Inspection·July 18, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A Skilled Nursing Facility (SNF) Beneficiary Notification Review, completed by facility staff after the survey entrance conference on 07/15/2024, revealed Resident #61's Medicare Part A Skilled Services Episode began on 03/12/2024 and the resident's last covered day of Part A services was 05/01/2024, which left the resident with 49 covered Part A skilled services days remaining. The document indicated that facility staff did not provide a SNF ABN Form CMS-10055 to the resident. Resident #61's medical record revealed no evidence that indicated a SNF ABN Form CMS-10055 was provided to the resident or responsible party. During an interview on 07/16/2024 at 2:59 PM, the Social Service Director (SSD) stated she provided residents with a Notice of Medicare Non-Coverage (NOMNC) but did not know what the SNF ABN Form CMS-10055 was. She stated she would have to ask her supervisor about the form. During an interview on 07/17/2024 at 1:42 PM, the SSD stated if a resident was discharged from therapy services, then therapy staff would provide the notice of discharge. She stated that she assisted the Director of Rehabilitation Services (DORS) if he needed her to assist. During an interview on 07/17/2024 at 2:45 PM, the DORS stated that therapy staff provided discharge notices if they issued the last covered day of therapy. He stated that he would usually issue the notice of discharge about a week before the planned discharge date , but they definitely issued the notice within three days of discharge, to give himself some time if he could not reach the responsible party or the family. He stated that he provided the NOMNC; that was his standard of practice for all patients whether they were on Part A or Part B, whenever they finished therapy. He stated that he had heard of the SNF ABN Form CMS-10055 before but did not give that form when a resident was discharged . He stated that they issued the SNF ABN Form CMS-10055 when residents were admitted but not upon discharge from therapy services. He did not know when they should be given. He stated that he did not know it was regulatory to issue the SNF ABNs for residents who remained in the facility and had Part A benefit days remaining. During an interview on 07/18/2024 at 9:07 AM, the Director of Nursing (DON) stated if a resident was being discharged from Part A therapy, the DORS was responsible to provide the notices of discharge. She stated that he contacted the responsible parties and talked them through the resident's progress and the reasons for the decision to discharge and provided the NOMNC to the resident or the responsible party. She stated that she had not heard of the SNF ABN Form CMS-10055 prior to this survey. She stated she did not know anything specific about Resident #57's notices. She stated she did expect all notices to be provided as appropriate. During an interview on 07/18/2024 at 10:17 AM, the Administrator stated as far as notifications of a change in payor source when being discharged from Part A Skilled therapy, the NOMNC was provided at least 72 hours prior to the discharge. He stated that he was familiar with the SNF ABN Form CMS-10055; however, the NOMNC had been what they used. He stated that the SNF ABN Form CMS-10055 was not something that they had focused on as a facility, only the NOMNC. He stated that he had reached out to others in their corporation, and it was not something they had been doing as a whole. The Administrator stated that he expected that they provide notices of discharge from Part A skilled services timely and accurately within the appropriate timeframes, and that staff provided all relevant forms as directed by the regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 2 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and facility document and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #41 and Resident #63) of 2 residents reviewed for MDS discrepancies. Residents Affected - Few Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, reflected, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. An admission Record revealed the facility admitted Resident # 41 on 08/02/2021. According to the admission Record, the resident had a medical history that included a diagnosis of schizophrenia. Resident #41's Preadmission and Resident Review (PASRR) Level I Screening, dated 08/03/2021, revealed the resident had a diagnosed mental disorder and received psychotropic medications. The Level I Screening was positive for a suspected serious mental illness (MI), and a Level II evaluation was required. Resident #41's Individual Determination Report, dated 03/24/2022, revealed the resident required nursing facility services due to a medical or mental health condition, and specialized services were recommended. However, an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, revealed Section A1500 was coded to reflect that Resident #41 was not considered to have a serious mental illness by the state Level II PASRR process. An admission Record revealed the facility admitted Resident # 63 on 11/22/2022. According to the admission Record, the resident had a medical history that included a diagnosis of schizophrenia. Resident #63's Preadmission and Resident Review (PASRR) Level I Screening, dated 11/23/2022, revealed the resident had a diagnosed mental disorder and received psychotropic medications. The Level I Screening was positive for a suspected serious mental illness (MI), and a Level II evaluation was required. Resident #63's Individual Determination Report, dated 12/15/2022, revealed the resident required nursing facility services due to a medical or mental health condition, and specialized services were recommended. However, an annual MDS, with an ARD of 08/11/2023, revealed Section A1500 was coded to reflect that Resident #63 was not considered to have a serious mental illness by the state Level II PASRR process. During an interview on 07/17/2024 at 3:30 PM, MDS Coordinator #11 said she was not aware Resident #41 and Resident #63 had a diagnosis of schizophrenia. She confirmed both MDS assessments were inaccurate and indicated Section A1500 should have been coded as yes, the residents were considered by the state Level II PASRR process to have a serious mental illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 3 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 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 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 07/18/2024 at 8:46 AM, the Director of Nursing (DON) said she expected MDS assessments to be accurate. During an interview on 07/18/2024 at 9:24 AM, the Administrator said he expected MDS assessments to be accurate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 4 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, record review, and facility policy review, the facility failed to post daily staffing in a conspicuous location and failed to update the posting with any changes due to changes in staffing. This had the potential to affect all residents that resided in the facility. Residents Affected - Many Findings included: A facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 08/2022, revealed Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The section titled, Policy Interpretation and Implementation, revealed, 1. The number of licensed nurses (RNs [registered nurses], LPNs [licensed practical nurses], and LVNs [licensed vocational nurses]) and the number of unlicensed personnel (CNAs [certified nurse assistants] and NAs [nurse assistants]) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The policy revealed, Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted; d. twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non-licensed nursing staff working for the posted shift. The policy revealed, The charge nurse competes the form and posts the staffing information in the location(s) designated by the administrator. A facility document titled, Call-Ins for 2024 revealed that on 07/10/2024, 07/11/2024, 07/12/2024, and 07/16/2024, one LVN and one CNA called in. On 07/13/2024, two CNAs and one RN called in. On 07/14/2024, two CNAs called in and on 07/15/2024, one CNA called in. The Daily Report for Nursing Staff Directly Responsible for Resident Care forms for 07/10/2024 through 07/16/2024 revealed no alterations were made to the postings to reflect the staff that had called in and the changes in the total number of direct care staff providing resident care. An observation on 07/16/2024 at 3:50 PM revealed the Daily Report for Nursing Staff Directly Responsible for Resident Care form was found hanging on the wall across from the Administrator's office on the service hall. The posting was located in the administrative hallway to the left of the main lobby/entrance, in the corner by the fire door wall. There were only two resident rooms located in the administrative hallway. During an interview on 07/18/2024 at 8:26 AM, the Staffing Coordinator stated she was responsible for posting the daily staffing numbers. She stated that she posted it the morning for the whole day. She stated that she did not update the daily report for staffing hours as the numbers were just projected numbers. She stated the Human Resources (HR) Coordinator documented the actual staffing numbers when she completed the State's staffing form to ensure they had the correct staffing numbers per patient day (PPD). She stated that she did not know the staffing sheets needed to be updated each shift; she had never been told that. She stated that there were only two or three rooms on the hall where they posted the daily staffing numbers. The Staffing Coordinator stated that ever since she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 5 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 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 0732 Level of Harm - Potential for minimal harm Residents Affected - Many started working at the facility, that was where the posting numbers had been posted. She stated that she had never been told it needed to be posted where all could see. During an interview on 07/18/2024 at 8:43 AM, the HR Coordinator stated that the daily postings she got from the Staffing Coordinator were not updated with call in's, it was only what the Staffing Coordinator posted in the mornings. During an interview on 07/18/2024 at 9:24 AM, the Director of Nursing (DON) stated the Staffing Coordinator posted the daily staffing numbers and if she was not available, she would ask the Social Service Director (SSD) or the business office staff to post it. She stated that the Staffing Coordinator did come in on some weekends, but she would have to ask her if she posted it on the weekends. She stated that the Staffing Coordinator sent out daily reports to show call-ins at least two hours before each shift and sent it to each shift and the nurse on shift updated the posting on shift. She stated that nurses were to make the changes. She stated that she reviewed the staffing numbers every day. The DON stated that the posting was located on the hall outside the Administrator's office. She stated that they had four residents potentially on the hall, so only those residents and their families would see it. She stated that the posting was not really in a conspicuous area; she could see that very few people would see it. During an interview on 07/18/2024 at 9:54 AM, the Staffing Coordinator stated that on the weekends she printed the daily staffing numbers for Saturday and Sunday so the nurses could go through and pull the actual one. She stated that the nurses updated the forms if needed for any changes to the numbers. During an interview on 07/18/2024 at 10:27 AM, the Administrator stated that he could see how a very limited number of residents, visitors, and families would be able to see the staffing sheets where they were currently posted. He stated that the form should be updated with any call-ins per shift. He stated that he expected the staffing sheets to be as accurate as possible in real time when accurate information was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 6 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure food was palatable, which affected 3 (Residents #6, #8, and #41) of 3 residents reviewed for food concerns and had the potential to affect all residents receiving meals from the dietary department. Residents Affected - Many Findings included: A facility policy titled, Food and Nutrition Services, revised in 10/2017, reflected, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it served at a safe and appetizing temperature. Resident Council meeting notes, dated 05/03/2024, revealed the residents complained that Food is too tough and dry. Resident Council meeting notes, dated 06/07/2024, revealed the residents complained that Food is always cold, food has no taste, and Food is too dry. During an interview on 07/15/2024 at 12:14 PM, Resident #41 said the food at the facility was awful. According to an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview on 07/15/2024 at 2:40 PM, Resident #6 said the food at the facility was not good, and the meat was tough. According to a quarterly MDS, with an ARD of 05/04/2024, Resident #6 had a BIMS score of 15, which indicated the resident was cognitively intact. During an interview on 07/15/2024 at 3:55 PM, Resident #8 said the food at the facility was not good. According to a quarterly MDS, with an ARD of 05/08/2024, Resident #8 had a BIMS score of 13, which indicated the resident was cognitively intact. During an observation of the lunch meal service on 07/16/2024, a test tray was requested. The test tray was prepared and placed on a meal service cart at 11:56 AM. The test tray consisted of chicken, rice, and beets. The meal service cart left the kitchen at 12:00 PM, arrived on the unit at 12:02 PM, and staff began passing the trays at 12:03 PM. The last resident was served at 12:15 PM. At 12:25 PM, the meal tray was tested with the Dietary Supervisor. The Dietary Supervisor described the chicken as dry and said the rice had no flavor. During a follow-up interview on 07/16/2024 at 12:56 PM, Resident #41 stated the chicken was dry, and the rice did not have a taste. During a follow-up interview on 07/16/2024 at 12:57 PM, Resident #6 stated the chicken was dry and tasted like sawdust. Resident #6 stated the rice tasted as though staff had not used enough water when preparing it. During a follow-up interview on 07/16/2024 at 2:13 PM, Resident #8 said the chicken was dry and the rice did not have a flavor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 7 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 07/17/2024 at 9:41 AM, the Dietary Supervisor said the chicken that was served on 07/16/2024 was dry, and the rice was bland. The Dietary Supervisor indicated the cook should have added broth to the chicken to maintain the moisture of the food. During an interview on 07/18/2024 at 9:09 AM, the Administrator said he expected the taste and presentation of the food to be acceptable. Event ID: Facility ID: 055448 If continuation sheet Page 8 of 9 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 055448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff utilized proper hand hygiene during meal service on 07/16/2024, which had the potential to affect all residents receiving meals from the dietary department, aside from the 12 residents with pureed diet orders, as the pureed trays were served by a different staff member. Findings included: A facility policy titled, Food Preparation and Service, revised in 11/2022, revealed the section of the policy titled, General Guidelines specified, 2. Cross-contamination can occur when harmful substances i.e. [id est, that is], chemical, or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. The section of the policy titled, Food Distribution and Service specified, 5. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents and 7. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. During an observation of the lunch meal service on 07/16/2024 beginning at 11:23 AM, [NAME] #1 used her gloved right hand to open the oven, and then used the same gloved hand to remove a grilled cheese sandwich and place it onto a resident's tray. She did not wash hands or change gloves. At 11:55 AM, [NAME] #1 was again observed using her gloved right hand to open the oven, then used the same gloved hand to place tater tots onto a resident's tray, then continued meal service without changing gloves or washing hands. [NAME] #1 was observed using her gloved right and left hand to pick up chicken breasts and place them on residents' trays. Without washing hands or changing gloves, [NAME] #1 continued using the same gloved hands to place rolls on residents' trays during the remainder of the meal service. During an interview on 07/16/2024 at 12:39 PM, [NAME] #1 said she knew that after touching multiple items, she should have changed her gloves. [NAME] #1 confirmed she did not change her gloves after opening the oven or touching food items with her gloved hands. During an interview on 07/17/2024 at 9:41 AM, the Dietary Supervisor said the cook should have asked her helper to open the oven and remove the food items. The Dietary Supervisor further stated the cook should have changed gloves after opening the oven and should not have touched multiple food items with the same gloved hands. During an interview on 07/18/2024 at 8:41 AM, the Director of Nursing (DON) stated that if dietary staff touched residents' food, they should change gloves. During an interview on 07/18/2024 at 9:17 AM, the Administrator said he expected dietary staff to follow better hand hygiene practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055448 If continuation sheet Page 9 of 9