Health inspection·June 21, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of the admission Record in R70's EMR under the Profile tab indicated he was admitted to the facility on [DATE]. Review of the Social Service Review, in R70's EMR under the Miscellaneous tab, dated 02/22/21, indicated there was no evidence the facility offered R70, or his family any information related to the formulation of an advance directive or offer to help formulate one. 6. Review of the admission Record in R148's EMR under the Profile tab indicated he was admitted to the facility on [DATE]. Review of the Social Service Review, in R148's EMR, under the Miscellaneous tab, dated 01/05/24, indicated there was no evidence the facility offered R148 or his family any information related to the formulation of an advance directive or offer to help formulate one. During an interview with the Social Services Director (SSD) on 06/21/24 at 4:15 PM, the SSD said she and the Social Service Assistant (SSA) do the initial assessment relative to advance directive at the time of admission. The SSD said her role is to assess and identify if a resident has an advance healthcare directive. She said any documents are then scanned into the EMR. During an interview with the Director of Nursing (DON) on 06/21/24 at 7:01 PM, the DON said the admission Nurse is supposed to collect the Advance Directives from the resident or resident's family and adds it to the EMR. She said that if a resident does not have one it is offered to them. The DON said that advance directive education, teaching and assistance to formulate an advance directive needs to be done when a resident is admitted to the facility. Review of the facility policy titled Advance Directives dated September 2023 indicated that Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives, the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so, written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative, written information includes a description of the facility's policies to implement advance directives and applicable state law. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 2 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or representative; and the Ombudsman with written notification of a facility-initiated transfers for five of six sampled residents (Resident (R) 2, R32, R96, R130, R148) reviewed for hospitalization out of 36 total sampled residents. This failure had the potential to affect the residents and/or their representative about the reason for the transfer and the resident's appeal rights. Findings include: Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated dated 10/2023 stated, . Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., [example] in a monthly list of residents that includes all notice content requirements .Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge . Review of the undated facility admission packet provided by the facility, revealed Our written notice of transfer to another facility .will include the effective date, the location to which you will be transferred or discharged , and the reason the action is necessary. 1. Review of R96's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with a primary diagnosis of end stage renal disease. R96 had a Power of Attorney (POA) on file. Review of R96's Notice of Transfer or Discharge dated 05/14/24 located in the EMR under the Assessments tab indicated he was transferred to the hospital on [DATE]. Review of R96's discharge assessment MDS with an ARD of 05/13/24 indicated he was discharged to a short-term general hospital. During an interview on 06/19/24 at 4:20 PM, Medical Records (MR) stated prior to 01/01/24 the facility would fill out a handwritten Notice of proposed discharge/transfer form, would notify the resident/responsible party of the transfer via phone, and then send a copy of the notification to the Ombudsman. MR stated after 01/01/24 the facility started filling out the Notice of Transfer or Discharge form electronically in the EMR, would notify the responsible party (RP)/POA of the transfer/discharge, would offer a copy to the RP, and then fax a list of transfers/discharges to the Ombudsman. MR confirmed R96's RP/POA was not provided a copy of the transfer/discharge form for the hospitalization on 05/13/24. During an interview on 06/19/24 at 4:39 PM, the Director of Nurses (DON) stated the nurses only fill out the transfer/discharge notification forms if the resident was sent out directly from the facility. The DON stated she was not aware of the resident/responsible party and Ombudsman were required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 3 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0623 to be notified in writing discharges/transfers. Level of Harm - Minimal harm or potential for actual harm 2. Review of the admission Record in R130's electronic medical record (EMR) under the Profile tab indicated he was admitted to the facility on [DATE]. The admission Record indicated that R130 was his own responsible person. Residents Affected - Some Review of the e-Interact Situation, Background, Assessment, and Recommendation (SBAR) Summary for Providers in R130's EMR under the Progress Notes tab, dated 01/12/24, indicated R130 experienced a change in mental status with an altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). The e-Interact SBAR Summary for Providers indicated R130 exhibited confusion and was unable to answer basic questions properly. Review of a Dialysis Progress Note in R130'2 EMR under the Miscellaneous tab indicated R130 experienced the change in condition while at dialysis on 01/12/24 and was transferred to the hospital from the dialysis center. Review of the Transfer/Discharge Notice in R130's EMR, dated 01/12/24, indicated the facility notified the State Ombudsman of the transfer. The Transfer/Discharge Notice did not indicate that a written notice of the transfer, including the reason for the transfer, was provided to R130, in writing. 3. Review of the admission Record in R148's EMR under the Profile tab indicated he was admitted to the facility on [DATE]. The admission Record indicated that R148 was his own responsible person. Review of the Physician Orders for June 2024 in R148's EMR under the Orders tab indicated an order was given on 06/11/24 to transfer the resident to the hospital for evaluation. Review of the e-Interact SBAR Summary for Providers in R148's EMR under the Progress Notes tab, dated 06/11/24, indicated R148 was transferred to the hospital following a fall with a head laceration. Review of the Transfer/Discharge Notice in R148's EMR, dated 06/11/24, indicated the facility notified the State Ombudsman of the transfer. The Transfer/Discharge Notice did not indicate that a written notice of the transfer, including the reason for the transfer, was provided to R148, in writing. During an interview with the Administrator on 06/21/24 at 9:00 AM, the Administrator said the facility does not provide written Transfer/Discharge Notices. 4. Review of R32's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R32's annual MDS with an ARD of 03/11/24 revealed the facility assessed the resident to have a BIMS score of one out of 15 which indicated the resident was severely cognitively impaired. Review of R32's Progress Note dated 06/12/24 revealed the resident fell on [DATE] and an x-ray revealed she had a displaced femoral neck fracture. She was sent to the emergency room (ER) for evaluation. Review of R32's Madera Rehabilitation and Nursing Center Notice of Transfer or Discharge 06/12/24 and located in the resident's EMR under the Assessments tab revealed R32 was sent to the emergency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 4 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0623 room (ER) because it was necessary for your welfare and your needs cannot be met in the facility. Level of Harm - Minimal harm or potential for actual harm R32 was not given a copy of the Madera Rehabilitation and Nursing Center Notice of Transfer or Discharge found in the Assessments tab of the electronic medical record (EMR.) The form indicated R32 was sent to the ER because it was. Residents Affected - Some 5. Review of R2's quarterly MDS with an ARD date of 04/12/24, located in the MDS tab of the EMR revealed R2 had an admission date of 09/17/20, had a BIMS score of 13 out of 15, indicating R2 was cognitively intact. Review of R2's health status note, dated 02/19/24, located in the EMR under the Progress Note tab revealed, Resident transferred out to [name of hospital] due to extreme pain in right hip and upper leg. send to hospital. RP [Resident's responsible party] made aware. Review of R2's Notice of Transfer or Discharge, dated 02/19/24, located in the EMR under the Assessment tab, revealed R2 was transferred to the local hospital, The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility, and 2. Name/Designation of Person notified a. Name [family member's name] b. Contact Type: Agent, c. Telephone: [number]. The transfer information did not include the notice was provided in writing to resident. Review of R2's Health Status Note, dated 04/02/24, located in the EMR under the Assessment tab, revealed during med [medication] pass resident noted to be lethargic and sob. [short of breath] received order to send resident out to hospital for further evaluation. Rp notified via phone . Review of R2's Notice of Transfer or Discharge, dated 04/02/24, provided by the facility, revealed R2 was transferred to the local hospital and The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility and 2. Name/Designation of Person notified a. Name [family member] b. Contact Type: Agent, c. Telephone: [number]. The transfer information did not include the notice was provided in writing to the resident. During an interview on 06/20/24 at 4:47 PM, Medical Records (MR) was asked about transfer notices for R2 for the 02/19/24 and 04/02/24 transfers. MR stated there were no written transfer notices provided for R2, just a verbal notice to the RP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 5 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy review, the facility failed to ensure residents and/or their responsible party was given a written bed hold policy/notice at the time of their hospital transfer for four of six residents reviewed for hospitalizations (Resident (R) 2, R96, R130, and R148) out of a total sample of 36 residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility. Findings include: Review of the facility policy titled Bed Holds and Returns, dated October 2023 indicated All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours,) and The written bed-hold notices provided to the residents/representatives explain in detail: a. the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; b. the reserve bed payment policy as indicated by the state plan (for Medicaid residents); and c. the facility policy regarding bed-hold periods. Review of the undated, facility admission packet, provided by the facility, revealed, If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. There was no mention of the bed hold notice being provided in writing upon transfer to the resident or the resident representative. 1. Review of R96's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with a primary diagnosis of end stage renal disease. R96 had a Power of Attorney (POA) on file. Review of R96's discharge assessment Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/13/24 indicated he was discharged to a short-term general hospital. Review of R96's Notice of Transfer or Discharge dated 05/14/24 located in the EMR under the Misc [Miscellaneous] tab revealed the Bed Hold Section indicated the facility was to hold the bed. No reserve bed payment information was included on the form. The form stated, .Residents or representatives must decide within 24 hours of notification of transfer, whether or not the facility should hold a bed, for up to seven days. Medicaid provides for a 7-day bed hold and requires the facility to admit into the next available bed if this time-frame exhausts. Daily room rates apply to non-Medicaid recipients . Review of R96's quarterly MDS with an ARD of 04/22/24, located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out 15 which indicated the resident was cognitively intact. During an interview on 06/18/24 at 3:12 PM, R96 stated he did not receive bed hold notification (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 6 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0625 paperwork. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/19/24 at 4:39 PM, the Director of Nursing (DON) stated nurses completed the bed hold forms; however, she was not aware of the requirement of the reserve bed payment information was to be included on the form. Residents Affected - Some During an interview on 06/21/24 at 2:10 PM, Licensed Vocational Nurse (LVN) 1 stated when a resident was sent to the hospital, the nurse filled out a bed hold notice. LVN1 stated the original goes to medical records and no copy was provided to the resident/RP that she was aware of. The nurse would receive orders to hold the bed for 7 days. If a resident/RP wanted to know the rate for bed holds, they could speak with the Social Worker for the cost of bed holds. 2. Review of the admission Record in R130's electronic medical record (EMR) under the Profile tab indicated he was admitted to the facility on [DATE]. The admission Record indicated that R130 was his own responsible person. Review of the e-Interact Situation, Background, Assessment, and Recommendation (SBAR) Summary for Providers in R130's EMR under the Progress Notes tab, dated 01/12/24, indicated R130 experienced a change in mental status with an altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). The e-Interact SBAR Summary for Providers indicated R130 exhibited confusion and was unable to answer basic questions properly. Review of a Dialysis Progress Note in R130's EMR under the Miscellaneous tab indicated R130 experienced the change in condition while at dialysis on 01/12/24 and was transferred to the hospital from the dialysis center. Review of the Bed Hold section of the Transfer/Discharge Notice in R130's EMR, dated 01/12/24, did not indicate that a written notice of the facility Bed Hold notice was provided to R130. 3. Review of the admission Record in R148's EMR under the Profile tab indicated he was admitted to the facility on [DATE]. The admission Record indicated that R148 was his own responsible person. Review of the Physician Orders for June 2024 in R148's EMR under the Orders tab indicated an order was given on 06/11/24 to transfer the resident to the hospital for evaluation. Review of the e-Interact SBAR Summary for Providers in R148's EMR under the Progress Notes tab, dated 06/11/24, indicated R148 was transferred to the hospital following a fall with a head laceration. Review of the Bed Hold section of the Transfer/Discharge Notice in R148's EMR, dated 06/11/24, did not indicate that a written notice of the facility Bed Hold notice was provided to R148. During an interview with the Administrator on 06/21/24 at 9:00 AM, the Administrator said the facility did not provide written Bed Hold notices. 4. Review of R2's quarterly MDS with an ARD date of 04/12/24, located in the MDS tab of the EMR revealed admission date of 09/17/20; and a BIMS score of 13 out of 15, indicating R2 was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 7 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of R2's health status note dated 02/19/24, located in the EMR under the Progress Note tab revealed, Resident transferred out to [name of hospital] due to extreme pain in right hip and upper leg . advised to send to hospital. Rp [Resident's responsible party] made aware. Review of R2's Notice of Transfer or Discharge, dated 02/19/24, located in the EMR under the Assessment tab, revealed under the Bed Hold Section Residents or representatives must decide within 24 hours of notification of transfer, whether or not the facility should hold a bed, for up to seven days. Medicaid provides for a 7-day bed hold and requires the facility to admit into the next available bed if this time-frame exhausts. Daily room rates apply to non-Medicaid recipients. The section also included 1. The Above Individual (A. 2.) was notified by facility staff regarding bed hold provisions, and has decided to: a. Yes, Authorize a Bed Hold for the Above-Named Resident. A.2. revealed Name/Designation of Person notified a. Name [family member's name]. The method in section 4. was left blank which included options a. Sent with Transfer Paperwork to Acute Hospital b. Copy Hand Delivered upon Transfer / Discharge c. Sent via USPS (Enter Address of Record below). The bed hold section did not include the resident, or the RP was provided written notice. Review of R2's health status note dated 04/02/24, located in the EMR under the Assessment tab, revealed during med [medication] pass resident noted to be lethargic and sob. [short of breath] . received order to send resident out to hospital for further evaluation. Rp notified via phone . left facility . Review of R2's Notice of Transfer or Discharge, dated 04/02/24, provided by the facility, revealed under the Bed Hold Section Residents or representatives must decide within 24 hours of notification of transfer, whether or not the facility should hold a bed, for up to seven days. Medicaid provides for a 7-day bed hold and requires the facility to admit into the next available bed if this time-frame exhausts. Daily room rates apply to non-Medicaid recipients. The section also included 1. The Above Individual (A. 2.) was notified by facility staff regarding bed hold provisions, and has decided to: a. Yes, Authorize a Bed Hold for the Above-Named Resident. A.2. revealed Name/Designation of Person notified a. Name [family member's name]. Section 3. Written Copy Provided to Above individual (A. 2.) on: was left blank. The method in section 4. was checked for a. Sent with Transfer Paperwork to Acute Hospital. The bed hold section did not include the resident or RP was provided written notice. During an interview on 06/20/24 at 4:47 PM, Medical Records (MR) was asked about R2's bed hold notices for the 02/19/24 and 04/02/24 transfers to the hospital. MR stated there were no written bed hold notices provided to the resident and only a verbal notice to the RP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 8 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to develop comprehensive care plans that reflected the residents' current status for 10 residents (Resident (R) 5, R9, R21, R33, R70, R93, R96, R148, R161, and R420) of 38 sampled residents. The residents' care plans were developed; however, the care plan did not reflect the residents' right to refuse treatment (Do Not Resuscitate (DNR)) and did not reflect residents' sex offender registry status. These failures had the potential for staff not to be informed of residents' care needs or offender history of residents. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person Centered, dated [DATE] indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident. The policy indicated The comprehensive, person-centered care plan: .includes the resident's stated goals upon admission and desired outcomes. 1. Review of the admission Record in R5's electronic medical record (EMR) under the Profile tab indicated he was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, heart failure, and chronic pain. Review of the Physician Orders dated for [DATE], in R5's EMR under the Orders tab, indicated R5's code status was listed as Full Code meaning R5's medical team should perform all necessary procedures to save his life in a medical emergency including cardiopulmonary resuscitation (CPR) if he has no heartbeat and is not breathing. Review of the Care Plans in R5's EMR under the Care Plan tab indicated the facility did not develop a care plan to address his Full Code status. 2. Review of the admission Record in R9's EMR under the Profile tab indicated she was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and Alzheimer's disease. Review of the Physician Orders dated for [DATE], in R9's EMR under the Orders tab, indicated R9's code status was listed as Do Not Resuscitate (DNR) meaning her medical team should not perform cardiopulmonary resuscitation if her breathing or heart stops. Review of the Care Plans in R9's EMR under the Care Plan tab indicated the facility did not develop a care plan to address her DNR status. 3. Review of the admission Record in R21's EMR under the Profile tab indicated he was admitted to the facility on [DATE] with diagnoses which included bladder cancer, type 2 diabetes, and hypertension. Review of the Physician Orders dated for [DATE], in R21's EMR under the Orders tab, indicated R21's code status was listed as DNR. Review of the Care Plans in R21's EMR under the Care Plan tab indicated the facility did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 9 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 develop a care plan to address his DNR status. Level of Harm - Minimal harm or potential for actual harm 4. Review of the admission Record in R33's EMR under the Profile tab indicated she was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis. Residents Affected - Some Review of the Physician Orders dated for [DATE], in R33's EMR under the Orders tab, indicated R33'3 code status was listed as Full Code. Review of the Care Plans in R33's EMR under the Care Plan tab indicated the facility did not develop a care plan to address her Full Code status. 5. Review of the admission Record in R70's EMR under the Profile tab indicated he was admitted to the facility on [DATE] with diagnoses which included PTSD (Post Traumatic Stress Disorder). Review of the Physician Orders dated for [DATE], in R70's EMR under the Orders tab, indicated R70's code status was listed as Full Code. Review of the Care Plans in R70's EMR under the Care Plan tab indicated the facility did not develop a care plan to address his Full Code status. 6. Review of the admission Record in R161's EMR under the Profile tab indicated she was admitted to the facility on [DATE] with diagnoses which included COPD (chronic obstructive pulmonary disorder). Review of the Physician Orders dated for [DATE], in R161's EMR under the Orders tab, indicated R161's code status was listed as DNR. Review of the Care Plans in R161's EMR under the Care Plan tab indicated the facility did not develop a care plan to address her DNR status. 7. Review of the admission Record in R148's EMR under the under the Profile tab indicated he was admitted to the facility on [DATE], with diagnoses which included cirrhosis and Type 2 diabetes. Review of the Physician Orders dated for [DATE], in R148's EMR under the Orders tab, indicated R148's code status was listed as Full Code. Review of the Care Plans in R148's EMR under the Care Plan tab indicated the facility did not develop a care plan to address his Full Code status. During an interview with the Director of Nursing (DON) on [DATE] at 7:01 PM, the DON said she was aware that resident's code status was missing from the care plans and that should have been done. The DON said the code status of residents was not included on the care plans prior to [DATE] when the survey team requested the care plans. She said the code statuses were added to the care plans at that time and included within the Activities of Daily Living (ADL) Deficit Interventions section of each care plan. 8. Review of R420's admission Record located in the EMR under the Resident tab revealed he was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of unspecified kidney. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 10 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of R420's Clinical Physician Orders located in the EMR under the Orders tab included an order for Code Status: DNR as of [DATE]. Review of R420's POLST dated [DATE] and located in the EMR under the Miscellaneous tab and indicated R420 had chosen DNR for code status. Residents Affected - Some During an interview on [DATE] at 9:51 AM, R420 confirmed his code status was DNR. Review of R420's Care Plan located in the EMR under the Care Plan tab, revised [DATE] did not include code status/advance directive status. 9. Review of R96's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE]. Review of R96's five day MDS with an ARD of [DATE] revealed the facility assessed the resident to have a BIMS score of 14 out of 15 indicating he was cognitively intact. a. Review of R96's active Clinical Physician Orders located in the EMR under the Orders tab did not include code status/advance directive status. An order dated [DATE] for DNR (do not resuscitate) was discontinued on [DATE]. Review of R96's Physician Orders for Life-Sustaining Treatment (POLST) located in the EMR under the Miscellaneous tab and dated [DATE] indicated R96 had chosen DNR for code status. During an interview on [DATE] at 3:12 PM, R96 confirmed his code status was DNR. b. Review of R96's untitled and undated document from the State of California Department of Justice provided by the Social Services Director (SSD) indicated R96 had offenses including .lewd or lascivious acts with a child under [AGE] years of age . as of 2012. Review of R96's Care Plan located in the EMR under the Care Plan tab, revised on [DATE], did not include code status/advance directive status or registered sex offender status. During an interview on [DATE] at 4:15 PM, the Social Services Director (SSD) stated it was her responsibility to determine if the resident wanted to develop an advance directive. Once an advance directive was in place, she would provide the document to the medical records department. She was not sure whose responsibility it was to enter an order for code status or add the information to the care plan. Additionally, regarding R96, the SSD stated she was not aware of his sex offender status until [DATE] when the Social Services Assistant (SSA) shared this information with her. The SSD stated the SSA confirmed the information online; however, he did not record the information in a progress note or in the care plan. During an interview on [DATE] at 5:39 PM, the Administrator stated it was his expectation for all residents' code status to be included in the clinical physician's orders and in the care plan. During an interview on [DATE]at 7:03 PM, the Director of Nursing (DON) stated it was her expectation for the admitting nurse to determine if residents had an advanced directive upon admission. If the resident did not have an advanced directive, the SSD would offer education and provide POLST form for the resident or their representative to choose their code status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 11 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10. Review of R93's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was originally admitted to the facility on [DATE]. Review of R93's Progress Notes dated [DATE] and located in the Progress Notes tab in the EMR revealed on [DATE] Social Services Director (SSD) received a call from the [NAME] Police Department and was informed by an officer R93 was registered sex offender who had failed to keep the police department up to date on his living arrangements for several years. The officer stated she would be visiting the facility to see R93. The SSD confirmed R93 had been a resident for the past two years and had a diagnosis of dementia. On [DATE] two officers from the [NAME] Police Department came to the facility and requested to see R93 to verify he was there. SSD escorted them to the unit to see R93 at his bedside. They attempted to explain paperwork they brought in with the rules related to being a registered sex offender. The SSD explained to the officers the resident lacked capacity to make medical decisions. The officers requested the attending physician call them about R93. The SSD also called R93's wife to inform her of the visit and left a detailed message. On [DATE] the SSD spoke with R93's wife and she stated she .thought it was resolved when they left the other district. During an interview on [DATE] at 5:13 PM, the SSD confirmed the [NAME] Police Department had been out to the facility, but the officers were not able to give her any specifics. When asked why she had not care planned the concern at the time she became aware, she stated, [I] didn't feel it was necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 12 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure there was a dialysis contract for two of six residents (Resident (R) 44 and R87) reviewed for dialysis of 36 sample residents. This has the potential to affect the residents overall care between the facility and dialysis center. Findings include: Review of facility policy titled ''End-Stage Renal Disease, Care of a Resident with,'' revised 09/23, revealed, ''Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation . 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed.'' 1. Review of R44's admission Record located in the resident electronic medical records (EMR) under the ''Profile'' tab, revealed the resident was re-admitted on [DATE] with diagnoses that included ESRD. Review of R44's ''Physician Orders'' for June 2024. Located in the resident's EMR under the ''Order'' tab, indicated American Renal Associates ([NAME]) Dialysis on Monday, Wednesday, and Friday at 8:00 AM. During an interview on 06/18/24 at 4:57 PM, the Administrator indicated that there was not a dialysis contract for the dialysis center where R44 and R87 received dialysis treatments. 2. Review of R87's quarterly MDS with an ARD of 04/11/24, located in the MDS tab of the EMR revealed R87 admission date of 11/02/22 with a diagnosis of end stage renal disease and received dialysis. Review of R87's orders, dated 01/19/24, located in the EMR under the Order tab revealed Hemodialysis Schedule: Monday, Wednesday, and Friday Dialysis Location: 1560 Country Club Dr, Ste 101Madera, CA [California] 93638 [PHONE NUMBER] Dialysis Transportation All American (559) [PHONE NUMBER]: 10:30 AM On chair time: 12PM. Review of R87's Care Plan,9 revised 05/09/24, located in the EMR under the Care Plan tab revealed, The resident needs Hemodialysis out of facility r/t [related to] renal failure (ESRD). >Hemodialysis Schedule: MWF [Monday Wednesday Friday] Dialysis Location: [NAME] Kidney Center . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 13 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility policy review, the facility failed to implement their water management plan and failed to conduct an assessment to identify where bacterium Legionella and other waterborne pathogens could grow. This had the potential to affect all residents in the facility who consumed water. Residents Affected - Many Findings include: Review of the facility's policy titled Legionella Water Management Program, dated 09/2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .d. The identification of situations that can lead to Legionella growth, such as: (1) construction; (2) water main breaks; (3) changes in municipal water quality; (a) the presence of biofilm, scale, or sediment; (5) water temperature fluctuations; (6) water pressure changes; (7) water stagnation; and (8) inadequate disinfection . e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. Review of the testing for Legionella, dated 08/03/23, provided by the facility and completed by an outside company revealed the results of a sample taken from the kitchen sink, potable type, included 0.05 CFU/mL with the final results listed as ND [none detected]. Additional information included Legionella identification is carried out using a direct fluorescent antibody (DFA) for Legionella pneumophila (serogroups 1-14), a DFA for L. pneumophila serogroup 1 (LP1) and a DFA for 15 other Legionella species. L. pneumophila (2-14) has tested positive by DFA for L. pneumophila but negative for LP1. Legionella spp. have tested negative by DFA but are positive for growth on selective media. ND = None Detected/Below LOD. The limit of detection (LOD) is the lowest reportable CFU/mL count and is dependent on the sample volume processed and the dilutions used during testing . During an observation and interview on 06/21/24 at 4:36 PM, the facility's laundry room revealed the floor tiles under the wash machine on the right and numerous floor tiles next to the machine were noted to be wet, stained, and warped. The Account Manager (AM) who oversaw the laundry services was asked about the tiles and stated a pipe was leaking under the washer. AM confirmed the floor stayed wet and tiles were ruined due to the constant exposure to the water leaking. The AM stated staff mop the floor several times per shift to keep any standing water from occurring and growing microorganisms. The AM stated management was aware of the leak. During an interview on 06/21/24 at 5:26 PM, the Maintenance Supervisor (MS) was asked what plan was in place to assess and monitor for Legionella. MS stated he didn't assess or monitor for Legionella. He only checked the water temperatures. MS stated he was not aware of the regulation. MS was asked if he routinely flushed or cleaned drains and pipes such as showers and sinks to minimize standing water in the curved part of the pipes [P traps]. MS stated he only used a snake [a tool used to remove clogs in drains] to clean out debris in shower drains and pipe but did not use hot water, disinfectant, or complete visual inspections of drains or pipes. MS stated the ice machine was cleaned and sanitized monthly by an outside company. MS was asked about the water leak in the laundry room and MS stated he was not aware of it. MS stated he did bring in an outside company around May 2023 who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 14 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 conducted Legionella testing throughout the facility. MS stated the first sample taken from the three-compartment sink in the kitchen was positive for Legionella. MS stated the positive results revealed a very small non-harmful level. MS stated a second test was conducted and it was negative. The Administrator confirmed the first test showed positive for Legionella and replaced the three-compartment sink and faucet after the second test. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 15 of 16 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 055147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in 32 of 73 rooms (Rooms 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 and 50). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings include: Review of a letter signed by the facility's Administrator dated [DATE], provided by the facility, revealed To Whom it may concern, The following rooms at [NAME] Rehabilitation and Nursing Center are less than the required square footage: 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50. (While this letter revealed room [ROOM NUMBER] did not have the required SF, the room measured 166.75 and had two beds, which meets the required SF.) Review of undated Maintenance Records provided by the facility, revealed the following rooms at the facility were less than the required square footage (SF): Rooms: 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 38, 40, 42, 44, 46, 48 measured at 143.75 SF and all had two beds. Rooms: 39, 41, 43, 45, 47, 49, 50 measured 212.75 SF, and all had three beds. room [ROOM NUMBER] measured 166.75 SF. room [ROOM NUMBER] measured 218.5 SF and had three beds. room [ROOM NUMBER] measured 224.25 SF and had three beds. Rooms: 16, 17, 18, 19 measured 222 SF and all had three beds. During an observation on [DATE] at 3:54 PM, the following rooms were observed with the facility's Administrator: Rooms 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 38, 39, 40, 41, 42, 43, 45,46, 47, 48, 49, and 50. Each room contained a designated space for a resident bed, bedside table, closet/storage space, overbed table, lighting, call bell, bathroom, and privacy curtains. Each room and bathroom had space to ambulate and wheelchair access. During an interview on [DATE] at 9:51 AM, the Administrator stated they have a room waiver for multiple rooms that expired 04/24. The Administrator went on to say the waiver is renewed when they receive a deficiency, and they submit a plan of correction requesting a waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055147 If continuation sheet Page 16 of 16