conducted with the CDM. The CDM stated nursing does communicate resident food preferences or dislikes to the kitchen however, she was not aware Resident 25 did not like the magic cup or sweet foods and had not received communication from nursing stating Resident 25 did not like the magic cup or sweet foods. 4. Review of the facility Policy and Procedure titled, Resident Care Plans revised on 4/30/17 showed in part, .The care plan is to be updated when the resident experiences acute, temporary changes, in the medical, psychological and functional condition. On 10/19/23 at 10:33 AM a review of Resident 25's electronic medical record and concurrent interview was conducted with the ADON. The ADON confirmed when a resident experiences a significant weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 11 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete change, the resident centered plan or care should be updated to reflect the weight change. The ADON confirmed the care plan for Resident 25 had not been updated to reflect the -9.2 lbs., 7% unplanned severe weight loss on 9/30/23 or the -13 lbs., a 10% unplanned severe weight loss on 10/6/23. The ADON added it was the RD's responsibility to update the resident care plan with any significant weight changes. On 10/20/23 at 9:02 AM, a phone interview was conducted with the RD. The RD confirmed she was responsible to update resident care plans with significant weight changes. The RD confirmed she had not updated the care plan for Resident 25 to reflect the unplanned severe weight loss of -9.2 lbs., 7% on 9/30/23 or the -13 lbs., 10% unplanned severe weight loss on 10/6/23. Cross reference to F657. Event ID: Facility ID: 555625 If continuation sheet Page 12 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day/ 7 days a week. Residents Affected - Many This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 3: (April - June 2023), indicated the facility had no RN on duty for: 4/29/23 Saturday (Sa), 5/20/23 (Sa), 5/27/23 (Sa), 6/3/23 (Sa), 6/4/23 Sunday (Su), 6/10/23 (Sa), 6/11/23 (Su), 6/12/23 Monday (M), 6/13/23 Tuesday (T), 6/14/23 Wednesday (W), 6/15/23 Thursday (Th), 6/17/23 (Sa), 6/18/23 (Su), 6/24/23 (Sa), 6/25/23 (Su) During a review of the RN monthly schedule, dated April, May, and June 2023, indicated there was no RN coverage for Saturdays or Sundays during the month of June. During an interview on 10/18/23 at 2:30 pm, the Assistant Director of Nursing (ADON) confirmed, We have had just a few shifts without a RN. During an interview on 10/19/23 at 10:00 am, the Interim Director of Nursing (IDON) confirmed, We had a few shifts during that time period we were short, but we have hired more RNs. The PBJ is linked to each facility's personnel payroll system. If an RN is even late to sign-in, the system determines there is not a RN on for that time period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 13 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure safe handling of prescription medications with census of 66, based on standards of practice and regulatory requirements when: Residents Affected - Some 1. The Emergency Kit (or EKit, an emergency supply of drugs that used based on a doctor order for urgent needs of a resident) for injectable (or a shot) drugs was not safely secured after use and was not replaced on timely manner in the main medication room. 2. The disposition of discontinued or unusable prescription medications were not cosigned by two licensed staff in both medication rooms. These unsafe medication handling practices could contribute to risk of diversion (abuse of prescription drugs) and drug loss. Findings: 1. During an inspection of the facility's medication room, at Station 1, on 10/18/23, at 12:45 PM, accompanied by Licensed Nurse D (LN D), the Ekit for injectable medication was observed to be open and unsealed. The EKit container had a yellow carbon copy of a slip indicating it was used on 10/10/23 for a new medication order by the doctor. LN D acknowledged the finding and stated the EKit should have been re-sealed after use and replaced by the pharmacy provider. In an interview with Assistants Director of Nursing (ADON), at DON's office, on 10/18/23, at 3:22 PM, the ADON stated the EKit should have been sealed right after the use with the temporary blue tag provided inside the EKit. ADON stated when the nurse faxed the EKit usage paper to the provider pharmacy, it should have alerted the pharmacy to replace the kit with the next delivery. Review of the facility's policy, titled Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 2007, the policy indicated Emergency medication and supplies are kept secure, checked periodically for integrity . stored in accordance with State Board of Pharmacy and federal regulations. The policy further indicated Upon removal of any medication . from the emergency kit, the nurse document the medication or item on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy . The faxed log sheet will inform the pharmacy of items used from the emergency kit. This will notify the pharmacy to replace the kit . The policy on section 11 indicated before reporting off duty, the charge nurse indicates the opened or sealed status of the emergency kit at the shift change report . 2. During inspection of the facility's medication room, in the locked unit at Station 2, on 10/17/23, at 9:59 AM, accompanied by Licensed Nurse and Infection preventionist (IP), the two-drawer black container stored discontinued drugs and on the top of that a binder that had pages of Drug Destruction Log indicating drugs were disposed by one licensed nurse. During inspection of the facility's medication room, at the main Station 1, on 10/18/23, at 12:47 PM, accompanied by Licensed Nurse D (LN D), the three-drawer container was observed to be full of discontinued medications. LN D stated she was not sure when they got disposed and who documented in the medication destruction log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 14 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 Review of the facility's document binder, at the main Station 1, titled Drug Destruction Log, on 10/18/23, at 2:30 PM, the log had pages of prescription medication destruction signed by one nurse most recently on September 2023. In an interview with ADON, on 10/18/23, at 3:40 PM, the ADON stated the disposed prescription medication were placed in a pharmaceutical waste bin and they poured coffee ground over them. ADON stated the medication destruction was recorded in a log with signature of a licensed nurse. ADON was not aware of any regulation that required two-person co-signature for prescription drug disposition. In an interview with Interim Director of Nursing (IDON) and ADON, on 10/20/23, at 10:11 AM, the IDON stated the non-narcotic prescription medications required no witness for destruction. IDON stated the risk of prescription medication loss and diversion during disposition was no different than a loss or diversion from a medication cart. Review of the facility's policy, titled Disposal of Medications, dated 2007, the policy was provided by the facility on 10/18/23, indicated non-controlled medications shall be destroyed by the nursing care center in the presence of a pharmacist or nurse. And one other witness as per state regulation. Documentation of non-controlled medication may be completed on . a medication disposition log . and shall be retained as per federal and state regulations. The policy on page 3 further indicated The medication disposition log or form shall contain the following information: a. For the State of _________(blank line), the appropriate method non-controlled medication destruction is as follows: . b. For the State of _____ (blank Line), these non-controlled medications shall be disposed of by the nursing care center in the presence of appropriately titled professional (check appropriate line): . (no line was marked). The fill in the blank section was not marked in the copy provided by the facility. In an interview with IDON and ADON, in DON's office, on 10/20/23, at 1:25 PM, when asked about the medication disposal policy provided on 10/18/23, the IDON stated the facility had a best practice policy without a co-signature for disposal of the prescription medications. The ADON stated they will look and provide the policy they are following. Review of the facility's policy, provided on 10/20/23, titled Disposal of Medications, dated 2007, last revised on 1-31-22, the policy indicated non-controlled medications shall be destroyed by the nursing care center in the presence of a pharmacist or nurse. And one other witness as per state regulation. Documentation of non-controlled medication may be completed on . a medication disposition log . and shall be retained as per federal and state regulations. The policy on page 3 further indicated The medication disposition log or form shall contain the following information: a. For the State of California (blank space handwritten), the appropriate method non-controlled medication destruction is as follows: ____ (blank space hand marked by an X) Transfer to a container for release to a pharmaceutical waste contractor . b. For the State of California (handwritten), these non-controlled medications shall be disposed of by the nursing care center in the presence of appropriately tiled professional (check appropriate line): . _______ (blank space hand marked by an X) Others as listed: ________ Lic nurse employed by nursing care center ( blank space handwritten note; Lic means licensed). The policy on page 4, indicated c. a non-controlled medication disposition log or form shall be used for documentation and shall be retained as per federal privacy and state regulations. The log shall contain the following information: . Signatures of the required witnesses. Attempts to reach to facility's Consultant Pharmacist (CP) on 10/20/23 at 12:38 PM, 1:14 PM and 1:57 PM, was not successful. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 15 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 66 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 38 opportunities which resulted in a facility wide medication error rate of 13.16 % in two out of nine residents (Resident 8 and Resident 15) during medication administration observation. Residents Affected - Some These failures may result in unsafe medications use, medication error, and not following the doctor's orders. Findings: 1. During a medication pass observation of Resident 15, with Licensed Nurse A (LN A), on 10/17/23, at 9:13 AM, LN A administered a total of 10 medications and called the doctor's office on not having two medications not available to administer. LN A stated a blood thinner called Eliquis and a pain medication called Meloxicam was out of supply and not available to administer. Review of Resident 15's medical record, titled Medication Administration Record (or MAR, a legal document that listed medications ordered by doctor and administered by licensed nurse), dated October 2023, the MAR record and medication observation timing indicated the following irregularities: a. Carafate Oral Tablet 1 GM (or Sucralfate, used treat and prevent stomach ulcers; GM is unit of measure); Give 1 tablet by mouth before meals and at bedtime for GERD (or Gastroesophageal Reflux Disease; when stomach contents come back up into your esophagus and causes pain) -Start Date- 3/21/23. Carafate was due to be given at 7 AM before meal and was given after the breakfast at 9:13 AM. b. Senna Oral Tablet 8.6 MG (or Sennosides, a laxative); Give 2 tablet by mouth two times a day for Bowel maintenance Hold for loose stools -Start Date- 5/07/23. Medication observation indicated LN A administered Senna-S instead (a combination product of laxative Senna and stool softener Docusate) that was a different product than what was ordered. c. Aldactone Oral Tablet 25 MG (or Spironolactone; water pill for heart disease); Give 1 tablet by mouth one time a day related to . HEART FAILURE (a type heart disease); Hold for SBP (or Systolic Blood Pressure; type of blood pressure with normal number between 80-120) less than 110 -Start Date- 1/25/23. Medication observation indicated LN A did not administer the Aldactone. The MAR was marked as given at 9 AM. Resident's SBP number was more than 110 and recorded as 138. d. Biotin Oral Tablet 5 MG (Biotin, A B vitamin Supplement); Give 1 tablet by mouth one time a day for supplement -Start Date- 4/14/23. Medication observation indicated LN A did not administer Biotin. The MAR was marked as given at 9 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 16 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm In an interview with LN A, at the main nursing station, on 10/17/23, at 4:58 PM, LN A stated the pharmacy provider delivered the Eliquis and the Meloxicam was to be delivered during the evening shift. LN A acknowledged that she missed giving Aldactone and Biotin pills. LN A stated that she realized that she gave Senna-S instead of regular senna laxative. LN A stated she was running late on giving the 7 AM dose of Carafate before meal (breakfast). Residents Affected - Some 2. During a medication pass observation of Resident 8, with Licensed Nurse C (LN C), on 10/18/23, at 8:35 AM, LN C administered a total of 11 medications. Review of Resident 8's medical record, titled Medication Administration Record (or MAR, a legal document that listed medications ordered by doctor and administered by licensed nurse), dated October 2023, the MAR record and medication observation timing indicated the following irregularities: a. Oyster-Cal 500 Tablet (Calcium supplement); Give 1 tablet by mouth one time a day for Supplement -Start Date-9/27/23. b. Ferrous Sulfate Tablet 325 MG (or iron pill, a supplement used to treat anemia or low blood iron); Give 1 tablet by mouth two times a day for supplementation; Give with Food to Minimize GI (stomach) Upset. Do Not Crush or Chew. Do not administer w/ (With) Calcium, Milk or Milk products. -Start Date- 3/27/23. Medication observation indicated both iron pill and calcium were given together at the same time on 10/18/23 at 8:35 AM. The MAR documentation was marked as given at 9 AM. In an interview with Interim Director of Nursing (IDON), on 10/20/23, at 10:29 AM, the IDON stated doctor's order and instruction on the MAR should be followed during medication administration. Review of the facility's policy, titled Nursing Responsibility, last reviewed on 1/31/22, the policy under section 17 indicated Licensed nurses are responsible for administering medications and treatments as follow: . Medications and treatments are to be administered as prescribed; Review of the facility's policy, titled Medication Administration, last reviewed on 1/31/22, the policy under Administration of Medications to Residents indicated Medications are to be administered according to physician's orders using the Six Rights of Medication Administration . Read the resident's medication administration record (MAR) in its entirety . Select appropriate medication from the medication cart . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 17 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 ensure safe medication storage practices in three out of five medication and treatment Carts (cart or container on a wheel that stored immediate use medications) with census of 66 residents when medications were not marked with beyond use date (the date a product should no longer be used) based on manufacturer recommendations. These failed practices may result in unsafe and spoiled medication use in the facility. Findings: 1. During a concurrent inspection of facility medication Cart #2, at facility's Station 1, accompanied by Licensed Nurse D (LN D), on 10/17/23, at 10:17 AM, the medication cart stored medications with no markings for when it was first opened or with a beyond use date per manufacturer recommendations as follow: a. Basaglar Insulin pen (also known as Glargine; a shot medicine used to treat blood sugar disease; the medicine in pen shape for ease of administration) was stored in the medication cart for daily use and the label on the medications was missing the Date Opened. The insulin pen had a label with handwritten note to discard after 28 days after opening. b. Latanoprost eye drop (used to treat an eye disease called glaucoma) bottle was stored in the medication cart for daily use and the not dated when first was opened. The pharmacy label for Date Opened was not marked with any date. Product label indicated that Once a bottle is opened for use, it may be stored at room temperature . for 6 weeks. c. Four boxes of single use inhalation medication called ipratropium Bromide and albuterol Sulfate Inhalation solution (or DuoNeb- a breathing treatment for asthma and lung disease) for different residents were open and out of foil with no marking for the date opened. The product label indicated once removed from the foil pouch, the individual vials should be used within two weeks. d. An opened container of inhalation medication called Fluticasone Furoate/Vilanterol inhalation Powder (or Ellipta, breathing medication to treat asthma or lung disease), was not dated when first opened. The label on the container indicated Discard the inhaler 6 weeks after opening the moisture-protective foil ray . LN D acknowledged the findings and stated she was not sure why the products were not marked with open date when it was first opened. 2. During a concurrent inspection of facility treatment Cart at Station 1, accompanied by Licensed Nurse B (LN B), on 10/17/23, at 10:39 AM, the treatment cart stored four opened containers of prescription medication called triamcinolone 0.1% Cream (also called TAC cream, % a measure of potency; used to treat rash or skin disease), marked as RX Only (means prescribed by a doctor's order) in the active storage area of the cart. The TAC cream tubes had no pharmacy label on them to show who it was belonged to or how to use them. Further inspection of the treatment cart at Station 1, indicated a bottle of medicated shampoo called Ketoconazole 2% (a medicated shampoo used to treat yeast (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 18 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 infections), marked as RX Only, and a handwritten note indicating house supply. The bottle did not have a pharmacy label with a resident name on it. LN B acknowledged the finding and was not sure why the prescription labels were missing, or how the products were used without a label or resident name. Residents Affected - Some 3. During a concurrent inspection of facility medication Cart #1 at Station 1, accompanied by Licensed Nurse B (LN B), on 10/17/23, at 10:50 AM, the medication cart stored the following medications with no markings for when it was first opened per manufacturer recommendations: a. one container of a medication called Combivent Respimat inhalation spray (a breathing medicine used to treat asthma or other respiratory diseases) was stored in active storage area with no marking on when it was first opened. The pharmacy label for beyond use date was not marked. The label on the container indicated Discard 3 months after insertion of cartridge into inhaler. b. one opened container of test strip called Evencare G2 Blood Glucose Test Strips (a testing strip used to measure blood sugar by using a device called glucometer) was not dated when it was first opened. The label on the bottle indicated Use within 6 months after first opening or before the expiration date. LN B acknowledged the findings. In an interview with Assistant Director of Nursing (ADON), on 10/18/23, at 3:22 PM, the ADON stated the nursing staff should mark the multidose container of medications with the date opened and follow the label instruction for beyond use date. ADON stated the pharmacy services provided a table with list of products with short dating that required marking the date it when opened. Review of the facility's policy, titled Medication Storage, last reviewed on 1/31/22, the policy indicated it is the policy of this facility that all medications, drugs and biologicals (class of medicines which are grown and purified) to be stored in a safe, . manner . as directed by the manufacturer . in accordance with federal and state regulations. Review of the facility's policy, titled Medication Administration, last reviewed on 1/31/22, the policy indicated Medications are to be administered from containers, . that are clearly marked with the name of medication, concentration, dose, route and expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 19 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, and interview, the facility failed to ensure federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 10/18/23 at 9:25 AM an interview was conducted with the CDM. The CDM was asked for documentation she had received six hours of California dietary service requirements contained in Title 22 of the California Code of Regulations. The CDM was not able to provide evidence of six hours of California dietary service requirements contained in Title 22 of the California Code of Regulations as specified in the HSC 1265.4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 20 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and facility document review, the facility failed to ensure the menu was followed for 2 of 18 residents who received a controlled carbohydrate diet (CCHO, a diet that contains carbohydrate rich foods in fairly equal amounts) for Residents 52 and 272. This failure had the potential to result in the resident to not receive the CCHO diet as planned. Findings: A review of the facility document titled Cooks Spreadsheet week 3 Tuesday dated 10/17/23 showed, for the lunch meal the CCHO diets should be served one serving of peanut butter cake for dessert, no icing. A review of Resident 52's medical record showed Resident 52 was admitted on [DATE] with a diagnosis including type 1 diabetes mellitus (a chronic condition where the pancreas produces little to no insulin). A review of resident 52's physician orders showed a CCHO mechanical soft texture, thin liquid consistency diet was ordered on 1/23/23. During the lunch meal dining observation on 10/17/23 in Dining room [ROOM NUMBER] at 12:13 PM, Resident 52's lunch meal tray contained one piece of peanut butter cake with icing. On 10/17/23 at 12:23 PM and interview was conducted with Licensed Vocational Nurse E (LN E) who confirmed that Resident 52 received one piece of peanut butter cake with icing on her lunch meal tray. When asked how LN E checked for accuracy of a CCHO diet, LN E stated she would ask the kitchen. LN E stated a CCHO diet would usually not be served regular cake with icing. The Certified Dietary Manager (CDM) was contacted and confirmed Resident 52 should have received one piece of peanut butter cake without icing. A review of the facility document titled Cooks Spreadsheet Week 3, Wednesday dated 10/18/23 showed, for the lunch meal the CCHO diet should be served one half cup of fresh fruit for dessert. A review of Resident 272's medical record showed Resident 272 was admitted on [DATE] with a diagnosis including type 2 diabetes mellitus. A review of resident 272's physician orders showed a CCHO regular texture, texture, thin liquid consistency diet was ordered on 8/26/23. On 10/18/23 during the tray line observation in the kitchen at 12:28 PM Resident 272's lunch meal tray contained a regular cranberry crunch square for dessert. The CDM confirmed the dessert was incorrect and replaced it with fresh fruit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 21 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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, facility document and Policy and Procedure review, the facility failed to ensure Food and Nutrition Services followed food safety and sanitation guidelines when: Residents Affected - Some 1. Two of two hand washing sinks didn't not reach 85 degrees Farenheight (° F, a unit of measuring temperature). 2. The temperature in the nourishment refrigerator located on Nursing Station 1 was 4° F above the recommended temperature range. 3. The ice machine located in kitchen was not clean. 4. The sanitizer solution in the third compartment of the manual dishwashing sink was less than 200 parts per million. 5. Time temperature control for safety foods (TCS) prepared at ambient temperature (room temperature) were not monitored on the cool down log. 6. Food preparation equipment was not air dried. 7. Food service utensils were not in sanitary condition. 8. Food service utensils were not of approved material. 9. Food was not stored properly in 1 of 2 walk in freezers. 10. The floor drain next to the ice machine was not clean. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 66 who received food prepared in the kitchen. Findings: 1. According to USDA Food Code 2022, Section 5-202.12 Handwashing Sink, Installation (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 85° F During a review of facility's policy, Titled Hand Washing Procedure dated 2023, indicated that staff should use warm running water at 100 F to 108° F. On 10/17/23 at 8:52 AM during a concurrent interview and observation with Certified Dietary Manager (CDM) in the kitchen, she stated that the hot water heater that supplies hot water to the kitchen had been broken for a week. CDM confirmed that hot water temperature at handwashing sinks #1 was 70° F and at hand washing sink #2 hot water temperature was 62.4° F according to surveyor's digital thermometer. On 10/17/23 at 9:11 AM during an interview and with the Director of Plant Operations (DPO), he confirmed the hot water heater has been broken for a week. DPO stated he had one quote for repair and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 22 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 second repair company was coming that day. Level of Harm - Minimal harm or potential for actual harm On 10/17/23 at 9:13 AM during a concurrent interview and observation with the CDM, she stated that staff would mix hot water from the coffee maker and cold water in a bowl to make warm water for hand washing. No bowl was observed. Dietary Aide B (DA B) was asked to demonstrate how he washed his hands. DA B demonstrated by washing his hands with water from the faucet in sink #1 with water temperature at 70° F. Residents Affected - Some 2. According to the US Food and Drug Administration titled Keep your appliances at the proper temperatures dated 1/18/23, keep the refrigerator temperature at or below 40° F or 4° Celcius (C, a metric unit of measuring temperature). The freezer temperature should be 0° F (-18° C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. http://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely A review of a facility's Nourishment Refrigerator log sheet, the maximum temperature of the refrigerator should be 41° F. On 10/19/23 at 9:06 AM, a concurrent interview and observation was conducted with Director of Staff Development (DSD) at Nurses Station #1 medication room. A nourishment refrigerator located in medication room was noted to be 46 F. All temperature entries in the log for the month of October 2023 were above 41° F. When asked if it was safe to store food above 41° F, the DSD stated she was not sure. The DSD confirmed that DPO should be notified that the refrigerator was not within approved temperature range. On 10/19/23 at 9:18 during a concurrent interview and observation with the DPO, he verified that the temperature in Nourishment Refrigerator on Station #1 was above 41° F. The DPO confirmed that the nourishment refrigerator was not noted in maintenance log. 3. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review of the facility's policy and procedure titled, Ice Machine Cleaning Procedures dated 2023, indicated, the ice machine needed to be cleaned and sanitized monthly. During a review of the ice machine's owner's manual, it indicated to descale and sanitize the ice machine every 6 months for efficient operation. If the ice machine requires more frequent descaling and sanitizing, consult a qualified service company. On 10/17/23 at 3:09 PM during a concurrent interview and observation with the DPO he stated he cleaned the ice machine every month. The DPO stated the ice machine was new, purchased April 2023, and the manufacturer said it didn't need to be cleaned for six months. Upon inspection of the interior of the ice machine, a white powdery substance was noted on the outside of the harvester curtain and the inside of the ice storage bin. The DPO verified white substance. When wiped with a paper towel a black substance was removed from the water trough (a tray that holds the water before it is frozen during the ice making process. The DPO confirmed the ice machine was not cleaned and he planned to clean it every three months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 23 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 4. During review of facility's policy titled 3-Compartment Procedure for Manual dishwashing it indicated that the third compartment is for sanitizing, test the concentration with the appropriate test strip, which is dipped in the sanitizer solution for 1-2 seconds before reading. Must read 200 parts per million (PPM) of sanitizer solution. On 10/17/23 at 9:40 AM during a concurrent interview and observation of the manual dish washing procedure in the kitchen with the CDM and Dietary Aide A (DA A), the DA A demonstrated the process to check the sanitizing solution concentration in the third compartment. When tested, the sanitizing solution test strip indicated 100 PPM. The CDM confirmed the sanitizing solution was not at correct concentration. 5. According to the USDA Food Code 2022 Section 3-501.14 3-501.14 Cooling (B) Time/temperature control for safety food shall be cooled within 4 hours to 41° F or less if prepared from ingredients at ambient temperature . A review of the facility policy and procedure titled Cooling and Reheating of Potentially Hazardous or Time/Temperature for Safety Food dated 2023 showed, Ambient Temperature Food: TCS food shall be cooled within four hours to 41° F or less if prepared from foods at ambient temperature . On 10/17/23 at 12:44 PM an observation and concurrent interview was conducted with [NAME] 2 with the CDM present. [NAME] 2 was preparing coleslaw for the dinner meal. The coleslaw temperature was 48.1° F, according to the surveyor's digital thermometer. [NAME] 2 stated he only took a temperature of the coleslaw before dinner tray line. When asked if [NAME] 2 was familiar with a cool down log for TCS foods, [NAME] 2 obtained a binder with a log titled, Cool Down Log. The CDM stated there was a separate log for foods prepared at ambient temperature but confirmed the log for ambient foods was not in the binder. On 10/17/23 at 3:13 PM the CDM provided a blank copy of the ambient cooling log. The CDM stated she forgot to put the log in the binder. The CDM was unable to provide any completed cooling logs for ambient foods. 6. According to the USDA Food Code 2022, Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried . During review of facility's Policy labeled Dishwashing it indicated dishes are to be air dried before stacking and storing. All items are air-dried which means no water droplets are present. On 10/18/23 at 10:52 AM in kitchen, five steam table pans were noted to be stacked and stored wet. The CDM verified the steam table pans should be air dried. 7. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review of facility's policy titled Sanitation dated 2023, it indicated all utensils, counters, shelves and equipment shall be kept clean . On 10/17/23 at 9:11 AM during concurrent interview and observation in kitchen with CDM, 3 skillets were noted to have a thick, hard black substance on the cooking surface of the skillets. The CDM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 24 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 verified and stated she was planning on ordering new skillets. Level of Harm - Minimal harm or potential for actual harm 8. According to the USDA Food Code, Section 4-101.17 Wood, Use Limitation. (A) Residents Affected - Some . wood and wood wicker may not be used as a FOOD-CONTACT SURFACE. On 10/18/23 at 10:52 AM during a concurrent interview and observation in the kitchen with CDM, three wooden spoons were noted in utensil storage bin. CDM asked [NAME] A if he used them, and he stated he does use them. The CDM discarded the wooden spoons. 9. During a review of facility's policy titled Storage of Food and Supplies dated 2023, it indicated all shelves and storage racks or platforms should be in accordance with federal regulations to facilitate air circulation and promote easy and regular cleaning. On 10/17/23 at 10:05 AM during concurrent interview and observation with the CDM in the walk-in freezer located in the large storeroom, three empty plastic milk crates were noted to be used to elevating food supplies off the floor. CDM stated there wasn't enough shelf space to store food. 10. During a review of the facility's policy titled General Cleaning of Food and Nutrition Services Department dated 2023 it indicated that floor drains must be scheduled for routine cleaning in order to be maintained in a functional condition. Food and nutrition staff should remove large debris as it accumulates and are encouraged to clean drains weekly. Maintenance department will assist with more thorough cleanings to ensure the viability of the plumbing features. On 10/17/23 at 3:09 PM during concurrent interview and observation with DPO in kitchen the floor drain next to the ice machine was noted to have an encrustation of a hard white substance around the drain perimeter with scattered black, grey and tan discoloration. DPO verified presence of substance, stated he will clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 25 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interviews, observations and record review the facility failed to ensure the policy for resident food brought from the outside allowed food to be reheated. In addition, family members, and visitors who brought food from the outside were not informed of safe food handling practices, and employees were not educated on safe food handling practices. Residents Affected - Some This failure had the potential for food brought in from the outside to not be handled in a safe manner. Findings: During review of facility's policy and procedure titled Food from Outside Source reviewed on 1/31/22, indicated facility staff are not allowed to reheat foods brought in from outside the facility. Nursing and/or dietary staff are to discuss proper food storage and handling with the family to promote food safety. On 10/18/23 at 9:11 AM during interview with Assistant Director of Nursing (ADON) when asked how families get educated on safe food handling, she stated she refers to Certified Dietary Manager (CDM). On 10/18/23 at 12:57 PM during interview with Registered Dietician (RD) she stated she is not involved with educating the family members on food brought into facility and nursing takes care of it. On 10/19/23 at 8:30 AM during interview with Director of Staff development (DSD) when asked about any education on safe food handling for staff and family, the DSD confirmed there was a sign in sheet for an in-service completed on 7/14/23, however, there was no documentation of a lesson plan which showed what was covered in the in-service. On 10/19/23 at 8:51 AM during interview with CDM she stated she is not involved with educating family on safe food handling of outside food and refers to nursing. On 10/20/23 at 12:20 PM during interview with ADON when asked if staff was allowed to reheat food brought in from outside the facility. The ADON confirmed the policy stated food could not be reheated by staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 26 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, Policy and Procedure review, the facility failed to ensure refuse was stored in a sanitary manner when: Residents Affected - Some One of three outdoor refuse dumpsters was not closed, and the surrounding area was not maintained in a sanitary manner. This failure had the potential to attract vermin. Findings: During review of facility's policy titled Sanitation, dated 2023, it indicated kitchen wastes .should be kept in leak proof, non-absorbent and tightly closed containers and shall be disposed of as necessary to prevent a nuisance or unsightliness. According to USDA Food Code, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered .with tight-fitting lids or doors if kept outside the food establishment. According to USDA Food Code, Section 5-501.115 Maintaining Refuse Areas and Enclosures: A storage area and enclosure for REFUSE .shall be maintained free of unnecessary items . and clean. On 10/18/23 at 9:40 AM an observation of the outdoor refuse storage area and concurrent interview was conducted with the Director of Plant Operations (DPO). One of three dumpsters was overfilled with trash preventing the lid from closing completely. The DPO confirmed all dumpsters should be completely closed. The area surrounding the dumpsters was littered with used gloves, empty food containers, paper and vegetation. The DPO confirmed the area was not clean and could attract vermin FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 27 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility did not report a failed water heater to state and local agencies for 12 days. This failure had the potential to place all residents at risk for exposure to germs and illness related to a lack of hot water. Residents Affected - Many Findings: A facility policy, titled, Unusual Occurrences, reviewed 4/30/22, was reviewed. The policy indicated a list of unusual occurrences that should have been reported to the California Department of Public Health (CDPH) within 24 hours by telephone and confirmed in writing. Among the reportable occurrences was any that, constituted an interference with facility operations, or which threatened the welfare, safety or health of residents, personnel, or visitors. During a concurrent interview and record review, on 10/17/23, at 11:30 AM, in the facility laundry room, Housekeeper (HSK) A stated the hot water had been off for one and a half weeks. HSK A confirmed a temperature log for the month of October 2023 contained a last recorded water temperature of 151 degrees Fahrenheit on 10/5/23 at 4:30 AM. No further temperatures had been recorded on the log. During an interview, on 10/20/23, at 10:03 AM, the Dirrector of Plant Operations (DPO) stated the kitchen notified them of no hot water on 10/5/23. DPO stated there were three water heaters on the roof of the facility, one for the kitchen and laundry, and two smaller tanks for residents' showers. The tank supplying the kitchen and laundry was the one that had failed. During an interview, on 10/17/23, at 11:50 AM, the Administrator (ADMIN) stated they hadn't called the County Health Department or CDPH about the water heater failure on 10/5/23. ADMIN stated they were still deciding on whether to repair or replace the failed water heater. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 28 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 2. A facility policy, titled, Laundry and Resident Linens, revised 1/31/17, was reviewed. It's stated purpose was to prevent the spread of infections via laundry/linen. The policy indicated that all employees would have followed current infection control practices while handling residents' linens. Residents Affected - Few During a concurrent interview and observation, on 10/17/23, at 11:30 AM, in the laundry room, Housekeeper (HSK) A was folding a clean sheet in the presence of two surveyors, and several inches of the bottom of sheet were on the floor. When asked by the two observing surveyors about the sheet being in contact with the floor, HSK A confirmed it was on the floor, stating, We mop the floor every day. Based on observation, interview, and record review the facility failed to ensure and maintain infection control practices with census of 66 when: 1. The facility failed to ensure safe cleaning and sanitization of the shared glucometer (medical device used to measure blood sugar from a drop of blood) when the glucometer was not disinfected on three out of three residents (Residents 12, Resident 31, and Resident 273) tested for blood sugar level, based on standards of practice and manufacturer recommendations. 2. The facility failed to maintain infection control practices when one Housekeeping Staff (HSK A) failed to keep a clean sheet off the floor. These failures had the potential to cause the spread of germs which could have placed the vulnerable resident population at risk for infection and illness. Findings: 1. Review of facility's policy titled, Cleaning Point of Care Equipment (Blood Glucose Meter), in effect and last revised on 4/20/22, the policy indicated It is the policy of this facility to clean all point of care equipment, including blood glucose meters, according to manufacturer's recommendations. Point of care equipment will not be used between two residents without being cleaned according to the manufacturer recommendations. The policy on section 2 indicated Alcohol is not to be used for cleaning potentially contaminated surfaces with bloodborne pathogens (bugs that can infect blood). The policy on section 5 indicated The meter (glucometer) should be cleaned (remove dirt, soil or blood) and disinfected (killing the germs) prior to storage. Review of Evencare G2 glucometer (brand name glucometer used in the facility) manufacturer instructions, dated 2017, last accessed via https://www.medline.com/media/catalog/Docs/MKT/LIT316_MAN_EvenCare%20G3%20In-Service%20Gu.pdf, the document indicated there were two steps for cleaning and disinfecting the meter. Cleaning and disinfecting the meter was very important in the prevention of infectious disease. Cleaning also allowed for subsequent disinfection to ensure germs and disease-causing agents were destroyed on the meter as follow: A. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter until visibly clean. B. To disinfect the meter, wipe with one of the validated disinfecting wipes and allow to remain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 29 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wet for the contact time (time needed for the disinfectant stay in touch with the outer surface of the glucometer to kill all the germs) listed on the wipe's directions for use. The glucometer manufacturer (Evercare G2's glucometer) also indicated a validated and/or EPA (A U.S. Environmental Protection Agency, a federal agency responsible for the protection of human health and the environment) endorsed wipes for disinfecting the meter should be used. During an observation on 10/17/23, at 11:34 AM, at facility's Station 1, Licensed Nurse D (LN D), with gloved hand, wiped the glucometer for less than 30 seconds with one wipe from a container labeled as Clorox Bleach Germicidal. LN D then used a plain tissue to dry the outer surface of glucometer before taking it to the Resident 12's room. LN D after measuring Resident 12's blood sugar, washed her hands and then with gloved hand wiped the outer surface of glucometer for less than 30 seconds using Clorox Bleach Germicidal wipe. During an observation at facility's Station 1, with Licensed Nurse B (LN B), on 10/17/23, at 11:52 AM, LN B took the glucometer and other supplies into the Resident 31's room to measure the blood sugar. LN B poked the finger for blood sample and measured the blood sugar by soaking the test strip with with blood attached to the glucometer. Once finished with measurement, LN B placed the glucometer in her pants pocket and exited the room. LN B then quickly cleaned the outer surface of glucometer with a 2x2 (2 inch by 2-inch size) alcohol swab and did not follow manufacturers specifications for cleaning and disinfecting the glucometer after checking Resident 31's blood glucose. During an observation at facility's Station 1, with LN B, on 10/17/23, at 12:04 PM, LN B used the same glucometer and new supplies, went into the Resident 273's room to measure the blood sugar. LN B with gloved hand poked Resident 273's finger to get drop of blood when the glucometer did not register any blood sugar number. LN B then exited the room and brought new supplies to get blood sample for testing. LN B measured the blood sugar and exited the room. LN B with same gloves, cleaned the glucometer with a 2x2 alcohol pad and did not follow manufacturers specifications for cleaning and disinfecting the glucometer after checking Resident 273's blood glucose. During an interview with LN B, at the nursing Station 1, on 10/18/23, at 12:30 PM, LN B explained that the facility expectation was to use the purple top disinfecting wipes (Medline Super Sani-Cloth Germicidal Wipe), to allow the glucometer to remain wet for the time specified on the label (2 minutes), and stated, I used an alcohol swab to clean the glucometer. LN B confirmed that using a 2x2 alcohol swab to clean the glucometer between residents was not the process taught for infection prevention. During an interview with Assistant Director of Nursing (ADON), in her office, on 10/18/23, at 2:44 PM, the ADON confirmed that all medical equipment used for more than one resident should be cleaned and disinfected after each use. And explained the facility expectation was to perform hand hygiene, wear gloves, place a barrier, use the appropriate facility supplied wipe and allow the equipment to remain wet for the time specified on the package. During an interview with Infection Prevention Nurse (IP), on 10/18/23, at 3:38 PM, the IP explained that bleach wipes should be used to clean the glucometer and that the glucometer should remain wet for the time specified on the label. And indicated that the facility has three types of wipes available, each having different instructions: a)Clorox Healthcare Bleach Germicidal Wipe (brand name product) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 30 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 b)Medline Super Sani-Cloth Germicidal Wipe (brand name product) Level of Harm - Minimal harm or potential for actual harm c)Medline Micro-Kill One Germicidal Alcohol Wipes (brand name product; not the same as a 2x2 alcohol swab) Residents Affected - Few Review of the label on the facility's wipe, titled Clorox Healthcare Bleach Germicidal Wipe, the label indicated that most bacteria and viruses are only killed when the surface remains wet for at least 3 minutes and indicated a range of 1 to 5 minutes is needed to disinfect dependent on the infective germ. Review of the label on facility's wipe, titled Medline Super Sani-Cloth Germicidal Wipe, the label indicated that to disinfect a surface, it must remain wet for 2 minutes minimum. Review of the label on facility's wipe, titled Medline Micro-Kill One Germicidal Alcohol Wipes, the label indicated that to disinfect a surface must remain wet for a minimum of 1 minute. The wipe did not cover an infectious bugs called C. Diff (or Clostridium difficile, a bug that caused severe diarrhea). During an interview on 10/18/23, at 4:16 PM, the DON, ADON, and IP all confirmed that cleaning the glucometer with a 2x2 alcohol swab was not adequate to prevent the spread of infections and two step cleaning and disinfection with required wet time should be followed in-between resident use of glucometer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 31 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 interviews, observations and record review the facility failed to ensure essential equipment was maintained in safe working order when: Residents Affected - Many 1. The temperature of the nourishment refrigerator located in nursing station one was above 41 degrees Fahrenheit (° F, a unit of measuring temperature). 2. The manufacturer guidelines were not followed for cleaning and sanitizing the ice machine. 3. A walk-in freezer located in the large storeroom in the basement had ice build-up on the inside of the door, around the fans and around a pipe. These failures had the potential for the equipment to not be maintained to ensure proper functioning. Findings: During a review of facility's policy and procedure titled Maintenance Shop dated 2023, it indicated it was the policy to maintain a Maintenance Log of service visits, repairs and inspections of the facility's fixtures, equipment, systems and buildings. 1. According to the US Food and Drug Administration titled Keep your appliances at the proper temperatures dated 1/18/23. Keep the refrigerator temperature at or below 40° F or 4° Celcius (C, metric unit of measuring temperature). The freezer temperature should be 0° F (-18° C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. http://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely According to facility's Nourishment Refrigerator log sheet, the maximum temperature of the refrigerator should be 41 ° F. On 10/19/23 at 9:06 AM, a concurrent interview and observation was conducted with Director of Staff Development (DSD), at Nurses Station #1 medication room. A nourishment refrigerator located in medication room was noted to be 46 ° F. All temperature entries in the log for the month of October were above 41 ° F. When asked if it was safe to store food above 4 ° F, the DSD stated she was not sure. The DSD confirmed that the Director of Plant Operations (DPO) should be notified that the refrigerator was not within approved temperature range. On 10/19/23 at 9:18 during a concurrent interview and observation with the DPO, he verified that the temperature in Nourishment Refrigerator on Station #1 was above 41 ° F. The DPO confirmed that the nourishment refrigerator was not noted in maintenance log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 32 of 33 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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 - Many 2. During a review of the ice machine's manufacturer's descaling and sanitizing procedure instructions located on the inside cover of the ice machine showed to use [Manitowoc] ice machine descaler and sanitizer. On 10/17/23 at 3:09 PM during a concurrent interview and observation with the DPO stated the ice machine was new, purchased April 2023. Upon inspection of the ice machine cleaning and descaling chemicals provided by the DPO, it was noted that they were not the correct chemicals recommended by the manufacturer. The DPO stated he would obtain correct chemicals to clean/descale and sanitize the machine. 3. On 10/19/23 at 3:25 PM during a concurrent interview and observation with DPO in large walk-in freezer located in the basement storeroom, he confirmed the presence of ice build-up on a pipe and the ceiling above the ventilation fans and on the inside vent of door. He stated he was not aware of the ice buildup, and it should have been documented on the maintenance log. On 10/19/23 at 3:32 PM during a concurrent interview and observation with the Certified Dietary Manager (CDM) in large walk-in freezer, she confirmed the presence of ice build up on pipe and the ceiling above the ventilation fans and on the inside vent of door. She confirmed she had not entered it on the maintenance log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555625 If continuation sheet Page 33 of 33