Health inspection·February 25, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few death within a population, often expressed as a rate risk)). The H&P indicated Res 1 fell off a vehicle and suffered a ground level fall with multiple fractures (crack or break in a bone). Res 1 had pubic rami fractures (crack or break in the small bones at the very front of the pelvis), comminuted and displaced fractures involving the right superior and inferior pubic rami (indicate a high-energy pelvic injury where the bone is broken into multiple pieces and shifted, often resulting in an unstable pelvic ring ( bowl-shaped bony ring at the base of spine that acts as the anchor point between upper body and legs)), right alae of the sacrum displaced fracture (the wing-shaped bone at the base of the spine (sacrum) on the right side is broken, and the pieces may have shifted out of place often causes severe lower back/buttock pain), associated small soft tissue hematoma (collection of clotted blood outside blood vessels) at the intraperitoneal of retzium (hidden area of lower pelvis, right between bladder and pubic bone (the front of your pelvis)), right L5 (L1 to L5, five large, bones located in the lower back between the rib cage and pelvis) lateral transverse process comminuted displaced fracture (bony projection on the right side of the 5th lumbar vertebra is broken into multiple pieces and shifted from its normal position). The H&P indicated Res 1 underwent percutaneous fixation right posterior pelvis percutaneous reduction and fixation anterior pelvis (a minimally invasive technique to stabilize anterior and posterior pelvic ring disruptions through small incisions, reducing blood loss and infection risk compared to open surgery).During an interview on [DATE] at 12:20 p.m. with Res 1, Res 1 stated she had expressed her concerns to the Director of Social Services (DSS), the Business Manager (BM), and nursing leadership (unable to recall specific name) at the facility. Res 1 showed pictures of the bed side drawer with personal belongings inside, the flooring appeared to be dirty with some black residue and streaks on it and stated she had taken these pictures upon admission to the facility. Res 1 stated she was unable to take a picture of dirty bed as she was already transferred onto the bed. During an interview on [DATE] at 12:55 p.m. with the Director of Staffing Development (DSD), the DSD stated she was familiar with Res 1. The DSD stated Res 1 expressed concerns upon admission about her room and they were all addressed promptly. The DSD stated Res 1 arrived at 6:20 a.m. on [DATE], during the shift change on [DATE]-night shift going into early morning [DATE] day shift. The DSD stated Res 1 had a concern that she was placed in an unclean bed upon arrival to the facility. The DSD stated Res 1 also had concerns that personal belongings and clothes were present in a closet and drawer, and both of the storage spaces were not clean. The DSD stated and validated that the closet and bed side drawer were not empty after the previous resident was discharged , however, she stated she was not aware and was not able to validate whether the bed and bed linens were dirty upon admission of Res 1. The DSD stated Res 1 also had concerns with the floor not being cleaned and it was addressed immediately. The DSD stated Res 1 expressed these concerns to her and the BM and she apologized to Res 1 for her experience. The DSD stated the facility in-serviced the staff and housekeeping about the importance of ensuring the room was ready for the resident upon admission. The DSD was not able to comment on why the room closet and bed side drawer were not cleared of the personal belongings of the last resident [Res 3], who was assigned to the bed prior to Res 1. The DSD stated the facility process was to clean the bed, change the linens immediately after the resident was discharged or sent to hospital. The DSD stated the bed where Res 1 was placed upon admission was on hold until midnight for Res 3. The DSD stated Res 1 arrived at 6:20 a.m. (approximately six hours later after the bed hold had expired for Res 3) and was placed in the bed. The DSD stated per the facility's Certified Nursing Assistant (CNA -provides essential daily care to patients in nursing homes under the supervision of nursing staff) staff present on the shift, stated the bed linen was clean, however, the resident stated the linen was not clean when she was placed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055423 If continuation sheet Page 2 of 5 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 055423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manning Gardens Care Center, Inc 2113 E. Manning Avenue Fresno, CA 93725 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it. The DSD stated the facility was required to hold a bed for seven days when a resident went to the hospital. The DSD stated the facility process was to leave personal belongings in place during bed holds, however, the bed and the linens were cleaned. The DSD stated she expected the facility staff to remove the belongings of previous residents and provide a safe and clean environment to every resident upon arrival. During an interview on [DATE] at 3:12 p.m. with the Infection Prevention Nurse (IP), the IP stated she had been working at the facility in her role since 2021. The IP stated she was familiar with Res 1's concerns. The IP stated she heard from her colleagues when she started her shift on [DATE] that Res 1 was very upset about her bed, personal storage space, and the floor. The IP stated Res 1's concerns were regarding cleanliness of the bed and the dirty and sticky flooring. The IP stated it was not acceptable to have sticky flooring or dirty beds. The IP stated Res 1 was very upset, and the dirty floors and dirty bed could potentially be a source of infection. The IP stated the facility's normal process was to clean the floor and bed in between residents and she was unable to comment whether the facility's normal process was followed. The IP stated she was unsure if the bed was clean or dirty prior to admitting Res 1. The IP stated the facility process was to clean the bed prior to each admission.During an interview on [DATE] at 3:20 p.m. with the BM, the BM stated he was made aware of Res 1's concerns. The BM stated he spoke to Res 1 to get her signatures on the admission paperwork. The BM stated Res 1 notified him of her concerns regarding cleanliness of the floor. The BM stated the floor appeared to have a sticky residue in the back corner. The BM stated he was unable to comment regarding whether the bed was dirty or had soiled linen. The BM stated Res 1 was already on a clean bed when he went to talk to her. The BM stated he went in to speak with Res 1 around 9:00 a.m. and Res 1 arrived at facility around 6:20 a.m. The BM stated he did not open the closet or the drawer, but stated Res 1 mentioned the drawer had some belongings from the previous resident. During an interview on [DATE] at 3:58 p.m. with Registered Nurse (RN) 1, RN 1 stated she was the admitting nurse for Res 1 upon admission to the facility. RN 1 stated Res 1 arrived right before her shift ended. RN 1 stated she went in to check on Res 1 and did not recall Res 1 mentioning any concerns to her. RN 1 stated the admission assessment and paperwork were completed by the incoming shift staff. RN 1 stated she did not recall noticing any personal belongings in the bed side storage.During an interview on [DATE] at 4:15 p.m. with Res 2, Res 2 stated she was present in the next bed in the same room when Res 1 was admitted . Res 2 stated Res 1 was placed in a dirty bed and it had personal belonging of [Res 3], who was sent to hospital. Res 2 stated the closet, the drawer and the bed had items from the previous resident and the facility was holding the bed for Res 3's return. Res 2 stated it was not fair to Res 1 to lie in someone else's dirty bed. During an interview on [DATE] at 4:01 p.m. with Housekeeping Staff (HS) 1, HS 1 stated she had been working at the facility for a year. HS 1 stated the facility process when someone was discharged from the facility or sent out to hospital, CNAs collected all the personal belonging and emptied bedside drawers and the closet. HS 1 stated the HS team did not clean closets or drawers unless they had been emptied completely. HS 1 further stated the bed linens and personal belongings had to be removed for the HS team to clean the bed. HS 1 stated she was not working when Res 1 was admitted to the facility and was not able to comment on Res 1's concerns or whether the facility process was followed.During an interview on [DATE] at 10:17 a.m. with HS 2, HS 2 stated she had been working at the facility for over ten years. HS 2 stated the room turn over process was that when a resident left, the CNA stripped [removes everything from the bed ] the bed and called the housekeeping staff to clean the room. HS 2 stated the housekeeping team member got the bed ready by wiping and disinfecting the bed. HS 2 stated she also cleaned the drawer and the closet as soon as she could after the CNA emptied them. HS 2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055423 If continuation sheet Page 3 of 5 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 055423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manning Gardens Care Center, Inc 2113 E. Manning Avenue Fresno, CA 93725 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few housekeeping staff did not touch personal belongings. HS 2 stated if the facility was holding the bed for a resident to return to the facility then the housekeeping team left the bed alone and did not remove personal belongings. HS 2 stated she was familiar with Res 1 and worked with Res 1 upon her admission. HS 2 stated she started her shift at 7:00 a.m. shortly after the Res 1's arrival to the facility. HS 2 stated the nursing staff was in Res 1's room with Res 1's roommate, when she first started her shift and she had planned to return. HS 2 stated shortly after she returned to Res 1's room and Res 1 expressed concerns to her regarding the dirty bed, dirty floor, closets and bed side drawer. HS 2 stated she apologized to Res 1 and cleaned everything in Res 1's room. HS 2 stated Res 1 was very appreciative and stated she was little tired from the long ride to the facility. HS 2 stated as far as she was aware, the facility was waiting for the previous resident to return to the facility to the same bed. HS 2 stated the facility did not have HS staff at night and she did not work on the same side the previous week and was not able to comment whether the room was cleaned or not. HS 2 stated the floor was dirty with sticky stuff, however, the patient was already on the bed, and she was unable to comment whether the linen was dirty when the resident first arrived to the facility. During an interview on [DATE] at 12:40 p.m. with the RN 2, RN 2 stated she was the primary RN for Res 1 when she was admitted . RN 2 stated she did not recall Res 1 expressing any concerns when she completed Res 1's initial assessment. RN 2 stated when she assessed Res 1, she was already on the bed. RN 2 stated she did notice items in the closet and asked CNA to put everything away and empty the closet for Res 1's use. During an interview on [DATE] at 10:30 a.m. with the administrator (ADM), the ADM stated he was made aware of Res 1's concerns regarding the sticky floors. The ADM stated he was not aware of any other concerns. The ADM stated as far as he was aware no one at the facility saw any belongings in the bed side storage or the bed being dirty upon Res 1's admission. The ADM stated he would have to check with admissions person as they make arrangements and was not able to comment on whether the bed where Res 1 was placed was on hold for Res 3 prior to Res 1's arrival. The ADM stated it was not common for night shift to receive admissions and there was a possibility the staff may not have realized the previous resident's personal belongings needed to be removed prior to admitting Res 1, however, he needed to validate with the facility staff. The ADM stated he had not heard that the bed linens or the bed was dirty when Res 1 was admitted . During an interview on [DATE] at 2:09 p.m. with the ADM, the ADM stated if the bed was on hold for Res 3 prior to Res 1's admission, the facility staff would not have removed the personal belongings and housekeeping would not have cleaned the drawers and storage closet. The ADM stated the facility process was to clean the bed after the resident's transfer or discharge from the facility, even if the bed was placed on hold and the resident returned to the facility. The ADM stated this (Res 1's) admission was an unusual circumstance, as the hold [for Res 3's bed] was up at midnight and Res 1 was admitted around six in the morning. The ADM stated it was unusual for the night shift staff to admit residents and the facility could have done a better job with coordinating the admission and ensuring Res 1 was satisfied. The ADM stated he was not able to validate the concerns regarding the dirty bed or soiled linens, however, it could be possible that Res 3's belongings were left in a closet and/or bedside drawers when Res 1 arrived at the facility. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Home like environment, dated [DATE], the P&P indicated, . Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . Clean, sanitary and orderly environment . Clean bed and bath linens that are in good (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055423 If continuation sheet Page 4 of 5 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 055423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manning Gardens Care Center, Inc 2113 E. Manning Avenue Fresno, CA 93725 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete condition .During a review of the facility's P&P titled, Infection Control, dated [DATE], the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .The objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .During a review of facility's P&P titled, Quality of Life - Dignity, dated February 2020, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem . Residents are treated with dignity and respect at all times . The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay . Residents' private space and property are respected at all times .During a review of the facility's P&P titled, Resident Rights, dated [DATE], the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity . rights that include the resident's right to . dignified existence . be treated with respect, kindness, and dignity . be free from abuse, neglect, misappropriation of property, and exploitation . Event ID: Facility ID: 055423 If continuation sheet Page 5 of 5