Other·October 6, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 9/19/17 through 9/21/17. The facility was licensed for 50 beds. The census at the time of the survey was 43. The sample size was 11. For Entity Reported Incident CA00542034 regarding Quality of Care/Treatment, a federal deficiency was identified (see F323).

F323 - 483.25(d) had a scope and severity of G. Class "B" citations were issued for F323 and F226. Representing the California Department of Public Health: 37686, Health Facilities Evaluator Nurse; 34383, Health Facilities Evaluator Nurse; and 38243, Health Facilities Evaluator Nurse.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 10/31/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 1 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement their policy and procedure for one of 11 sampled residents (7) when an allegation of abuse was not reported to law enforcement agency and California Department of Public Health (CDPH) within 24 hours after the incident had occurred. This failure had the potential to affect the resident's safety and protection from harm. Findings: Review of Resident 7's Minimum Data Set (MDS, an assessment tool), dated 8/22/17, indicated the resident could make decisions and required assistance for transfers, dressing, hygiene, and bathing. During an interview and record review with the director of nursing (DON) on 9/20/17 at 3:40 p.m., she stated Resident 7 made an allegation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 2 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of abuse regarding certified nurse assistant A (CNA A), who got to the resident's knees, held her hands, and kissed her on the cheek. She also stated the allegation of abuse was not reported to the law enforcement agency and CDPH within 24 hours after the incident. During an interview with the administrator on 9/21/17 at 8:45 a.m., she confirmed Resident 7's abuse allegation should have been reported to the law enforcement agency and CDPH within 24 hours. Review of the facility's 9/2013 policy, titled "Abuse prevention program," indicated the administrator or his/her designee will report the alleged incident to the law enforcement agency and to CDPH within 24 hours.

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 10/31/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for two of 11 sampled residents (1 and 4) when staff were standing while feeding the residents in the dining room. This practice had the potential to negatively affects the residents' psychosocial well-being. During an observation on 9/19/17 at 12:15 p.m., Resident 1 and Resident 4 were in the dining room, along with several other residents, for lunch. Certified nurse assistant G (CNA G) was assisting the residents with their meals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 3 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE While standing, CNA G fed Resident 4. After she was finished feeding Resident 4, she proceeded to feed other residents, including Resident 1. CNA G remained standing while feeding the other residents. During an observation on 9/19/17 at 12:25 p.m., licensed vocational nurse H (LVN H) entered the dining room to help CNA G feed the residents. LVN H was also standing while feeding the residents. During an interview with the director of staff development (DSD) on 9/19/17 at 12:25 p.m., she confirmed CNA G and LVN H were standing while feeding the residents in the dining room. The DSD stated staff should be sitting while feeding the residents, not standing or hovering over them. The DSD explained that standing while feeding residents made the dining atmosphere less home-like and more intimidating for the residents. The facility's 10/2009 policy titled "Assistance with Meals" indicated, "Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: (1) Not standing over residents while assisting them with meals."

F250 SS=D PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.40(d)

F250 10/31/2017 (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide medicallyrelated social services for one of 11 sampled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 4 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents (8) when Resident 8's motorized wheelchair was not working properly and it was not followed up. This failure had the potential to negatively affect the mental and psychosocial well-being of the resident. Findings: Review of Resident 8's clinical record indicated he was admitted on 8/2014 with diagnoses including seizures (a sudden surge of electrical activity in the brain) and hypertension (increase in blood pressure). His Minimum Data Set (MDS, an assessment tool) dated 5/10/17, indicated he was cognitively intact and required assistance for bed mobility, transfers, hygiene, and bathing. During an observation and interview with Resident 8 on 9/20/17 at 10:35 p.m., Resident 8 was sitting on his motorized wheelchair and it was not working. He stated the motorized wheelchair has not been working properly since March 2017 and the social service director (SSD) was aware. Resident 8 stated he could not move around the facility without his chair and he felt neglected. During an interview with the social service director (SSD) 9/20/17 at 11:05 a.m., he confirmed Resident 8's motorized wheelchair was not working since March 2017. The SSD was unable to find documentation that indicated Resident 8's motorized wheelchair was followed up to the appropriate agency. He stated he should have followed up Resident 8's motorized wheelchair. During an interview with the director of nursing on 9/20/17 at 4 p.m., she stated Resident 8's motorized wheelchair should have been followed up. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 5 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the facility's "Job Description of Director of Social Services", dated 10/2016, indicated determines the residents' eligibility for assistance provided, complete all necessary forms and make reasonable arrangements for residents assistance whenever possible. Oversees and plan social service program for residents and support the residents.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 10/31/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to meet professional standards of practice for one of 11 sampled residents (8) when a physician order for Keppra (medication for seizure) level every six months (February and August) was not followed. This failure could potentially compromise the health and safety of the resident. Findings: Review of Resident 8's clinical record indicated he was admitted in 8/2014 with diagnoses including seizures (a sudden surge of electrical activity in the brain) and hypertension (increase in blood pressure). His Minimum Data Set (MDS, an assessment tool), dated 5/10/17, indicated he was cognitively intact and required assistance for bed mobility, transfers, hygiene, and bathing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 6 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 8's physician order dated 2/15/17, indicated Keppra level every six months (February and August). During an interview with the Minimum Data Set Coordinator (MDSC) on 9/21/17 at 8:45 a.m., he stated he was unable to find the Keppra level for August. He confirmed there was no Keppra level and the physician order should have been followed. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 10/31/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 7 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards for one of 11 sampled residents (4) when staff did not ensure a pad alarm (a device applied to the bed surface that beeps when the resident tries to get up) was turned on. This failure resulted in Resident 4's fall, left hip fracture (cracked or broken left hip), skin tears on both elbows, and a cut on the left side of his forehead. Findings: Resident 4's clinical record was reviewed. He was admitted on 12/27/16 and had the diagnoses of dehydration (reduced amount of water in the body), anxiety, dementia (a mental disorder that impairs reasoning), and Alzheimer's Disease (progressive mental deterioration). A Minimum Data Set (MDS, an assessment tool), dated 4/4/17, indicated Resident 4 had moderate cognitive impairment and that he required cues and supervision to make decisions. The MDS also indicated Resident 4 required extensive assistance (staff provide weight bearing support) for transfers and was totally dependent (requires full staff performance) for moving on and off the unit. A "Fall Risk Evaluation," dated 4/19/17, indicated Resident 4 had a fall risk score of 17 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 8 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (a score of 10 or above represents high risk for falls). Review of Resident 4's clinical record indicated he had a physician's order, dated 12/30/16, for a self-releasing belt with alarm (a seat belt that beeps when the resident unfastens it) while in the wheelchair. Resident 4 also had a physician's order, dated 1/8/17, for use of a pad alarm due to poor safety awareness. A care plan, dated 4/10/17, indicated Resident 4 had multiple falls due to poor safety awareness. The care plan indicated Resident 4 was to have a self-releasing seat belt with alarm applied to his wheelchair and a pad alarm applied to his bed to alert staff when he tried to transfer without assistance. A nurse's note, dated 6/27/17, indicated Resident 4 was found on the floor with skin tears on both elbows and a bleeding cut on the left side of his forehead. The nurse's note indicated that Resident 4's "bed alarm did not go off" at the time of the fall. A nurse's note, dated 6/29/17, indicated Resident 4 complained of pain in his left leg, and that he was unable to move his left leg freely. A "Radiology Report," dated 6/30/17, indicated Resident 4 had a nondisplaced left intertrochanter fracture (left hip fracture). A nurse's note, dated 6/30/17, indicated Resident 4 was sent to the acute hospital for further evaluation related to a left hip fracture. A "Discharge Summary" from the acute hospital, dated 7/3/17, indicated Resident 4 required open reduction and internal fixation (ORIF, a type of surgery) for the fracture of his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 9 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE left hip. During an interview with the director of nursing (DON) on 9/20/17 at 9:20 a.m., she confirmed Resident 4 had a fall on 6/27/17 and was sent to the acute hospital on 6/30/17 due to a hip fracture. The DON stated that certified nurse assistant C (CNA C) was caring for Resident 4 on the day he fell. According to the DON, CNA C did not turn on Resident 4's bed pad alarm prior to the fall. During an interview with licensed vocational nurse A (LVN A) on 9/20/17 at 11:05 a.m., she confirmed she was the nurse on duty during Resident 4's fall on 6/27/17. LVN A stated she responded to a yell for help and found Resident 4 on the floor lying on his side. According to LVN A, Resident 4 was in bed prior to the fall. LVN A stated Resident 4's bed pad alarm did not beep at the time of the fall, and that she did not remember if she checked if the bed pad alarm was turned on prior to the fall. During an interview with the director of staff development (DSD) on 9/20/17 at 11:20 a.m., she stated CNAs and licensed nurses were responsible for checking if residents' alarms were on and functioning. The DSD further explained that licensed nurses should document that they have checked the alarms in the treatment administration record (TAR, record of treatment provided to the resident) once every shift. The DSD looked through Resident 4's clinical record and confirmed there was no documentation indicating Resident 4's bed pad alarm had been checked on the day of his fall, or for the entire month of 6/2017. During an interview with the DON on 9/20/17 at 11:50 a.m., she stated CNA C did not follow Resident 4's plan of care because she did not turn on his bed pad alarm prior to his fall on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 10 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/27/17. The DON stated CNA C was written up (a disciplinary action) because she did not follow Resident 4's plan of care. The DON also explained that licensed nurses were responsible for checking residents' alarms every shift and documenting this on the TAR. The DON looked through Resident 4's clinical record and confirmed there was no documentation indicating his bed pad alarm was checked for the month of 6/2017. During an observation on 9/20/17 at 12:40 p.m., accompanied by the DON, Resident 4 was sitting in his wheelchair and wearing his self-releasing belt with alarm. The light on the alarm labeled "in use" was not blinking. The DON looked at the alarm switch and confirmed it was in the "off" position. The DON stated the alarm was off and that it should have been on. The DON flipped the alarm switch to the "on" position, the alarm made a loud beep, and the light labeled "in use" began to blink. During a concurrent interview with the DON, she acknowledged that if Resident 4's bed pad alarm had been turned on at the time of his fall on 6/27/17, staff could have "possibly" assisted the resident before he fell. During an interview with CNA C on 9/21/17 at 11:39 a.m., she confirmed she was Resident 4's CNA when he fell on 6/27/17. CNA C stated she was in the room directly across the hall from Resident 4's room when the fall occurred. CNA C stated she did not hear Resident 4's bed pad alarm beep at the time of the fall. Review of a "Notice of Disciplinary Action" for CNA C, dated 6/27/17, indicated Resident 4 "did not have his alarm on, causing resident to have a fall/injury." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 11 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility's 8/2014 policy titled "Fall Prevention and Management Program" indicated, "The facility will implement a fall prevention and management program that supports providing an environment free from the hazards over which the facility has control."

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 10/31/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 12 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of 11 sampled residents (7) was free from unnecessary medications when the target behaviors (behaviors that have been selected for change) and side effects of psychotropic medications (medications used to treat mental disorders) were not monitored. This failure had the potential to result in inadequate monitoring of medication effectiveness, side effects, and adverse consequences. Findings: Resident 7's clinical record was reviewed. She was admitted on 8/15/17 with the diagnoses of bipolar disorder (a mental disorder marked by periods of elation and depression) and major depressive disorder (a mental disorder characterized by low mood, low self-esteem, and low energy). Review of Resident 7's "Physician Orders" indicated she had an order, dated 8/16/17, for Abilify (a medication primarily used to treat bipolar disorder) 5 milligrams (mg, unit of dose measurement) one tablet by mouth every day for major depressive disorder with psychotic symptoms. The order did not specify target behaviors. Resident 7 also had an order, dated 8/18/17, for Cymbalta (medication used to treat depression) 60 mg one capsule by mouth every day for major depressive disorder with psychotic symptoms. Again, the order did not specify target behaviors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 13 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 7's medication administration record (MAR, documentation of medications given to the resident) for 9/2017 indicated she did receive the above medications. There was no documentation on the MAR indicating licensed nurses monitored for target behaviors or side effects related to Abilify or Cymbalta. During an interview with the director of nursing (DON) on 9/21/17 at 7:20 a.m., she stated each psychotropic medication should have a diagnosis and a target behavior. The DON explained that licensed nurses should document the number of occurrences of target behaviors on the MAR every shift. According to the DON, the nurse who admitted Resident 7 should have initiated the target behavior monitoring in the MAR. During an interview with licensed vocational nurse F (LVN F) on 9/21/17 at 9:12 a.m., she stated that each psychotropic medication should have a target behavior. LVN F explained that licensed nurses should monitor the target behavior every shift and document this in the MAR. LVN F stated that licensed nurses should also monitor for psychotropic medication side effects every shift and document this in the MAR. LVN F looked through Resident 7's MAR and confirmed there was no documentation of target behavior monitoring or side effects monitoring for Abilify and Cymbalta. The facility's 8/2014 "Psychotherapeutic Drug Management" policy indicated psychotropic medications will be written on the MAR and should include the manifestations for the drug (i.e. hitting) and the side effects of the drug.

F334 SS=D INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS FORM CMS-2567(02-99) Previous Versions Obsolete

F334 Event ID: U4KL11 12/31/2017 Facility ID: CA040000064 If continuation sheet 14 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.80(d)(1)(2) (d) Influenza and pneumococcal immunizations (1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. (2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 15 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement their immunization program for one of 11 sampled residents (7) and two non-sampled residents (12 and 13). This failure had the potential of spreading pneumonia (a serious disease that affects the lungs and makes it difficult to breathe) and influenza (an illness caused by the influenza virus) in the facility. Findings: Review of clinical records for: a. Resident 7 indicated she was admitted with diagnoses including chronic kidney disease (CKD, a progressive loss in kidney function) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 16 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and diabetes mellitus (DM, refers to a group of diseases that affect how your body uses blood sugar). Her minimum data set (MDS, an assessment tool) dated 8/28/17, indicated her brief interview for mental status (BIMS) score was 15. Her immunization/vaccination record with date of admission 8/15/17 did not indicate any entries for pneumovax (brand name for the pneumococcal polysaccharide vaccine, which doctors recommend to seniors and other at-risk adults to protect themselves from the pneumococcal disease, a serious health threat that can lead to death) and influenza vaccine (FLU, protects a person against getting influenza caused by the influenza virus). b. Resident 12 indicated she was admitted with diagnoses including hypertension (high blood pressure) and heart failure (a condition in which the heart has lost the ability to pump enough blood to the body's tissues). Her MDS dated 4/5/17 indicated her BIMS score was 15. Her immunization/vaccination record with no date of admission, lacked an entry for pneumovax and indicated influenza vaccine was last given on 10/5/15. c. Resident 13 indicated she was admitted with diagnoses including hypertension and DM. Her MDS dated 6/15/17 indicated her BIMS score was 11. Her undated immunization record lacked an entry for pneumonia (PNA, a serious disease that affects the lungs and makes it difficult to breathe) vaccine and indicated the last influenza vaccine given was on 10/8/15. During an interview with the director of staff development (DSD), on 9/21/17 at 11:08 a.m., she reviewed the immunization records of Residents 7, 12 and 13 and was unable to find any immunization entries/records for PNA and FLU vaccines for these residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 17 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the director of nursing (DON), on 9/21/17 at 11:30 a.m., she stated there were no records under the immunization sections in the residents' charts. The facility policy on Pneumococcal Disease Prevention, dated 01/01/12, indicated the resident's medical record includes documentation that indicates the resident either received the pneumococcal polysaccharide vaccine or did not receive the vaccination due to medical contraindication or refusal. The facility policy on Influenza Prevention & Control, dated 01/01/12, indicated the resident's medical record includes documentation that indicates the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

F360 SS=D PROVIDED DIET MEETS NEEDS OF EACH RESIDENT CFR(s): 483.60

F360 10/31/2017 The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to adequately assess and consider serving hot meals to two of 11 sampled residents (7 and 8) and two nonsampled residents (12 and 13) when sandwiches were served four out of seven nights in a week. This failure had the potential of not honoring food preferences for these residents. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 18 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of clinical records for: a. Resident 7 indicated she was admitted with diagnoses including chronic kidney disease (CKD, a progressive loss in kidney function) and diabetes mellitus (DM, refers to a group of diseases that affect how your body uses blood sugar). Her minimum data set (MDS, an assessment tool) dated 8/28/17, indicated her brief interview for mental status (BIMS) score was 15. Her nutritional assessment was blank and did not indicate a food preference for sandwiches; b. Resident 8 indicated he was admitted with diagnoses including DM and hypertension (high blood pressure). His MDS dated 8/21/17, indicated his BIMS score was 15. A dietary questionnaire dated 5/9/17 indicated a dislike for "white bread" and no food preference for sandwiches; c. Resident 12 indicated she was admitted with diagnoses including hypertension and heart failure (a condition in which the heart has lost the ability to pump enough blood to the body's tissues). Her MDS dated 4/5/17 indicated her BIMS score was 15. Her quarterly nutritional assessments for 1/12/17, 4/6/17, and 7/16/17 did not indicate a food preference for sandwiches; and d. Resident 13 indicated she was admitted with diagnoses including hypertension and DM. Her MDS dated 6/15/17 indicated her BIMS score was 11. Her quarterly nutritional status assessments for 3/17/17, 6/15/17, and 9/15/17 did not indicate a food preference for sandwiches During the resident council meeting, on 9/19/17 at 2:00 p.m., Residents 7, 8, 12 and 13 verbalized dinners were bad due to cold FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 19 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sandwiches served at dinner time. All four residents indicated they were not okay with just sandwiches served for dinner, they preferred a full hot meal for dinner. Review of the facility menu for week 1, received on 9/19/17 from the Dietary Supervisor (DS), indicated for dinner: hamburger for Tuesday, philly steak sandwich for Thursday, grilled cheese sandwich for Friday, and grilled ham & swiss sandwich for Saturday. During an interview with the DS on 9/20/17, he reviewed the food committee meeting minutes for 5/3/17 (with five resident attendees) and 7/5/17 (with four resident attendees), the DS stated that sandwiches were discussed during these meetings but he confirmed Residents 7, 8, 12, and 13 did not attend these meetings. During an interview with the DS on 9/21/17, at 12:15 p.m., he confirmed only a few residents attended the food committee meetings and he did not assess Residents 7, 8, 12, and 13 to see if they preferred sandwiches for dinner. The facility policy on Resident/Patient Food Preferences, dated 2012, indicated: the dietary service supervisor or designee should visit resident/patient within 24-72 hours of admission to determine food preferences; food preferences should be reviewed quarterly with the resident/patient by the dietary service supervisor and recorded in the medical record, profile, and try card; all residents/patients must be offered a substitute food item when an item they dislike is on the menu.

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 10/31/2017 (i)(1) - Procure food from sources approved or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 20 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1) two air gaps were not maintained between the drainpipes that involved a small preparation sink and a two-compartment sink in the kitchen to help prevent contamination in case of a backflow, and 2) white substances were found inside the ice maker area of the ice machine. This failure had the potential to cause food borne illnesses to 43 residents who received their food and water from the kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 21 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. During an observation on 9/19/17 at 7:50 a.m., in the kitchen, a black drain pipe from a small preparation sink and a brown drain pipe from a two-compartment sink lacked sufficient air gaps; both rested directly on the drains in a manner that did not maintain an air gap between the pipes and the drain. The maintenance director (MD) observed the drains that had not provided sufficient air gaps. According to standards of practice within the food service industry, an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. (2013 Federal Food Code) 2. During an observation on 9/19/17, at 8:15 a.m., in the kitchen, white substances were found inside the ice maker area of the Ice-OMatic ice machine (see before pictures). This was confirmed by both the dietary supervisor (DS) and the MD who were present during this observation. The MD stated they were "calcium deposits" and that he cleaned the ice machine monthly as per regulations/recommendations. The DS stated the white substances, "can go to the ice". During an interview with the administrator (ADM) and the DS on 9/19/17 at 9:25 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 22 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE both were informed to decommission (withdraw from service and decontaminate until safe) the ice machine. The ADM stated she would check it. The DS stated he would put a do-not-use sign on the ice machine and have the MD clean it. During another interview with DS on 9/19/17 at 9:55 a.m., he presented a receipt for twelve bags of ice and stated they would have a professional come and clean the ice machine immediately. During an interview with the DS on 9/19/17, at 2:55 p.m., he presented the ice machine cleaning receipt. On 9/19/17 at 3:30 p.m., three surveyors went to inspect the decommissioned ice machine and it was still found with white substances on both sides, the door liner, and door cover of the ice maker compartment (see after pictures). The facility policy on Ice Machine - Operation and Cleaning, dated October 1, 2014, indicated maintenance staff will clean the ice making mechanism according to manufacturer's guidelines. The Ice-O-Matic Installation, Start-up and Maintenance manual, dated 10/13, indicated the importance of properly caring for the stainless steel surfaces of the ice machine and bin to avoid the possibility of rust or corrosion, to clean the stainless steel thoroughly once a week, to clean frequently to avoid build-up of hard, stubborn stains; hard water stains left to sit can weaken the steel's corrosion resistance and lead to rust.

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 10/31/2017 The facility must provide routine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 23 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 24 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to ensure safe medication storage when expired medications were in the medication refrigerator. This failure had the potential to result in residents receiving medication with reduced potency. Findings: During an observation on 9/19/17 at 10:40 a.m., accompanied by the director of nursing (DON), there were six boxes of bisacodyl suppositories (medication inserted into the rectum to treat constipation) in the medication refrigerator. Five of the six boxes of bisacodyl suppositories had an expiration date of 6/2017. During a concurrent interview with the DON, she confirmed that five of the six boxes of bisacodyl suppositories in the medication refrigerator were expired. The DON stated the expired medications should have been thrown away. The facility's undated "Medication Storage in the Facility" policy indicated that outdated medications must be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 25 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F514 RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/31/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to maintain sufficient and complete medical information for two of 11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 26 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sampled residents (5 and 2). For Resident 5, the Physician's Orders for Life Sustaining Treatment (POLST Form, a medical order for the specific medical treatments you want during a medical emergency) dated 6/14/16 was lacking the signature of Resident 5 and/or responsible party. For Resident 2, the restorative nursing assistant (RNA, nursing interventions which promote the resident's ability to adapt and adjust to living independently and safely as possible) program was not documented properly. These failures has the potential of providing inaccurate care for the residents. Findings: 1. Review of Resident 5's clinical record indicated she was admitted on 6/14/16 with diagnoses including hypertension, left bundle branch block, hypokalemia, other disorders of psychological development, major depressive disorder, anxiety, and history of falling. Her minimum data set (MDS, an assessment tool) indicated her cognitive skills for daily decision making were moderately impaired. During a review of Resident 5's POLST form, dated 6/14/16, the section for Signature of Physician/Nurse Practitioner/Physician Assistant indicated only a License # and date of 6/18/16 and the section for Signature of Patient or Legally Recognized Decisionmaker indicated a signature and date of 6/18/16. During an interview with the minimum data set coordinator (MDSC), on 9/20/17 at 8:45 a.m., he reviewed the POLST form for Resident 5. The MDSC stated the signature of the physician was on the wrong spot and the form was not signed by the resident or responsible party. The MDSC immediately called the resident's family and left a message. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 27 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the facility's undated policy on POLST, indicated the POLST form is designed to be a portable, authoritative and immediately actionable physician order consistent with the resident's wishes and medical condition, so long as the form is completed by the resident and signed by a physician, nurse practitioner or physician assistant. A valid POLST form is to be honored across treatment settings. 2. Review of Resident 2's physician order, dated 5/23/17, indicated RNA program for bilateral upper extremities with passive range of motion three times a week or as tolerated. Review of Resident 2's restorative charting record for 9/2017 indicated there was no documentation for 9/2017 regarding the RNA program. During an interview with RNA E on 9/22/17 at 9:20 a.m., she confirmed Resident 2's restorative charting record was blank and there was no documentation regarding the RNA program for 9/2017. During an interview with the director of nursing (DON) on 9/20/17 at 4:25 p.m., she acknowledged Resident 2's RNA program should have been documented on the restorative charting record. Review of the facility's 3/1/15 policy, "Restorative Nursing Program", The restorative nursing aide carries out the RNA program according to the care plan and documents daily.

F517 SS=D WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 10/31/2017 The facility must have detailed written plans and procedures to meet all potential FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 28 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555935 (X3) DATE SURVEY COMPLETED 09/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STONEHAVEN SENIOR LIVING 1717 S Winery Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that they were prepared for emergencies when flashlights, batteries, and first-aid kits were not available in the emergency kit. These failures had the potential to compromise the health and safety of the residents. Findings: During an environment observation and interview with the maintenance director (MD) on 9/19/17 at 4:00 p.m., the emergency kit was observed with one flashlight and one small radio. The MD stated the licensed nurse was in charge of the emergency kit items. During an interview with the director of staff development (DSD) on 9/19/17 at 4:15 a.m., she confirmed one flashlight and one radio were not enough for the all the residents during emergency situations. During an interview with the administrator (ADM) on 9/21/17 at 8:50 a.m. she acknowledged the emergency kit should have flashlights, batteries, and a first-aid kit inside. Review of the facility's policy dated 1/2012, " Emergency Equipment and Systems", indicated the emergency kit will maintain emergency equipment which include at least the following items: flashlights, batteries, firstaid kits, radios, and batteries. The facility maintains equipment for emergency use at all nursing stations and in other locations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U4KL11 Facility ID: CA040000064 If continuation sheet 29 of 29