Health inspection·April 13, 2023

F 0550 Check mouth for residual food and remove it as needed, Level of Harm - Minimal harm or potential for actual harm Remain upright for 30 minutes after a meal. Residents Affected - Few During a concurrent observation and interview on 4/10/23, at 1:05 p.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 14's room, LVN3 stated the precautions above Resident 14's bed was not covered because it was a reminder to nursing staff, particularly for new direct care staff. LVN 3 stated care instructions should be covered to provide privacy from visitors. During a review of the facility's Policy and Procedure (P&P) titled Quality of Life, dated October 2009, the P&P indicated, residents shall be treated with dignity and respect at all times and Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 - Few 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 reconcile controlled substances (a drug subject to special handling, storage, and disposal because of its potential for abuse or addiction) for one of 51 residents (Resident 37). This failure had the potential for the loss or diversion of controlled substances. Findings: During a concurrent observation and record review on 4/11/23, at 11:17 a.m., with RN 1, Resident 37's Controlled Drug Record (CDR) for morphine sulfate (a controlled medication used for moderate to severe pain) 0.25 ml (milliliters - a unit of measurement), dated 4/4/23, was reviewed. The CDR indicated as follows: 4/4/23; PM; 0.25ml; 16 ml remaining. An observation of morphine bottle container showed, 14 ml remaining. During a subsequent interview with RN 1, RN 1 stated the amount remaining in the morphine bottle did not match the CDR. RN 1 further added, she did not do narcotic count with the going off duty nurse. During an interview on 4/12/23, at 1:27 p.m., with the Director Of Nursing (DON), DON confirmed Resident 37's morphine bottle did not match the CDR. DON also stated, going off duty nurse and coming on duty nurse were expected do narcotic count to ensure narcotics remaining in the pack/container are accurate. During a review of Resident 37's admission record dated 4/12/23, the admission record indicated Resident 37 was admitted to the facility 11/22 with multiple diagnoses that included Personal History of Malignant Neoplasm of breast (cancer). The admission record also indicated, Resident 37 was on Palliative Care (medical care treatment for people with serious illness). During a review of Resident 37's Order Summary Report, dated 4/12/23, the order summary report indicated a physician's order for Morphine Sulfate (concentrate) Solution 20 mg/ml Give 0.25 ml by mouth every 4 hours as needed . During a review of the facility's policy and procedures (P&P) titled, Controlled Substances, dated 12/2012, the P&P indicated, 9. Nursing staff must count controlled medications at end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 store and label medication in accordance with standards of practice by failing to date three open bottles of medications (sodium chloride, milk of magnesia and bismuth subsalicylate), and one open container of blood sugar test strip for two of three medication carts inspected. This failure had the potential to result in medications and test strip used to not be effective. Findings: During a concurrent observation and interview of medication cart 3 on 4/11/23, at 10:40 a.m., with LVN 2, LVN 2 pulled from medication cart drawer one bottle of sodium chloride (salt - an essential compound a body uses to function) and one container of blood sugar test strip (the strip work with glucose meters to read blood sugar levels) had no open date. LVN 2 stated, the standard practice was to date the bottles right away. During an interview on 4/12/23, at 1:45 p.m., with the Director of Nursing (DON), DON stated, medication bottles including blood sugar test strip should be labeled immediately with open date because medications can go bad within certain time they were open. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 12/2012, the P&P indicated, 9.When opening a multi-dose container, the date opened shall be recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure kitchen staff were competent in job duties related to: Residents Affected - Many 1. using the three compartment sink; 2. testing the sanitizer liquid in the red sanitization bucket; and 3. cleaning the juice machine. These failures have the potential for improper cleaning and sanitization which could lead to increased risk for food-borne illness for 45 residents who received food from the kitchen out of a facility census of 51. Findings: 1. During a concurrent observation and interview on 04/11/23, at 09:37 a.m., with Utility Worker (UW) and the Food and Nutrition Services Director (FNSD) in the kitchen dishwashing area, FNSD stated the 3-compartment sink is a back-up for washing dishes if the dish machine did not work. She stated UW was a dishwasher and would be responsible for cleaning dishes in the 3-compartment sink if needed. UW stood in front of the 3-compartment sink and spoke to how she would clean dishes and utensils in the sink. On the wall, above the 3-compartment sink, was a sign with directions on sink use. UW stated if dishwasher was not working, she would use three compartment sink. UW stated she would wash in sink number one, rinse in sink number two, then soak in sanitizer solution for 15 seconds in sink number three. The sign above the sink indicated soaking in sanitizer solution for 1 minute. A review of facility's Utility Worker's Job Description dated May 2020, showed the Utility Worker performs a number of kitchen duties including dishwashing and pot/pan washing. During an interview on 04/12/23, at 02:05 p.m., with Registered Dietician (RD), RD stated when using three compartment sink, kitchen equipment should be soaked in sanitizer solution for 1 minute per the sanitizer manufacturer's guidelines. During a review of document titled Warewashing Solutions [brand name of quaternary ammonium sanitizer], dated 2017, indicated in the directions [ .]2. Expose all surfaces of equipment, ware, or utensils to the sanitizing solution for not less than one minute.[ .] 2.During a concurrent observation and interview on 04/11/23, at 09:50 a.m., with [NAME] 2 and FNSD in the kitchen, [NAME] 2 stated he was responsible for filling red buckets with sanitizer solution. He demonstrated how he filled up the bucket and stated one of the steps was to test the solution strength with a sanitizer-testing strip. He was observed testing the sanitizing solution in a red sanitization bucket. [NAME] 2 was observed removing a test strip from a quaternary ammonium (a type of sanitizer) test strip container and then held the test strip in the solution for 17 seconds. He compared the color of the test strip against the color chart inside the test strip container and stated the strip showed a strength of 200 ppm (parts per million; concentration of sanitizer in water). [NAME] 2 stated he should have held the test strip for 15 seconds. Another test strip was held in the solution for 10 seconds and compared to the color chart. FNSD confirmed when the test strip was held in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 0802 the solution for 10 seconds, the strip showed the solute was 150 ppm. Level of Harm - Minimal harm or potential for actual harm A review of the manufacturer's instruction insert located inside the quaternary ammonia test strip container indicated Dip paper in quat solution .for 10 seconds. Residents Affected - Many Review of the document titled Sanitation Buckets dated 2019, showed all surfaces and equipment should be washed and then sanitized with a sanitizing solution. Sanitizing buckets must be established with appropriate sanitizing solution concentration, then the concentration range is to be tested. 3. A review of facility's Diet Aid job description dated August 2016, indicated principle duties for a Diet Aid includes [ .]Maintains station equipment and work area in a safe and sanitary conditions.[ .] During an interview on 04/12/23 at 09:20 a.m, with Dietary Aid (DA2) and Food Nutrition Services Director (FNSD), DA 2 stated the juice machine was cleaned every PM (afternoon/evening) shift, she sometimes works PM shift and was responsible for cleaning the juice machine. DA 2 stood in front of the juice machine and described her cleaning process. She stated she takes the nozzles off, cleans them with a brush and quaternary ammonium (a sanitizer solution), then reattaches the nozzles. FNSD stated the person cleaning the juice machine also soaked the nozzles in sanitizer solution overnight, then reattached the nozzles in the morning. FNSD stated there are no written instructions on how to clean the machine. During a concurrent observation and interview on 04/12/23, at 02:05 p.m., in the kitchen at the juice machine, with FNSD and Registered Dietician (RD), written instructions were observed inside the cover of the juice machine. FNSD stated written instructions are located inside the cover. A review of the machine cleaning instructions showed the daily cleaning included a water flush which showed to hold the flush button for 6-8 seconds. The daily cleaning instructions also showed to remove the rubber nozzle covers and Lift out rubber nozzle cover. Clean nozzle and nozzle cover with hot water, then sanitize, and rinse. FNSD confirmed when DA 2 was describing how she cleaned the juice machine, she did not describe using the water flush and she did not use hot water to clean the nozzles as described on the cleaning instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure menu was followed when one of 51 residents (Resident 4) was given pureed broccoli instead of minced and moist broccoli. Residents Affected - Few This failure has the potential for one of 51 residents to not get the type of food texture as indicated on the planned menu which could compromise the resident's intake of food and nutritional status. Findings: A review of the cook spreadsheet menu titled Daily Spreadsheet dated for 4/11/23, and used for lunch, the spreadsheet indicated a minced and moist diet receives minced and moist (food cut into very small pieces, less than 1/8 inch pieces; minimal chewing is required) seasoned broccoli florets. A review of Resident 4's diet card, dated 04/12/23, indicated [ .]3) Minced and most or mashed chilled steamed vegetables [ .]. During a concurrent observation and interview on 04/11/23, at 11:46 a.m., at tray line, Dietary Aide (DA 1) was looked at tray tickets and called out diets to [NAME] 1. [NAME] 1 then placed hot food on resident plates according to the diet DA 1 called out. [NAME] 1 was observed serving one scoop of pureed (food that is blended into smooth texture that does not require chewing) broccoli to Resident 4's tray. When the surveyor asked DA 1 if Resident 4 was supposed to receive pureed broccoli, DA 1 stated Resident 4 received the incorrect broccoli texture, that it should have been minced and moist instead of puree but did not notify [NAME] 1 that the incorrect texture was provided to the resident. When [NAME] 1 was questioned, she stated minced and moist diet should get pureed broccoli and did not consult menu spreadsheet which was available for reference. During a review of facility's policy and procedures titled Trayline Setup and Service, dated 07/02/18, indicted [ .]5. According to the diet called, the main plate is served .therapeutic spreadsheets are posted on trayline and are followed. [ .]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food safely when: Residents Affected - Many 1. Meat was not thawed according to storage guideline dates; 2. kitchen staff did not follow appropriate hand hygiene and glove use procedures when going between and handling dirty dishes and clean dishes; 3. Three out of 5 storage bins for bulk dry goods had crumbling plastic liners; 4. Four out of 12 pairs of tongs and 1 ladle had cracked handles; 5. 2 of 2 Ice machines in the kitchen and nourishment room had rough, discolored surfaces on ceiling of the ice bin where ice was stored; and 6. Food in resident's refrigerator was undated for one out of 2 residents (Resident 14) and food was kept more than 3 days for one out of 2 residents (Resident 351). These failures has the potential of placing the 45 residents who received food from the kitchen at risk for foodborne illnesses out of a census of 51. Findings: 1. During a concurrent observation and interview on 04/10/23, at 09:54 a.m., with Sous Chef (SC) and Food and Nutrition Services Director (FNSD), in the walk-in refrigerator, one box of boneless chicken thighs with a delivery date of 4/3/23 was on the bottom shelf and noted to be soft (thawed). SC confirmed delivery label on chicken thighs was 4/3/23. There was also a case of boneless chicken breast with a label showing received 4/6 the chicken was soft (thawed), a closed case of beef tenderloin showing a receive date of 4/6, a 7-pound package of pork butt with a receive date of 4/6; a package of Italian ground sausage with a receive date of 4/6, and an opened package of raw Italian sausage in a plastic container with a hand written date on the container showing 4/7/23 - 4/17/23. FNSD stated the date on the opened Italian sausage was incorrect and should be dated 4/7/23-4/10/23. SC confirmed the delivery dates on the chicken breast, beef tenderloin, pork butt, and Italian sausage was 4/6. He stated all of the meat was delivered fresh and not frozen and was put directly into the FNSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 stated kitchen gets foods delivery two times a week, Tuesdays and Fridays. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/10/23 at 11:47 a.m., the meat delivery invoice was reviewed with FNSD. The invoice showed the fresh meat observed in the refrigerator with delivery dates of 4/6 was delivered on 4/7/23 and the meat was delivered fresh not frozen, including the boneless chicken breast, beef tenderloin, and pork butt. Residents Affected - Many During a concurrent interview and record review on 04/10/23, at 1:19 p.m., with Food and Nutrition Services Director (FNSD), Refrigerated Storage Chart, dated May 2016, was reviewed. The Refrigerated Storage Chart indicated meats may be left in distributer packaging for refrigerator storage and fresh chicken (raw) can be stored up to two days, and fresh ground meat and stew meat can be stored for one to two days. During an interview on 04/12/23, at 12:15 p.m., with Registered Dietician (RD), RD stated her expectations for thawing meat, for example chicken, if the meat comes in fresh, it should go into the refrigerator and be used within 1-2 days. During a review of facility's policy and procedure titled, Food Storage, dated 04/06/23, indicated [ .]4. Hamburger and fresh chicken should be cooked within one to two days of purchase .[ .]. 2. During a concurrent observation and interview on 04/11/23 at 10:00 a.m., in the kitchen, with the FNSD and Utility Worker (UW), UW loaded used dishes and trays from the resident breakfast into the dishwashing machine. Then UW removed the cleaned dishes and trays from the clean dishes and trays from the dishwashing machine without changing gloves or washing hands in between handling the dirty and clean dishes and trays. FNSD stated UW should have removed her gloves and washed hands when going from dirty dishes to clean dishes. FNSD stated her expectation is also for staff to wash hands before glove changes. During a review of facility's policy and procedure titled Handwashing and Glove Use, dated 04/15/2020, showed hands must be washed following contact with any unsanitary surface. When gloves are used, handwashing must occur prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed. Gloves may only be used for one task. Review of the document titled Dishwashing Procedure revised 8/31/2018, showed when two people are in the dish room, on the dirty side, and one on the clean side. If one person does both (dirty and clean side), they must wash their hands between dirty and clean areas. 3. During a concurrent observation and interview on 04/10/23 at 10:27 a.m., in the kitchen, with FNSD, three bulk dry good storage containers were filled and labeled thickener, sugar, and panko (breadcrumbs). Each container was lined with a white plastic bag. Portions of the bags on the internal space of the containers were torn, cracked, and crumbling. FNSD confirmed portions of the bags were torn, cracked, and crumbling. A review of the FDA Food Code, dated 2022, indicated Food packages shall be in good condition and protect the integrity of the contacts so that the food is not exposed to adulteration or potential contaminants. Federal Food Safety Code also indicated food shall be protected from contamination by storing the food in a clean location that is not exposed to dust or other contaminants. 4. During a concurrent observation and interview on 04/10/23, at 10:25 a.m., in the kitchen, with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 - Many Food and Nutrition Services Director (FNSD), serving utensils were observed in a clean storage area. There were four pairs of tongs and one ladle with handles with a plastic coating. The coating on handles were cracked, uneven, and rough. FNSD confirmed handles that were cracked could be hard to clean effectively. A review of the FDA Food Code, dated 2022, indicated Contact Surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 5. On 04/11/23, at 9:11 a.m., in the kitchen, the ice machine was observed with the Maintenance Supervisor (MS 1). The ceiling of the interior ice storage bin had a rough, yellow/brown discolored surface surrounding the ice chute (where formed ice entered into the ice bin). MS 1 confirmed there was a rough, discolored surface on the ceiling inside the ice machine bin. During an observation on 04/11/23, at 9:21 a.m., in the nourishment room, the ice machine was observed with MS 1. The ceiling of the interior ice storage bin had a rough, yellow/brown discolored surface surrounding the ice chute. MS 1 confirmed there was a rough, discolored surface. A review of the FDA Food Code, dated 2022, indicated Nonfood-contact surfaces that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbable, and smooth material. 6. During a concurrent observation and interview with the Infection Preventionist 1 (IP 1) on 04/10/23, at 12:18 p.m., in the Resident Nourishment Room located at the nursing station, showed a freezer/refrigerator with food stored inside. There was one opened jar with purple liquid with a hand written label that showed smoothie with Resident 14's name. There were also 2 plastic reusable containers inside a plastic bag. The reusable containers had a hand written label on the lids which showed 4/4/23 and Resident 351's name. The reusable containers contained cooked food which resembled mashed potatoes with butter in one container and 3 meatballs with sauce in the other container. IP 1 confirmed there was no date on the smoothie jar to show when it was placed in the refrigerator. She also confirmed food could only be stored for 3 days. She stated the NOC (night) shift was responsible for discarding food after 3 days. The procedure posted on the refrigerator door showed all food brought by family will be thrown after 48 hours. During an interview on 04/11/23, at 9:14 a.m., with FNSD, FNSD stated either she or the nurses will remove food from the resident's refrigerator every 3 days. During a review of facility's policy and procedure titled Food From Outside Sources, dated 2020, the policy indicated 4 .Perishable food should be sealed and dated with a use-by date and placed in refrigeration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to ensure infection control practices were implemented when the following was noted for eight of eight residents: Residents Affected - Many 1. An unlabeled bedpan and basin were observed in the shared bathroom of Residents 14 and 34. A yellow basin labeled for Resident 34 was on the floor in the Resident's shared bathroom. 2. Resident 34's feeding pump had tannish-brown residue in the tubing channel and flaky, light brown residue on the base of the pole. 3. Resident 17's wheelchair had torn armrests and dried, flaky reddish-brown matter and white staining on the seat and in the metal frame. 4. The facility did not have appropriate isolation precaution signage for four of four sampled residents (2, 21, 100 and 349). 5. Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) did not perform hand hygiene and or change gloves during peri-care for Resident 8. These failures placed the facility's residents at risk for healthcare-associated infections. Findings 1. During a review of facility's admission Record for Resident 14, dated 4/12/23, Resident 14 was readmitted 11/22 after a hospitalization. During a review of Resident 14's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section G showed Resident 14 required extensive assistance by staff for personal hygiene and toileting. Section H showed Resident 14 was incontinent of bowel and bladder. During a review of facility's admission Record for Resident 34, dated 4/12/23, Resident 34 was admitted 7/22. During a review of Resident 34's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section G showed Resident 34 was totally dependent on two or more staff for personal hygiene and toileting. Section H showed Resident 34 was incontinent of bowel and bladder. During an observation on 4/10/23, at 10:50 a.m., in Resident 14 and 34's shared bathroom, a gray unlabeled bedpan and gray unlabeled basin were sitting in the rack on the wall between the toilet and the sink. A yellow basin was sitting on the floor. During a concurrent observation and interview on 4/10/23, at 1:13 p.m., with Licensed Vocational Nurse 3 (LVN3), in Resident 14 and 34's shared bathroom, LVN 3 stated the basins were used for bed baths. LVN 3 discarded the unlabeled bedpan. LVN 3 a discarded the gray basin, LVN3 stated was unlabeled and could not determine which resident it was used for. LVN 3 took the labeled basin from the floor and placed it in the holder on the wall. LVN 3 stated should discard it and then threw it away. LVN 3 stated unlabeled basins and bedpans could not be used on more than one resident because it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 - Many an infection control risk, as well as with the basins touching the floor. LVN 3 also stated it could cause UTI or other infections if germs on basins touched the residents. During a review of the facility's policy and procedure titled Cleaning and Disinfecting of Resident Care Items and Equipment dated 11/23/21, indicated only equipment that is designated reusable shall be used by more than one resident and single resident-use items, which are cleaned/disinfected between uses by a single resident and disposed of afterwards, include bedpans. 2. During an observation on 4/10/23, at 10:53a.m., in Resident 34's room, observed a tannish-brown residue in the tubing channel Resident 34's feeding pump. Also observed dry, flaky, beige residue on the base of the feeding pump pole. During a concurrent observation and interview on 4/10/23, at 1:13 p.m., with LVN 3, in Resident 34's room, LVN 3 stated the feeding pump residue was from the feeding formula. LVN 3 stated the nursing staff cleaned feeding pump once a week with a Sani-Cloth (a disposable pre-moistened disinfecting wipe). LVN 3 stated nursing was responsible for wiping down the equipment and housekeeping cleaned the feeding pump poles. 3. During a review of facility's admission Record for Resident 17, dated 4/12/23, Resident 17 was admitted 4/21. During a review of Resident 17's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section G showed Resident 17 normally used a wheelchair and was completely dependent upon staff to move about the facility. During an observation on 4/11/23, at 10:48 a.m., in the activity room, Resident 17's wheelchair had a tannish-brown flaky residue along the edge of the seat and on the metal frame. Resident 17's wheelchair also had white stains along the edge of the seat. The wheelchair arm pads were cracked and peeling on the outer edges of both armrests. During a concurrent observation and interview on 4/11/23, at 10:52 a.m., with LVN 3, in the activity room, LVN 3 stated the residue on Resident 17's wheelchair appeared to be old food. LVN 3 used her finger and flaked off some of the tannish-brown residue. LVN 3 stated environmental services (EVS) is responsible for cleaning the chairs. LVN 3 stated the armrests should be changed and were an infection risk for the resident. During a review of the facility's policy and procedure titled Cleaning and Disinfecting of Resident Care Items and Equipment dated 11/23/21, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations . The policy identified durable medical equipment as reusable items. During a review of CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2008, the Cleaning of Patient-Care Devices indicated clean medical devices as soon as practical after use (e.g., at the point of use) because soiled materials become dried onto the instruments. Dried or baked materials on the instrument make the removal process more difficult and the disinfection or sterilization process less effective or ineffective. It also indicated, inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 no longer functions as intended or cannot be properly cleaned and disinfected or sterilized. Level of Harm - Minimal harm or potential for actual harm 4. During a concurrent observation, and interview on 04/10/23, at 10:30 a.m., with Infection Preventionist (IP 2) the Resident 21 and 100's room had a signage Yellow Gowns outside by the door. IP 2 stated Resident 21 and Resident 100 were recently admitted with MDRO (Multidrug-resistant organisms Bacteria that resist treatment with more than one antibiotic and are found mainly in hospitals and long-term care facilities). IP 2 stated both residents were placed on Enhanced Precautions. (an infection control intervention to reduce transmission of MDROs in nursing homes). IP 2 stated the signage stating, yellow gowns was unclear and confusing and it should be labeled as Enhanced precautions instead. Residents Affected - Many During a concurrent observation, and interview on 04/10/2023, at 10:32 a.m., with IP 2 the Resident 2's room had a signage Contact Precautions outside by the door. (intended to prevent direct or indirect transmission of infection with the resident or the resident's environment). ). IP 2 stated Resident 2 was recently re-admitted with a with a Feeding Tube (a flexible plastic tube placed into stomach or bowel to provide nutrition). IP 2 stated the signage outside Resident 2's room was incorrect as it should state Enhanced Precautions. During a concurrent observation, and interview, on 04/10/2023, at 10:34 a.m., with IP 2, Resident 349's room had a signage STOP. Visitors: Please report to the Charge Nurse before entering the room. IP 2 stated that Resident 2 should also be on enhanced precautions he was a recent re-admitted after a surgery. IP 2 also stated signage outside the room was incorrect and misleading; and should state Enhanced Precautions. During an interview on 04/10/23 at 11:15 a.m., with the Director of Nursing (DON), DON stated No sign or incorrect sign means that staff have no way of knowing of the resident's condition. The DON stated, The sign is important as it helps prevent the spread of infections. During an interview on 04/11/23 at 09:48 a.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated he gets a report at the beginning of his shift for only his assigned residents, but answers call-lights throughout the facility. CNA 5 stated that he relied on the signage outside the room to guide him for providing care, and that he did not check with the assigned nurse every time prior to answering call lights throughout the facility. During a record review of facility's Policy and Procedures titled, Enhanced Standard Precautions Guidelines policy dated 10/24/2022, showed Upon admission identify residents at high risk for Multi-Drug resistant organisms (MDRO) colonization's and transmission .Document the decision for Enhanced Standard or Transmission-Based precautions, and room placement or roommate selection, Ensure that the appropriate instructions are provided to all Healthcare Personnel (HCP) who will be providing care, Communicate and educate all HCP about the reason for choosing a single-bed room or roommate selection. 5. During an observation on 4/12/23, at 10:09 a.m., in Resident 8's room, Certified Nursing Assistant (CNA)1 and CNA 2 provided peri-care to Resident 8 while she was lying in supine position in bed. CNA 1 at first, wiped a wooden nightstand with sanitizing wipes on the right side of Resident 8's bed. Without removing the gloves and or performing hand hygiene, CNA 1 uncovered Resident 8's legs, pulled the hospital gown up and removed Resident 8's incontinent brief. CNA 2 was on the left side of Resident 8's bed at that time and assisted to remove Resident 8's incontinent brief. CNA 1 then opened a wooden closet on Resident 8's right side of the bed, picked up a spray bottle, sprayed it on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 - Many Resident 8's peri area and closed the closet. CNA 1 stated it was a peri care spray. CNA 2 then wiped Resident 8's front peri area with cleaning wipes. CNA 1 and CNA 2 moved Resident 8 towards CNA 2, on the left side of Resident 8's body. CNA 1 opened the wooden closet again, picked up the peri spray, sprayed on Resident 8's bottom, put it back in the closet and closed the closet. CNA 1 then wiped Resident 8's bottom with cleaning wipes. CNA 1 again opened the wooden closet, got incontinent pad (also known as chucks), closed the closet, put the incontinent pad under Resident 8's bottom and put on a new incontinent brief. Without removing the gloves and/or performing hand hygiene, CNA 1 and CNA 2 repositioned Resident 8 back to supine position, pulled her up, put a pillow under her neck. CNA 2 continued to fix Resident 8's hair, wheeled Resident 8's bedside table closer her bed, used bed control to sit Resident 8 up, picked up a chocolates bag and put it inside the wooden closet, closed the closet, touched Resident 8's call bell, and then removed her gloves. During an interview on 4/12/23, at 10:22 a.m., CNA 1 stated she thought she changed her gloves after wiping the nightstand and prior to starting Resident 8's peri care. CNA 1 sated she should have had the peri spray out until the end of the procedure, so it was readily available throughout the care. During an interview on 4/12/23, at 10:25 a.m., CNA 2 stated she was supposed to change her gloves after peri care and prior to touching Resident 8's belongings for infection control. During an interview on 4/13/23, at 8:43 a.m., Infection Preventionist (IP)1 stated staff was expected to wash their hands and/or use alcohol based hand rubs (hand sanitizer) in between gloves changes; remove their contaminated gloves after cleaning resident's peri area and prior to touching resident's belongings and/or surroundings. IP1 also stated following infection control practices was important to minimize the spread of infections. During a record review of facility's Policy and Procedures titled Hand Washing and Hand Hygiene dated 9/30/22 showed, This facility considers hand hygiene the primary means to prevent the spread of infections . Employees shall wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .Before and after assisting a resident with personal care .after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to implement its COVID-19 [Coronavirus disease] Vaccination policy and procedures to ensure two of two sampled Residents (46 and 249) were fully vaccinated for Coronavirus Disease-19 (an acute respiratory illness with fever, cough, and capable of progressing up to and including death). This failure resulted in Residents 46 and 249 to be unaware of the risks and benefits associated with the COVID-19 vaccine. Findings During a review of the Resident 46's admission Record printed on 04/13/23, the record showed Resident 46 was admitted to the facility 03/23. During a review of the Resident 249's admission Record printed on 04/13/23, the record showed Resident 249 was admitted to the facility 02/23. During an interview and record review on 04/12/23, at 09:56 a.m., the Director Nursing (DON) was asked to provide a list of unvaccinated residents. DON stated Resident 46, Resident 249 were unvaccinated, and they did not have a pending and/ or granted exemptions for COVID-19 vaccination. The DON stated facility expected all resident's vaccination status to be checked upon admission, and if a resident was unvaccinated, the staff were to offer a COVID-19 vaccination along with an explanation of the risks and benefits of the vaccination. During a concurrent interview and record review on 04/12/23, at 10:14 a.m., with Infection Preventionist (IP 1), Clinical Records for residents 46 and 249 from 02/23/23 through 04/12/23 were reviewed. IP stated they were unable to locate COVID-19 vaccination record, documentation that vaccination was offered, or documentation that an explanation of risks and benefits of vaccination was provided to Resident 46 and 249. During a record Review of the Minimum Data Set (MDS-an assessment used to guide care) dated 03/02/23, the assessment showed Resident 249 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact mental status. During an interview on 04/13/23 at 11:19 a.m., Resident 249 stated that the facility did not offer COVID-19 vaccination nor provide them with information about the risks and benefits of the COVID-19 vaccine. During a record review of facility's undated policy titled COVID-19 VACCINATION showed, Education on the vaccine shall be provided in a manner that is easily understood and in advance of each vaccination dose. This information will include the U.S Food and Drug Administration (FDA) Emergency Use Authorization (WUA) fact sheet, benefits and side effects for each dose needed. Vaccines will be offered as available unless contradicted .If the vaccine is unavailable, the facility shall provide information on obtaining vaccination opportunities (e.g., health department or local pharmacy). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555895 If continuation sheet Page 15 of 15