Health inspection·February 14, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intake of fluids was approximately 820 milliliters per day. This represented an average of 480 milliliters per day less than the RD's assessed fluids needs for Resident 8. A review of the I&O records from 2/1/25 through 2/12/25 indicated Resident 8 had an average of 900 milliliters of fluids each day, which was 400 milliliters less than the RD's assessed fluids needs per day. During a concurrent observation and interview on 2/11/25, at 10:48 a.m., with Resident 8 in her room, the resident sat in wheelchair next to her bed. Resident 8 had a soft voice and was able to carry out a minimal conversation. The resident's bedside table was placed in front of resident's wheelchair but there was no water pitcher on the table. A small plastic water cup with cover was observed on the table behind the resident's wheelchair and was not within resident's reach. Resident 8's right hand was visibly shaking when she attempted to grab the call light. Resident 8 stated she was not able to reach her cup with water and added, I shout for help when I'm thirsty and my mouth is dry. During a follow up observation on 2/11/25, at 1:25 p.m., the resident was lying in bed on the left side, propped with pillows. A small plastic cup with brown substance was observed on the small table behind the residents bed, approximately 2-3 feet away and there was no water pitcher observed in resident's room. The resident's bedside table was observed at the entrance to the resident's bathroom. Resident 8 stated she had no water available to drink. During an observation on 2/12/25, at 8:25 a.m., Resident 8 was sitting in wheelchair in her room with breakfast tray in front of her. A small amount of juice was noted in the plastic cup. There was no water pitcher observed on the resident's table or anywhere in the resident's room. Resident 8 stated she liked ice water but the staff did not offer it to her this morning. After a moment, Resident 8 was observed calling help, help and waved her hand when the resident observed a CNA walking in the hall. The CNA was overheard saying ok and continued walking in the hall. The CNA passed the resident's room, entered another resident's room, and closed the door. Resident 8 continued calling help, help in her soft voice. During an observation on 2/12/25, at 4:25 p.m., Resident 8 was lying in bed on her side facing left side of the bed propped by pillows. Bedside table was observed away from the resident on the opposite side of the room. A plastic jug with small amount of water was observed on the small table behind the resident's bed, not within reach. Resident's call light was observed wrapped around the right side rails, hanging toward the floor not within resident's reach. Resident 8 feebly stated, My mouth is so dry. Resident 8 whispered that staff did not offer her water and nodded her head when asked if she wanted to have some water. During an interview on 2/12/25, at 4:30 p.m., Certified Nursing Assistant (CNA 1) stated Resident 8 was confused most of the time, but was able to state her needs. CNA 1 stated Resident 8 liked to drink ice cold water and asked for it when she wanted a drink. CNA 1 stated that Resident 8 had really bad shaking in both of her hands, but the right hand was worse and required assistance with feeding. CNA 1 added that if Resident 8 was not assisted, the resident would spill food and drinks. CNA 1 entered Resident 8's room and acknowledged that the bedside table was away and the call light and water jug were not within resident's reach. CNA 1 stated, She [Resident 8] doesn't know how to use the call light anyway. She always shouts for help and if she needs water. CNA 1 stated the CNAs were supposed to offer water to Resident 8 in between meals. During an interview on 2/12/25, at 4:50 p.m., with Nursing Supervisor (NS) 2, the NS 2 stated the CNAs had to offer the residents water or other beverages throughout the day and in between meals and the nurses were giving water with medications. NS 2 explained that evening shift nursing supervisor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 2 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 totaled the resident's fluids intake for the day and documented in the clinical records. The NS 2 did not provide any answer when asked how the facility monitored Resident 8's fluid intake to identify if the resident was meeting her recommended fluid needs and getting enough hydration. During a telephone interview with RD on 2/12/25, at 2:12 p.m., the RD stated that residents were assessed for their nutrition and hydration needs about two weeks after their admission. The RD explained that to determine if the residents had met their required fluid needs, the residents were reassessed later and the new recommendations were added if needed. The RD stated she sent nutritional recommendations to the dietary manager (DM) who communicated the information to nursing staff. The RD stated she could not remember if she reassessed Resident 8's fluid intake or if she was notified that the resident was not meeting the estimated fluid needs. A review of the facility's policy titled, Hydration - Clinical Protocol, dated 2001, indicated, The physician and staff will help define the individual's current hydration status .The staff .will provide supportive measures such as supplemental fluids .The staff will monitor for the .development, progression .of fluid .imbalance in at-risk individuals. During an interview with Director of Nursing (DON) on 2/13/25, a 10:03 a.m., the DON was asked if the facility had a system in place to monitor residents' fluid intake to ensure their fluid needs were met. The DON explained that CNAs documented the fluid amount the resident consumed on paper logs and then documented electronically for each shift and the evening shift supervisors calculated and entered the total amount into resident's electronic chart. The DON added, RD keeps an eye on that, also nurses address [fluid intake] in their weekly summaries. The DON reviewed the RD's recommendations for Resident 8 to have 1300 milliliters of fluids each day. The DON reviewed nursing weekly summaries dated 2/6/25 and 2/13/25 and acknowledged that the nurses documented in their summaries the amount of the fluid the resident received and validated that the amount was below RD's recommendations. The DON reviewed 24 hour documentation of Resident 8's I&O and acknowledged that the resident have not met her recommended fluid needs per January and February. The DON stated Resident 8's fluid needs were not identified and were not addressed during interdisciplinary meetings. The DON validated that not having proper hydration placed Resident 8 at risk for dehydration and could lead to other health issues related to constipation. The DON added that water and/or other fluids should be always available at Resident 8's bedside to prevent dehydration. The DON stated she would expect nursing to follow the RD's recommendations for fluid needs, expect CNAs round on Resident 8 more frequently, offer, encourage water in between meals, and the nurses address Resident 8's fluid consumption in their weekly summaries or progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 3 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35's routine dose of antidepressant was not discontinued after it was changed to PRN (as needed) and the PRN order did not have a specified end date. This failure had the potential to result in unnecessary medication for Resident 35, which had the potential for increased risk and exposure to side effects associated with psychotropic medications. Findings: During a review of Resident 35's admission record, the record indicated Resident 35 was admitted in January 2025 with diagnoses that included insomnia (trouble falling asleep or staying asleep) and depression (a condition characterized by persistent feelings of sadness, loss of interest, and low energy that interfere with daily life). Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 35 had intact cognition. During a review of Resident 35's physician order, dated 1/12/25, the order indicated, Trazodone [medication used to treat depression] 50 mg [milligrams, a unit of measurement] tablet .Give 0.5 tab via G-tube [gastrostomy tube, a tube that provides access to the stomach] At bedtime for Depression . During a review of Resident 35's physician order, dated 2/9/25, the order indicated, Trazodone 50 mg tablet .0.5 tab G-tube At bedtime as needed For depression . The order further indicated the stop date 00/00/00. During a review of Resident 35's Interdisciplinary Notes, dated 2/7/25, the notes indicated, [Resident 35] noted to have refused routine trazodone at bedtime 4x [four times] this week. [Resident 35] noted to be asking for trazodone later in NOC [night] shift 2x [two times] this week. Faxed MD [Medical Doctor] asking to change routine trazodone to PRN. Awaiting response . During a review of Resident 35's document FAX TO PHYSICIAN, dated 2/7/25, the document indicated, Resident has been refusing 0.5 tab (50mg) Trazodone at bedtime 4x this week. Resident has been asking for Trazodone later in NOC shift. Can we change routine order to PRN? .RESPONSE: OK. Verbal order received 2/9/25. During a review of Resident 35's Interdisciplinary Notes, dated 2/9/25, the notes indicated, .Gave okay to change Trazodone to PRN so [Resident 35] can get at night time when he chooses . During a concurrent interview and record review on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON confirmed Resident 35 had an order for Trazodone PRN. The DON stated, [Resident 35] had a routine before but it was discontinued now [2/13/25], it was clarified with the doctor. The DON confirmed Resident 35's Trazodone PRN order started on 2/9/25 and verified that the order did not have a stop date. During a concurrent telephone interview and record review on 2/13/25 at 3:05 p.m. with the Pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 4 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 0758 Level of Harm - Minimal harm or potential for actual harm Consultant (PC), the PC confirmed Resident 35 had an order for Trazodone 0.5 tab PRN for depression started on 2/9/25 and verified the routine dose was cancelled on 2/13/25. The PC stated, It should have been discontinued when they changed it to PRN .so he doesn't get double the dose .I guess they didn't catch it right away . The PC further stated the PRN order was recently added and stated, .they would need a stop date . to make sure psychotropic use is being monitored. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, revised 7/2022, the P&P indicated, 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .b. Anti-depressants .3 .Psychotropic medication management includes: .b. dose (including duplicate therapy) .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record .a. PRN orders for psychotropic medications are limited to 14 days .(1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 5 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for two of eight residents (Residents 4 and Resident 34). Residents Affected - Some This failure resulted in medications not being given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: 1a. During a review of Resident 4's physician order, dated 1/28/25, the order indicated, .[Metoclopramide HCl] [used to treat nausea and vomiting] - 5 mg (milligrams, a unit of measurement) *via G-tube [gastrostomy tube, a tube that provides access to the stomach]* 3 times a day for gastroparesis [a condition that affects the stomach muscles and prevent proper stomach emptying] . During a medication administration observation on 2/12/25 at 8:29 a.m., Licensed Nurse (LN) 1 administered five medications including Metoclopramide 5 mg by mouth. During a concurrent interview and record review on 2/12/25 at 11:19 a.m. with LN 1, LN 1 verified the order for Metoclopramide was to be given via G-tube and LN confirmed Resident 4 received the medication by mouth. LN 1 stated, [It is] important to make sure there are no interactions, for [Resident 4], the medications can work faster if taken on G-tube. 1b. During a review of Resident 34's physician order, dated 1/29/25, the order indicated, Acetaminophen [used to treat mild to moderate pain] 325 mg tablet .1 tab By Mouth Every 6 hours while awake For pain . During a medication administration observation on 2/12/25 at 11:28 a.m., LN 1 administered three medications including two tablets of Acetaminophen. During a concurrent interview and record review on 2/12/25 at 1:12 p.m. with LN 1, LN 1 verified Resident 34's order indicated to give one tablet of Acetaminophen 325 mg. LN 1 confirmed two tablets of Acetaminophen were given instead of one. 1c. During a review of Resident 34's physician order, dated 2/1/25, the order indicated, Insulin lispro .100 unit/mL [milligrams, a unit of measurement] subcutaneous [under the skin] solution - Inject up to 10 units per sliding scale subcutaneously with meals Subcutaneous 3 times a day . During a medication administration observation on 2/12/25 at 11:28 a.m. with LN 1, LN 1 was observed giving 3 units of Insulin Lispro on Resident 34's left abdomen. No food tray was observed at bedside. During a concurrent interview and record review on 2/12/25 at 1:12 p.m. with LN 1, LN 1 confirmed Resident 34's physician order indicated to give Insulin Lispro with meals. LN 1 confirmed Resident 34 did not have lunch yet and stated, They give snacks in between meals, his numbers are usually high . During an interview on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated, If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 6 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 Residents Affected - Some physician order is to give medication with meals, expectation is for it to be given with meals .if there are any concerns, clarify with the doctor .Medications are to be given as ordered and as scheduled, if to be given outside the schedule, clarify with the doctor. During an interview on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC stated, [The] expectation is to follow specifically what the order says, to maintain some consistency. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 7 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one of 14 sampled residents (Resident 34) when Resident 34's Insulin Lispro (a fast-acting type of insulin - a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered with meals as ordered by the physician. Residents Affected - Few This failure had the potential to result in the drop in Resident 34's blood sugar and the potential for Resident 34 to experience signs and symptoms of low blood sugar. Findings: During a review of Resident 34's admission records, the records indicated Resident 34 was admitted in January 2025 with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 34's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 34 had intact cognition. During a review of Resident 34's physician order, dated 2/1/25, the order indicated, Insulin lispro .100 unit/mL [milligrams, a unit of measurement] subcutaneous [under the skin] solution - Inject up to 10 units per sliding scale subcutaneously with meals Subcutaneous 3 times a day . During a review of Resident 34's care plan, undated, the care plan indicated, [Resident 34] is receiving insulin Lispro .for diabetes .Assess and monitor for s/s [signs and symptoms] of hypo/hyperglycemia [low/high blood sugar] . During a medication administration observation on 2/12/25 at 11:28 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed giving 3 units of Insulin Lispro on Resident 34's left abdomen. No food tray was observed at bedside. During a concurrent interview and record review on 2/12/25 at 1:12 p.m. with LN 1, LN 1 confirmed Resident 34's physician order indicated to give Insulin Lispro with meals. LN 1 confirmed Resident 34 did not have lunch yet and stated, They give snacks in between meals, his numbers are usually high . During an interview on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated, If physician order is to give medication with meals, expectation is for it to be given with meals .if there are any concerns, clarify with the doctor .Medications are to be given as ordered and as scheduled, if to be given outside the schedule, clarify with the doctor. During an interview on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC stated, [The] expectation is to follow specifically what the order says, to maintain some consistency. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . During a review of the facility's P&P titled Insulin Administration, revised 9/2014, the P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 8 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, Purpose .To provide guidelines for the safe administration of insulin to residents with diabetes .3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .Characteristics and Types of Insulin 1. The three key characteristics of insulin are: a. Onset of action how quickly the insulin reaches the bloodstream and begins to lower blood glucose .2. The four types of insulin and their characteristics are: .Type .Rapid-acting .Onset .10-15 minutes . Event ID: Facility ID: 555727 If continuation sheet Page 9 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 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: Residents Affected - Some 1. Expired and discontinued medications were not available for resident use; 2. Expired COVID-19 (a highly contagious respiratory disease caused by a virus) Test Kits were not available for resident use; 3. Opened single-use vial was discarded after use; 4. Medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and, 5. Medication refrigerator was maintained in proper working condition. These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage. Findings: 1. During a concurrent observation and interview on 2/11/25 at 10:49 a.m. with Licensed Nurse 3 (LN 3), an inspection of Station 2 Medication Storage Room identified the following expired and discontinued medications and medical supplies: - 28 Hydrogel absorbent sheet wound dressing (provide a moist environment for wounds to promote faster healing), expired 2/10/25; - Anasept gel antimicrobial skin and wound gel (used to cleanse and prevent infection of minor and serious wounds), 2 tubes expired on 11/1/24 and one tube expired on 10/19/24; and, - 5 Enteral (involves putting food substances or medicine into the digestive system) feeding bags with attached gravity set, expired on 9/8/2024. The LN 3 confirmed the items identified in Station 2 Medication Storage Room were expired and should have been removed from the facility's stock. During an observation on 2/11/25 at 11:37 a.m. in Nurse Station 3, two containers of bleach germicidal (used to kill or prevent the growth of germs) wipes were observed on top of the cart. The containers indicated the wipes were expired on 12/22/24. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with Nursing Supervisor 1 (NS 1), an inspection of Station 3 Medication Storage Room identified one container of expired bleach germicidal wipes with expiration of 2/8/25, and inside the food refrigerator were two yogurts expired 2/2/25 and one yogurt expired 1/1/25. The NS 1 confirmed the items identified in Station 2 Medication Storage Room were expired and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 10 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 should have been removed from the facility's stock. The NS 1 also confirmed the expired bleach wipes in Station 3 and stated, If they are expired, they don't work. During a concurrent observation and interview on 2/11/25 at 2:52 p.m. with LN 3, an inspection of Station 2 Medication Cart identified the following expired and discontinued medications and medical supplies: Residents Affected - Some - 5 Bisacodyl suppository (used to treat constipation), expired 2/10/25; and, - 1 Debrox earwax removal aid (used to soften and loosen excess ear wax) - no open date, expired 11/1/24. The LN 3 confirmed the items identified in Station 2 Medication Cart were expired and should have been removed from the facility's stock. During a concurrent observation and interview on 2/12/25 at 11:37 a.m. with LN 1, an inspection of Station 3 Medication Cart identified the following expired and discontinued medications and medical supplies: - 1 Miralax (used to treat constipation) 26.9 oz bottle, expired on 1/2025; and, - 1 box containing 9 sachets arginaid arginine powder (supplement to support the nutritional needs of people with chronic wounds), expired on 12/4/24. The LN 1 confirmed the items identified in Station 3 Medication Cart were expired and should have been removed from the facility's stock. 2. During an observation on 2/11/25 at 11:32 a.m. in Nurse Station 2, a box of BinaxNOW COVID-19 test kits was observed on top of the cart. The lot number on the box was peeled off and an expiration date of 5/2025 was handwritten on the box. The box contained multiple BinaxNOW test kits and a box of Osang Healthcare (OHC) containing two self-test kits with expiration date of 12/9/23. During a concurrent interview and record review on 2/11/25 at 11:35 a.m. with the Infection Preventionist (IP), a list of COVID-19 test extension of expiration dates was provided by the IP. The list indicated the lot numbers for BinaxNOW with corresponding extended expiration dates. The list did not indicate any lot number with expiration date of 2025. The list further indicated the OHC test kits' lot number was extended until 12/9/24. The IP stated the list provided was the latest list and confirmed the test kits were expired. During an interview on 2/11/25 at 3 p.m. with the Administrator (ADM), the ADM stated the facility received the COVID-19 test kits from another facility during the pandemic. The ADM stated they should have pulled out the expired kits when they received the new stocks. During an interview on 2/13/25 at 11:50 a.m. with the IP, the IP stated, We should not keep expired [medications and supplies], risk of efficacy is affected, not effective anymore and the potential side effects are more increased if they are expired, and they are less effective. During an interview on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated expired medications should be in the destruction area. The DON further stated, If it's expired it should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 11 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 not be given, and we don't want to take the risk for it to be given .Those should be tossed. When asked regarding the expired COVID-19 test kits, the DON stated, We already went through, and we discarded everything that we were not sure off .It can result in incorrect results. During a telephone interview on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC stated, .certain medication, we make sure they are labeled, not expired, we don't want to give resident expired medications. During a review of the facility's policy and procedure (P&P) titled 4.1: STORAGE OF MEDICATIONS, dated 6/2015, the P&P indicated, Procedures .H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .Expiration Dating (Beyond-use dating) .G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner . 3. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with NS 1, an inspection of Station 2 Medication Storage Room identified an undated open single-dose sterile water vial inside the medication refrigerator. NS 1 confirmed the observation and stated the sterile water vial should be labeled with resident name and open date. During an interview on 2/13/25 at 2:17 p.m. with the DON, the DON stated opened vials are expected to be labeled with open date, and single-use vials should be discarded after use. During a review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated, 13. Vials labeled as single dose or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure . 4. During a concurrent observation and interview on 2/11/25 at 10:49 a.m. with LN 3, an inspection of Station 2 Medication Storage Room identified one box of acetaminophen suppositories (administered rectally to treat mild to moderate pain) with peeled resident label. LN 3 confirmed the observation and verified unable to identify the resident on the label. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with NS 1, an inspection of Station 2 Medication Storage Room identified one box of acetaminophen suppositories with peeled resident label inside the medication refrigerator. NS 1 confirmed the observations and verified unable to identify the resident on the label on the box of acetaminophen. The NS 1 stated, We shouldn't rip the label, it should be destroyed, it might be used for residents. During a concurrent observation and interview on 2/12/25 at 11:37 a.m. with LN 1, an inspection of Station 3 Medication Cart identified one box of Culturelle probiotics (used to improve digestion and restore the natural balance of good bacteria in the digestive system) with peeled resident label. LN 1 confirmed the observation and stated, It needs to be thrown out because we don't know who it was for. During an interview on 2/13/25 at 2:17 p.m. with the DON, the DON stated, Once a medication is discontinued, they [staff] store them in the medication room for discarding . During a review of the facility's P&P titled Medication Labeling and Storage, revised 2/2023, the P&P indicated, Medication labeling .1. Labeling of medications and biologicals dispensed by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 12 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .8. If medication containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items . 5. During a concurrent observation and interview on 2/12/25 at 12:07 p.m. with LN 4, an inspection of Station 1 Medication Storage Room identified ice buildup on the medication refrigerator containing flu vaccines. LN 4 confirmed the observation. During a concurrent observation and interview on 2/13/25 at 9:03 a.m. with the DON in Station 1 Medication Storage Room, ice buildup was still observed on the medication refrigerator containing flu vaccines. The DON confirmed the observation. During an interview on 2/13/25 at 2:17 p.m. with the DON, the DON stated, Fridges are not supposed to have ice buildup, it could affect the temperature and cause temperature fluctuations. During a review of the facility's P&P titled Medication Labeling and Storage, revised 2/2023, the P&P indicated, The facility stores all medications, and biologicals in locked compartments under proper temperature, humidity and light controls . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 13 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch on 2/12/25 when four residents (Resident 4, 10, 16, 17) who were on Pureed (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) received 1/4 cup serving of meat instead of 1/2 cup of meat as indicated on the menu. This failure had the potential to result in compromising the medical and nutrition status of the four residents. Findings: During an observation of lunch meal service on 2/12/25 beginning at 11:39 a.m., the following was observed: Residents 4, 10, 16, 17 who were on a pureed diet, received 1/4 cup of pureed chicken. A concurrent review of the facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, WEEK 2 EXTENDED MENUS, WEDNESDAY WEEK 2 indicated that residents on pureed diet should have received 1/2 cup of pureed chicken. During an interview on 2/12/25 at 11:42 a.m. with Dietary Manager (DM), DM confirmed the blue scoop used to serve pureed chicken during lunch that day was equivalent to 1/4 cup. During a follow up interview on 2/14/25 at 10:00 a.m. with DM, DM acknowledged that not following the menu can affect residents nutrition. During a review the facility's policy and procedure (P&P) titled, Food Preparation and Timing dated 1/1/18, indicated, .Food preparation begins with menu. It should be followed to ensure that adequate nutrients are being served . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 14 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 16) received nectar thickened liquids as ordered by the physician, when Resident 16 was served thin liquids by Certified Nursing Assistant (CNA 2). This failure had the potential for Resident 16 to experience aspiration (accidental inhalation of food or fluids into the airways or lungs) and choking. Findings: During a review of Resident 16's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 16 was admitted to the facility May 2024 with multiple diagnoses which included pneumonia (an infection/inflammation in the lungs). During a review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/4/24, the MDS indicated Resident 16 had difficulty swallowing and required a mechanically altered diet (change in texture of food or liquids). During a review of Resident 16's physician's orders, dated 9/17/24, the physician's orders indicated, .DIET .Nectar Thick Liquids . During a review of Resident 16's care plan, undated, the care plan indicated, .Resident is at nutritional risk .approach .diet as ordered . During a concurrent observation, interview, and record review on 02/11/25 at 12:24 p.m., Resident 16 was having lunch in the main dining hall. Resident 16 was drinking a glass of regular water and coughing between sips. The tray ticket on Resident 16's tray indicated Resident 16 was on a pureed diet with nectar thickened liquids. Certified Nursing Assistant 2 (CNA 2) confirmed Resident 16 should not have been given regular water. CNA 2 stated, I am sorry. I placed the regular water at each station at the start of the meal and forgot to take hers (Resident 16) away. I did bring her nectar thickened apple juice, that she already drank, but I forgot to come back and take the water away. During an interview on 2/14/25 at 9:35 a.m. with the Director of Nursing (DON), the DON stated the expectation was for all diet orders to be followed (therapeutic and textured). The DON acknowledged there was a risk for aspiration if textured diet orders were not followed. During a review of the facility's policy and procedure ( P&P) titled, Therapeutic Diets, revised October 2017, the P&P indicated, .a 'therapeutic diet' is considered a diet ordered by a physician .as part of treatment for a disease or clinical condition .for example .altered consistency diet . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 15 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: Residents Affected - Some 1. An ice machine was not clean; 2. Refrigerated food and a nutritional shake were not labeled with open, prepared, use by, or expiration dates; and, 3. The concentration of the sanitizer solution for a sanitation solution (red) bucket was less than 200 ppm. These failures had the potential to cause food-borne illness in a highly susceptible population of 31 of 31 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 2/11/25 at 8:16 a.m. with Director of Dietary Services (DDS), during the initial kitchen tour, an ice machine was observed to have dark stains resembling rust in a compartment directly next to ice bin, white matter on the exterior of the ice machine, and white debris in the ice scoop container. The DDS stated that an outside vendor is responsible for maintenance of the ice machine and the ice machine was serviced last week. During an interview on 2/14/25 at 10:00 a.m. with the Dietary Manager (DM), DM confirmed rust inside inner compartments, white stains outside the ice machine, and debris inside ice scoop container. DM stated that an outside vendor was responsible for maintenance of the ice machine every 6 months. DM further stated facility staff were responsible for cleaning the ice machine weekly. DM acknowledged the expectation was for the ice machine to be clean including the ice scoop container. During a review of the facility's policy and procedure (P&P) titled, Cleaning procedure #24- Ice Machine, undated, the P&P indicated, .ICE SCOOP .Keep it protected from contamination . During a review of the ice machine's service manual, dated 6/18, the service manual indicated, .Clean and sanitize the ice machine every six months for efficient operation .if the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . 2. During a concurrent observation and interview on 2/11/25 at 8:27 a.m. with Dietary Supervisor (DS) and DM, during the kitchen's initial tour, an open tray of pasteurized eggs was not labeled with a received, opened, or use by date. DS confirmed the tray of eggs was not labeled. During a concurrent observation and interview on 2/11/25 at 10:49 a.m. with Licensed Nurse 3 (LN 3), there were two plates of dessert from the kitchen, in the Station 2 refrigerator. The food was not labeled with a prepared or use by date. LN 3 stated the food should have been labeled with a name and date. LN 3 further stated food could be spoiled if there was no date or wrong resident could have the received food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 16 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 During a concurrent observation and interview on 2/13/25 at 10:33 a.m. with LN 1, there was an open carton of nutritional shake in the Station 3 refrigerator. The opened nutritional shake was not labeled with a use by date. LN 1 confirmed the nutritional shake did not have a use by date. LN 1 further stated she was not sure how long the shake could be kept once it was opened. During an interview on 2/14/25 at 10 a.m. with DM, DM acknowledged that food that was not properly labeled can be a risk for expired food being served to residents. During a review of the facility's P&P titled, Food storage revised 1/1/18, the P&P indicated, .All open food items will have an open and use-by-date . During a review of the facility's P&P titled, Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods revised 1/1/18, the P&P indicated, .foods produced in the community should be dated with day one .and discarded on or before the 7th day . 3. During a concurrent observation and interview on 2/11/25 at 8:37 a.m. with DM, during the kitchen's initial tour, a red sanitation bucket did not have the appropriate sanitizer solution. DM tested the solution in the red sanitation bucket. The solution tested below 200 ppm (parts per million). Dietary Aide 1 (DA 1) stated she prepared the solution with a mixture of soapy water and Quaternary ammonia solution (disinfectant). DM stated the concentration range for red bucket sanitizer solution should be 200-400 ppm and should not be mixed with soapy water. During an interview on 2/12/24 at 10:29 a.m. with [NAME] 1 (CK 1), CK 1 confirmed that he used the red sanitation bucket that had the diluted Quaternary ammonia solution to clean food preparation area. During an interview on 2/14/25 at 10 a.m. with DM, DM acknowledged the facility used Quat ammonia solution and not maintaining solution at an effective level was a risk for food contamination. During a review of the facility's P&P titled, Sanitizer Bucket for Cleaning Cloths revised 11/1/21, the P&P indicated, .Sanitizer buckets are filled with .appropriate sanitizer at a high concentration .Quat ppm at 200 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 17 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 33 when: Residents Affected - Some 1. Unlabeled and undated jug of distilled water used for CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) was observed on the floor at Resident 13's bedside; 2. Coffee mug was observed on a commode seat in Resident 31's bathroom; 3. Blood pressure (BP) cuff was not disinfected after use between residents (Resident 139, Resident 2, Resident 188, and Resident 4); 4. BP cuff and BP machine was not disinfected with appropriate disinfectant; 5. Dust particles were observed on the exhaust in the clean linen room in the laundry area; 6. Dirt and black stagnant water was observed on the drain at the back of washers in the laundry area; 7. Resident 4, who used a CPAP, had an opened and unlabeled bottle of distilled water on his nightstand; and 8. Resident 5, who had a chronic pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), was not on Enhanced Barrier Precautions (EBP- a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MRDOs]). These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and potential exposure to these residents. Findings: 1. During a review of Resident 13's admission record, the record indicated Resident 13 was admitted in [DATE] with diagnoses that included sepsis (a life-threatening blood infection) and obstructive sleep apnea (intermittent airflow blockage during sleep. Resident 13's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 13 had moderate cognitive impairment. During a review of Resident 13's physician order, dated, [DATE], the order indicated, C-PAP machine Apply at bedtime and OFF in AM [morning] For Sleep apnea . During a review of Resident 13's care plan, undated, the care plan indicated, [Resident 13] Utilizes Continuous Positive Airway Pressure (CPAP) for COPD [chronic obstructive pulmonary disease, a chronic lung disease causing difficulty in breathing] .Monitor proper functioning of the device and make sure its [sic] clean . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 18 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 - Some During a concurrent observation and interview on [DATE] at 9:13 a.m. with Resident 13 in his room, an unlabeled and undated jug of open distilled water used for CPAP was observed on top of the nightstand. Resident 13 stated he does not use CPAP very often and cannot remember when the last use was. During an observation on [DATE] at 3:13 p.m. in Resident 13's room, a jug of unlabeled and undated open jug of distilled water was observed on the floor on the side of the nightstand. During an interview on [DATE] at 9:38 a.m. with Licensed Nurse (LN) 4, LN 4 stated CPAP machines are filled with distilled water. LN 4 stated jugs are labeled to know when it was opened and if it can still be used. LN 4 stated, .we don't know if it was two months already. During a concurrent observation and interview on [DATE] at 9:44 a.m. with LN 4 in Resident 13's room, an opened, unlabeled and undated jug of distilled water was observed on the floor on the side of the nightstand. LN 4 confirmed the observation and stated, [Staff] usually label it .It should not be on the floor. During an interview on [DATE] at 11:50 a.m. with the Infection Preventionist (IP), the IP stated distilled water should be labeled with the resident's name and anything for therapeutic purposes have an open date to know how long it has been used. The IP further stated jugs of distilled water are not placed on the floor for infection control. During an interview on [DATE] at 2:17 p.m. with the Director of Nursing (DON), the DON stated any fluids should be dated upon opening so staff will know when to discard them. During a review of the facility's policy and procedure (P&P) titled CPAP/BiPAP [Bilevel Positive Airway Pressure, a breathing support therapy to deliver oxygen under positive pressure] Support, revised 3/2015, the P&P indicated, 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber . 2. During a review of Resident 31's admission record, the record indicated Resident 31 was admitted in [DATE] with diagnoses that included cerebral infarction (blood flow to the brain is interrupted, causing brain tissue to die), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and unsteadiness on feet. Resident 31's MDS indicated Resident 31 was cognitively intact. During an observation on [DATE] at 10:08 a.m. in Resident 31's bathroom, a mug with a small amount of coffee was observed on top of the commode seat. During a concurrent observation and interview on [DATE] at 10:10 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 31's bathroom, CNA 3 confirmed the mug was on top of the commode seat and stated she put it there and forgot to take it. CNA 3 stated, It is important not to do that because of hygiene. During an interview on [DATE] at 11:50 a.m. with the IP, the IP stated coffee mugs are taken out to be washed once the resident was done with it. When a photo of the mug on the commode seat was shown, the IP stated, That's not supposed to be there .That is considered contaminated. The IP added that it was a hazard and an infection control issue and stated, It's definitely contaminated .that's not acceptable to me. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 19 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 - Some During a review of the facility's P&P titled Infection Prevention and Control Program, revised 12/2023, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 3. During a medication administration observation on [DATE] at 7:34 a.m. with LN 1, LN 1 was observed checking Resident 139's blood pressure before giving medications. After obtaining the blood pressure, LN 1 removed the cuff from Resident 139's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During a medication administration observation on [DATE] at 7:49 a.m. with LN 1, LN 1 was observed checking Resident 2's blood pressure before giving medications using the same blood pressure cuff and machine used for Resident 139. After obtaining the blood pressure, LN 1 removed the cuff from Resident 2's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During a medication administration observation on [DATE] at 8:08 a.m. with LN 1, LN 1 was observed checking Resident 188's blood pressure before giving medications using the same blood pressure cuff and machine used for Resident 139 and Resident 2. After obtaining the blood pressure, LN 1 removed the cuff from Resident 188's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During a medication administration observation on [DATE] at 8:14 a.m. with LN 1, LN 1 was observed checking Resident 4's blood pressure before giving medications using the same blood pressure cuff and machine used for Resident 139, Resident 2, and Resident 188. After obtaining the blood pressure, LN 1 removed the cuff from Resident 4's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During an interview on [DATE] at 8:36 a.m. with LN 1, LN 1 stated bleach wipes are used to disinfect blood pressure cuffs in between residents. LN 1 confirmed the blood pressure cuff was not disinfected in between residents during the medication pass observation and stated, [It is] important to prevent cross contamination. During an interview on [DATE] at 11:50 a.m. with the IP, the IP stated, We disinfect equipment before and after use in between residents, we have sanitizing wipes on all stations . During an interview on [DATE] at 2:17 p.m. with the DON, the DON stated the expectation was to disinfect blood pressure cuffs between each resident to not spread potential infection. During a review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/2022, the P&P indicated, 5. Reusable items are cleaned and disinfected or sterilized between residents . 4. During a medication administration observation on [DATE] at 9:17 a.m. with LN 2, LN 2 was observed disinfecting the blood pressure cuff and machine with hand sanitizer wipes before checking Resident 11's blood pressure after using it from another resident. During an interview on [DATE] at 12:18 a.m. with LN 2, LN 2 confirmed she used the hand sanitizer wipes and stated she should have used the manufacturer-approved disinfectant wipes. LN 2 further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 20 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 - Some stated, [It is] important because that wipe [manufacturer-approved disinfectant wipe] is used to kill bacteria on equipment and the wipe that was used do not. During an interview on [DATE] at 11:50 a.m. with the IP, the IP stated hand sanitizer wipes are used for residents' hands before and after eating. The IP stated, If it's not according to manufacturer's directions, it should not be used. During an interview on [DATE] at 2:17 p.m. with the DON, the DON stated the expectation was to disinfect equipment using the manufacturer-approved wipes. During a review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/2022, the P&P indicated, (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches .(3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA [Environment Protection Agency]-registered disinfectant labeled for use in healthcare settings . 5. During a concurrent observation and interview on [DATE] at 12:58 p.m. with the Lead Housekeeper (LHS) in the clean linen area of the laundry room, dust particles were observed on the exhaust and the LHS confirmed the observation. During a concurrent observation and interview on [DATE] at 9:31 a.m. with the Maintenance Coordinator (MC) in the clean linen area of the laundry room, dust particles were still observed on the exhaust. The MC confirmed the observation and stated that it should be clean. During an interview on [DATE] at 11:50 a.m. with the IP, when a photo of the exhaust was shown, the IP stated, .the likelihood [of the dust falling] was less likely but nevertheless, it should also be clean, the function is lesser if it's full of dust, and by gravity, it could fall. The IP further stated, .vents should be clean, not just for the linen but also for the people working there [laundry area]. During a review of the facility's P&P titled Departmental (Environmental Services) - Laundry and Linen, revised 1/2014, the P&P indicated, 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination . 6. During a concurrent observation and interview on [DATE] at 12:58 p.m. with the LHS in the washer area of the laundry room, dirt and black stagnant water was observed on the drain at the back of the washers and the LHS confirmed the observation. During an interview on [DATE] at 9:31 a.m. with the MC, the MC stated he cleaned the drain yesterday [[DATE]] after being notified about it. The MC stated, .it probably not supposed to look like that. During an interview on [DATE] at 1:28 p.m. with the IP, the IP stated the drainage in the washer room was not included in the monitoring for Legionella (a bacteria commonly found in water) because there was no report or any problem. The IP stated, I did not see the drainage, I did not know any open drainage. The IP further stated, We need to update the water management areas .that's definitely a water management issue .We missed that one .we don't want any stagnant water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 21 of 22 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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 - Some During a review of the facility's P&P titled Departmental (Environmental Services) - Laundry and Linen, revised 1/2014, the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . 7. During a review of Resident 4's face sheet (contains a summary of basic information about the resident), the face sheet indicated, Resident 4 was admitted to the facility [DATE] with multiple diagnoses which included pneumonia (an infection/inflammation in the lungs). During a review of Resident 4's Physician's Orders, the Physician's Orders indicated Resident 4 had a CPAP and needed assistance with CPAP. During a concurrent observation and interview on [DATE] at 10:03 a.m., an open bottle of distilled water was on Resident 4's nightstand next to the CPAP machine. The bottle was not dated with an open or use by date. Resident 4 stated that he used the CPAP at night and is not sure how long the open bottle of distilled water had been there. During an interview on [DATE] at 9:38 a.m. with Licensed Nurse (LN) 4, LN 4 stated CPAP machines are filled with distilled water. LN 4 stated jugs are labeled to know when it was opened and if it can still be used. During an interview on [DATE] at 9:35 a.m. with Director of Nursing (DON), DON stated the expectation is for open bottles of distilled water to be labeled with open and use by date. DON acknowledged risk for resident to use expired distilled water if open bottles are not labeled. During a review of the facility's policy and procedure (P&P) titled CPAP/BiPAP [Bilevel Positive Airway Pressure, a breathing support therapy to deliver oxygen under positive pressure] Support, revised 3/2015, the P&P indicated, 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber . 8. During a review of Resident 5's face sheet, the face sheet indicated, Resident 5 was admitted to the facility February 2019 with multiple diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 5's skin evaluation form, dated [DATE], the skin evaluation form indicated Resident 5 had a pressure injury to her left buttock from [DATE] and needed treatment. During an observation on [DATE] at 3:35 p.m., enhanced barrier precautions (EBP, infection control measures) were not in place for Resident 5 including signs on the door or outside Resident 5's room and personal protective equipments (PPEs) were not readily available outside Resident 5's room. During an interview on [DATE] at 9:35 a.m. with DON, DON stated EBP should be observed for residents at high risk for infection including pressure ulcers. During a review of the facility's P&P, titled Enhanced Barrier Precautions, revised [DATE], the P&P indicated, .EBP's are indicated .for residents with wounds .wound generally include chronic wounds .i.e., pressure ulcers .signs are posted in the door or wall outside residents room indicating the type of precautions and PPE required .PPE is available outside of the residents rooms . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 22 of 22