Health inspection·May 19, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 5/11/21, at 5:17 p.m. with the ADM, in Bathroom [ROOM NUMBER], the ADM stated he was aware of the broken tile and the uneven paint. The ADM stated his expectation for MAINT was for him to ensure safety in the facility. The ADM stated Bathroom [ROOM NUMBER] was a work in progress. The ADM stated the broken tile, loose baseboard and uneven paint did not look good. Residents Affected - Few A request was made for the facility's policy and procedure and the facility did not provide one prior to the exit of the survey. During review of the facility document titled Job Description . Maintenance Supervisor dated October 10, 1995, the Job Description indicated, . To ensure the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained . Duties . Ensure equipment and work areas are clean, safe and orderly . and promptly address any hazardous conditions and equipment . Perform minor repairs and supervise the day-today repair, improvement and preventative maintenance of the building, equipment . may perform and supervise floor care . 2. During an observation on 5/10/21, at 3:54 p.m., in Bathroom [ROOM NUMBER], the soap dispenser was not functional. The handle on the soap dispenser was loose and there was no soap in the dispenser. During an observation on 5/11/21, at 10:16 a.m , in Bathroom [ROOM NUMBER], the soap dispenser was not functional. The handle on the soap dispenser was loose and there was no soap in the dispenser. During a concurrent observation and interview on 5/11/21, at 4:45 p.m., with CNA 3, in Bathroom [ROOM NUMBER], CNA 3 stated the soap dispenser did not work. CNA 3 stated there was no soap in the soap dispenser. CNA 3 stated the soap dispenser should have worked because she needed to wash her hands after providing residents with care. CNA 3 stated she needed soap to wash her hands to ensure she did not get an infection and protect herself and the residents in the facility. During a concurrent observation and interview on 5/13/21, at 9:13 a.m., with CNA 7, in Bathroom [ROOM NUMBER], CNA 7 stated the soap dispenser did not work. CNA 7 stated the MAINT was notified the soap dispenser did not work. CNA 7 stated she verbally notified MAINT the soap dispenser did not work. During a concurrent observation and interview on 5/13/21, at 9:29 a.m. with the MAINT, in Bathroom [ROOM NUMBER], the MAINT stated one of the facility supervisors should have notified him the soap dispenser did not work. The MAINT stated once he was notified, he would notify the housekeeping supervisor to order a new soap dispenser, and he would replace the broken soap dispenser. The MAINT stated he had not been notified the bathroom soap dispenser was broken. The MAINT stated he did not have a system in place for staff to let him know when items needed to be fixed in the facility. During an interview on 5/13/21, at 10:38 a.m. with the MAINT, the MAINT stated he did not have a system in place for staff to notify him when items needed to be fixed in the facility. The MAINT stated he used to have an electronic record system for documenting preventative maintenance, but the system had not been working for the past three weeks. A request was made for the facility's policy and procedure and the facility did not provide one prior to the exit of the survey. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 2 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 During review of the facility document titled Job Description . Maintenance Supervisor dated October 10, 1995, the Job Description indicated, . To ensure the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained . Duties . Ensure equipment and work areas are clean, safe and orderly . and promptly address any hazardous conditions and equipment . Perform minor repairs and supervise the day-today repair, improvement and preventative maintenance of the building, equipment . may perform and supervise floor care . 3. During a concurrent observation and interview on 5/11/21, at 10:04 a.m., with Resident 34, in Resident 34's room, a gap between the window and the window frame seal was observed. Resident 34 stated, It does not look good, I have to tell [MAINT], I told him long time ago. Resident 34 stated, . It's sealed on the outside, so no heat or air come in, but it does not look good. During a concurrent observation and interview on 5/11/21, at 5:10 p.m., with the MAINT, in Resident 34's room, the MAINT stated the bedrail from Resident 34's bed had lifted the window frame. The MAINT stated he was not made aware of the gap between the window and the window frame. The MAINT stated the window seal should not have a gap because Resident 34 could get hurt by the wood and obtain a splinter and it was not safe. The MAINT provided measurements of the window gap, the measurements were measured 71 inches in length, five inches in width and the gap measure half inch. During a concurrent observation and interview on 5/11/21, at 5:15 p.m. with the ADM, in Resident 34's room, the ADM stated the window gap should be fixed and the facility had not identified the gap because the environment was not a priority. The ADM stated his expectation was for MAINT to fix things in the facility. The ADM stated Resident 34's window should not have a gap because it was not a feature to have and needed to be fixed and it was not okay that it looked because it if was okay then MAINT would not have to fix the window gap. A request was made for the facility's policy and procedure and the facility did not provide one prior to the exit of the survey. During review of the facility document titled Job Description . Maintenance Supervisor dated October 10, 1995, the Job Description indicated, . To ensure the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained . Duties . Ensure equipment and work areas are clean, safe and orderly . and promptly address any hazardous conditions and equipment . Perform minor repairs and supervise the day-today repair, improvement and preventative maintenance of the building, equipment . may perform and supervise floor care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 3 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview and record review, the facility failed to make information available for three of seven sampled residents (Residents 23, 25 and 29) when residents were unaware of how to file a grievance or complaint. This failure had the potential to result in Resident 23, 25 and 29 to have their concerns or grievances unaddressed. Findings: During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the Director of Social Services (DSS) was the grievance official. Resident 23 stated, I do not know how to file a grievance . During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 5/12/21, at 10:30 a.m., with Resident 29, Resident 29 stated, I don't know how to file a grievance on a form . Resident 29 stated he would notify staff if he had a complaint but had not filed a formal grievance. During a review of Resident 29's MDS assessment, dated 4/13/21, the MDS assessment indicated, Resident 29 was cognitively intact with a BIMS score of 15. During an interview on 5/12/21, at 10:36 a.m. with Resident 25, Resident 25 stated, I have not filed a grievance. I don't know to file a grievance. Resident 25 stated the facility should have forms to fill out but he did not know where the forms were located. During a review of Resident 25's MDS assessment, dated 4/9/21, the MDS assessment indicated, Resident 25 was moderately impaired with a BIMS score of 10. During a concurrent interview and record review on 5/13/21, at 11:18 a.m., with the DSS, the grievance folder was reviewed. The DSS stated residents in the facility could file a complaint or grievance regarding concerns with care or lost items. The DSS stated a complaint or grievance could be brought to her attention by the nurses and she would follow up with the residents. The DSS stated complaints could be made verbally to her by staff and the residents. The DSS stated when verbal complaints were brought up to her, she did not file the complaint on the grievance form. The DSS stated she should document the complaints on the grievance form. The DSS stated she would keep the grievance forms in a binder, and she would keep the binder in her office. The DSS reviewed the grievance folder and stated for the months of April 2021 and May 2021, there were no grievances filed. The DSS stated the previous DSS trained her on how to file a grievance, what a grievance was, the process to file a grievance and making sure the grievance or complaint was resolved. The DSS stated she placed the grievance forms outside of her office near the back of the building. The DSS stated she did not notify the residents where the forms were located and she should have notified the residents so residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 4 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were aware of how to locate the grievance forms and their right to file a grievance. The DSS stated she had not documented grievances or complaints and would address the concerns with the residents but did not have documentation. The DSS stated the grievance forms should be located in the nurse's station but was unsure if the grievance forms were located in the nurse's stations. During a concurrent observation and interview on 5/14/21, at 4:53 p.m., with the Director of Nursing (DON), the DON stated the grievance forms were located outside of the DSS' office towards the back of the facility. During a concurrent observation and interview on 5/14/21, at 4:55 p.m., with Licensed Vocational Nurse (LVN) 1 and Medical Records (MR), in the nurse's station, LVN 1 and the MR were unable to locate a grievance form. During an interview on 5/14/21, at 5:29 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she did not know what a grievance form was and did not know where to locate a grievance form if a resident asked for a grievance form. CNA 3 stated she would not be able to help a resident file a grievance forms if requested. During a concurrent interview on 5/15/21, at 9:51 a.m., with the DON and the Administrator (ADM), the DON was unable to name the grievance official. The ADM stated the DSS was the grievance official and she was responsible to follow up with the grievance forms. During a review of the facility's document titled, Resident Grievance/Complaint Procedures, undated, the facility document indicated, .A resident . may file a verbal or written grievance or complaint concerning, treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members . You are requested to follow the procedures outlined below when filing a written grievance or complaint: 1. Obtain a Resident Grievance/Complaint Form from the nurses' station or from outside the Social Services office. It is the policy of the facility to assist you in filing a grievance or complaint as needed . 4. Give the completed form to the Grievance Official. If the Grievance Official is not available you may leave the form with the supervisor on duty . 8. Grievance Official contact information: Name: [Administrator] . During a review of the facility's policy and procedure (P&P) titled, [Skilled Nursing Facility] Grievance Policy, dated 5/14/17, the P&P indicated, . A resident will be notified individually or through postings in prominent locations throughout the care center of: The right to file a grievance orally (meaning spoken) or in writing . A Grievance Official will: Oversee the grievance process . Receive and track grievances through their conclusion . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 5 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for three of three sampled residents (Residents 5, 13, and 39) when: Residents Affected - Some 1. Resident 5's MDS assessment of hearing and cognition were not coded accurately; 2. Resident 13's dialysis (use of machine to remove wastes from the body and keep body in balance) status was not coded (a system of signals used to represent letters or numbers in transmitting messages) accurately in Section O (Special Treatments, Procedures, and Programs) of the MDS assessment; and 3. Resident 39's MDS assessment for identification information was not coded accurately to indicate the accurate discharge status. These failures had the potential of the facility to not provide the necessary care and services to meet the residents' individualized needs. Findings: 1. During a concurrent observation and interview on 5/10/21, at 8:15 a.m., with Resident 5, in Resident 5's room, Resident 5 was hard of hearing and did not have hearing aids in his ears. During an interview on 5/11/21, at 9:40 a.m., with Resident 5, Resident stated he did not have hearing aids because the hearing aids were at home. During an interview on 5/12/21, at 12:24 p.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 5 was heard of hearing because when she talked to him while standing at the foot of his bed, Resident 5 could not hear her. CNA 7 stated Resident 5 did not have hearing aids. During a review of Resident 5's MDS assessment .Section B Hearing, Speech and Vision dated 2/19/21, the MDS assessment, Section B indicated, Ability to hear (with hearing aid or hearing appliances if normally used): Adequate-no difficulty in normal conversation, social interaction, listening to TV . During a review of Resident 5's MDS assessment Section C Cognitive Patterns dated 2/19/21, the MDS assessment, Section C Cognitive Patterns was blank. During a review of Resident 5's Care Plan (CP), dated 2/15/21, the CP indicated, Focus: Impaired Communication due to . [diagnosis] of hearing loss bilateral (both sides) . During a review of Resident 5's admission Record (AR- document that gives a resident's information at a quick glance), undated, the AR indicated, . admission Date: 2/12/2021 . Diagnosis Information . Unspecified Hearing Loss, Bilateral . Onset Date: 2/12/2021 . During a concurrent interview and record review on 5/13/21, at 1:43 p.m. with the Director of Staff Development (DSD) and the Minimum Data Set Consultant (MDSC), Resident 5's MDS assessment Section B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 6 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 Residents Affected - Some and Section C dated 2/19/21 were reviewed. The MDS assessment Section B indicated, Ability to hear (with hearing aid or hearing appliances if normally used): Adequate-no difficulty in normal conversation, social interaction, listening to TV . The MDS assessment Section C was blank. The DSD stated she had been working in the facility for one year. The MDSC stated he had been helping the facility to complete the MDS assessments since March 2021 and was training the DSD on MDS assessment completion. The DSD stated she started in April 2021 as the MDS assessment nurse. The MDSC stated he reviewed Resident 5's medical record and the nurse's documentation to determine Resident 5 hearing status. The MDSC stated Resident 5 was admitted with hearing loss. The MDSC stated hard of hearing indicated, . loss where they may be enough residual hearing . The MDSC stated Resident 5 had a communication deficit and bilateral hearing loss. The MDSC stated he co-signed the hearing assessment on 3/13/21 as adequate. The MDSC stated he did not assess Resident 5's hearing status and coded the assessment for hearing as adequate. The DSD stated Resident 5's BIMS was not assessed on 2/19/21 and the assessment was blank. The MDSC stated the Resident 5's BIMS assessment was blank because staff had not completed the assessment. The MDSC stated the BIMS assessment should be completed upon admission, quarterly and annually. The MDSC stated Resident 5's BIMS (Brief Interview for Mental Status-an evaluation of attention, orientation and memory recall) assessment was missed. During a review of the facility's policy and procedure (P&P) titled, [Resident Assessment Instrument (RAI) Process .Clinical Assessment and Reimbursement dated 8/20/15, the P&P indicated, .All Living Centers will utilize the CMS (Centers for Medicare and Medicare Services- federal agency that administers the nation's major healthcare programs) regulations which are considered the definitive source in completion of the [Resident Assessment Instrument] process. This include coding the MDS, completion of Care Area Assessments (CAA's) and the development of the comprehensive plan of care . All Living Centers will utilize the CMS RAI Manual for completion and compliance of the RAI Process . During a review of the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, . 1. the assessment accurately reflects the resident's status .In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident ' s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment . 2. During a concurrent observation and interview on 5/10/21, at 8:30 a.m., with Resident 13, Resident 13 sat in his wheelchair inside his room. Resident 13 had an elastic bandage on his right arm. Resident 13 stated he had a fistula (a connection that's made between an artery and a vein for dialysis access) on his right arm for dialysis. Resident 13 stated, I have been going to dialysis for years and I go to Fresno every Tuesdays, Thursdays and Saturdays. During a review of Resident 13's AR, the AR dated 4/27/21, indicated, . admission Date 2/22/21 . Diagnosis Information . End Stage Renal Disease (Kidney function declined that kidney function can no longer function on their own) . Dependence on Renal Dialysis . During a concurrent interview and record review on 5/12/21, at 9:40 a.m., with the MDS nurse, the MDS nurse reviewed the MDS Section O of Resident 13's five day MDS assessment dated [DATE]. The MDS nurse stated Resident 13's dialysis was not coded in Section O. The MDS nurse stated MDS Section O, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 7 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 Residents Affected - Some Dialysis was coded as No, the MDS nurse stated the MDS assessment should have been coded as Yes because Resident 13 received dialysis prior to admission in the facility and while Resident 13 was a resident in the facility. The MDS nurse stated Resident 13's dialysis status was not accurately assessed and should have been. During an interview on 5/18/21, at 10:11 a.m., with the Director of Nursing (DON), the DON stated she expected the MDS assessments to be accurate. The DON stated Resident 13 was already receiving dialysis prior to his admission in the facility and continued to receive dialysis while a resident in the facility. The DON stated Resident 13's MDS assessment should have been accurately assessed and coded in the MDS assessment section O. During a review of the facility's P&P titled, RAI Process .Clinical Assessment and Reimbursement dated 8/20/15, the P&P indicated, .All Living Centers will utilize the CMS (Centers for Medicare and Medicare Services- federal agency that administers the nation's major healthcare programs) regulations which are considered the definitive source in completion of the [Resident Assessment Instrument] process. This include coding the MDS, completion of Care Area Assessments (CAA's) and the development of the comprehensive plan of care . All Living Centers will utilize the CMS RAI Manual for completion and compliance of the RAI Process . During a review of the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, . 1. the assessment accurately reflects the resident's status .In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident ' s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment . 3. During a review of Resident 39's AR undated, the AR indicated, . admission Date 2/14/2021 . During a review of Resident 39's Progress Notes (PN), dated 3/12/21, the PN indicated, . Resident discharged today home [at] 11:15 a.m. with home health [physical therapy occupational therapy and nursing .] During a review of Resident 39's MDS assessment .Section A dated 3/12/21, the MDS assessment, Section A indicated, . Discharge Status .Acute Care Hospital . During a concurrent interview and record review on 5/13/21, at 2:16 p.m., with the DSD and the MDSC, Resident 39's AR undated and MDS assessment, Section A dated 3/12/21 were reviewed. The MDSC stated Resident 39 was admitted to the facility on [DATE] and discharged home on 3/12/21. The MDSC stated the MDS assessment, Section A indicated Resident 39 was discharged to the acute care hospital. The MDSC stated the discharge status was inaccurate and the assessment should have indicated Resident 39 was discharged to the community. The MDSC and DSD stated Resident 39's MDS assessment was inaccurate. The DSD stated she completed Resident 39's discharge assessment and the assessment was inaccurate. The MDSC stated it was important to have accurate assessment information for the residents in the facility because the Centers for Medicare and Medicaid (CMS- federal agency that administers the nation's major healthcare programs) would review the information and would track the information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 8 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 Residents Affected - Some During an interview on 5/19/21, at 9:01 a.m., with the Administrator (ADM), the ADM stated the facility had a Minimum Data Set Coordinator in August 2020. The ADM stated the facility had received assistance from other facilities to conduct the MDS assessments since August 2020. The ADM stated the MDSC was training the DSD to complete MDS assessments. The ADM stated the MDSC would come to the facility to assist in MDS assessment completion two to three days a week. The ADM stated his expectation was for the MDSC to come into the building and complete the assessments onsite. During an interview on 5/19/21, at 9:04 a.m., with the DON, the DON stated the MDSC and the DSD should complete accurate assessments for the residents in the facility because the information was transferred to CMS. The DON stated the expectation for the MDSC and DSD was to complete accurate assessments. During a review of the facility's P&P titled, RAI Process . Clinical Assessment and Reimbursement . dated 8/20/15, the P&P indicated, Living Centers adhere to all CMS regulations which are considered the definitive source in completion of the [Resident Assessment Instrument] process. This include coding the MDS, completion of Care Area Assessments (CAA's) and the development of the comprehensive plan of care . All Living Centers will utilize the CMS RAI Manual for completion and compliance of the RAI Process . During a review of CMS's RAI Version 3.0 Manual Version 1.17.1 dated October 2019, indicated, Chapter 3 Section A OBRA Discharge Status . Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location . Code . 1, community (private home . if discharge location is a private home . Section B: Hearing .Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders. Unaddressed communication problem related to hearing impairment can be mistaken for confusion or cognitive impairment . Steps for assessment 1. Ensure that the resident is using his or her normal hearing appliance if they have one . 2. Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using telephone, watching TV, attending activities). 3. Observe the resident during your verbal interactions and when he or she interacts with others throughout the day. 4. Think through how you can best communicate with the resident. For example, you may need to speak more clearly, use a louder tone, speak more slowly or use gestures. The resident may need to see your face to understand what you are saying, or you may need to take the resident to a quieter area for them to hear you. All of these are cues that there is a hearing problem. 5. Review the medical record. 6. Consult the resident's family, direct care staff, activities personnel, and speech or hearing specialists. Code 0, adequate: No difficulty in normal conversation, social interaction, or listening to TV. The resident hears all normal conversational speech and telephone conversation and announcements in group activities. Code 1, minimal difficulty: Difficulty in some environments (e.g., when a person speaks softly or the setting is noisy). The resident hears speech at conversational levels but has difficulty hearing when not in quiet listening conditions or when not in one-on-one situations. The resident's hearing is adequate after environmental adjustments are made, such as reducing background noise by moving to a quiet room or by lowering the volume on television or radio. Code 2, moderate difficulty: Speaker has to increase volume and speak distinctly. Although hearing-deficient, the resident compensates when the speaker adjusts tonal quality and speaks distinctly; or the resident can hear only when the speaker's face is clearly visible. Code 3, highly impaired: Absence of useful hearing. The resident hears only some sounds and frequently fails to respond even when the speaker adjusts tonal quality, speaks distinctly, or is positioned face-to-face. There is no comprehension of conversational speech, even when the speaker makes maximum adjustments . Section C: Cognitive Patterns . Steps for Assessment: Basic Interview Instructions for BIMS 1.Refer to Appendix D for a review of basic approaches to effective interviewing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 9 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete techniques. 2. Interview any resident not screened out by Should Brief Interview for Mental Status Be Conducted? (Item C0100). 3. Conduct the interview in a private setting. 4. Be sure the resident can hear you. Residents with hearing impairment should be tested using their usual communication devices/techniques, as applicable . Planning for Care o The BIMS is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment. A diagnosis of dementia should only be made after a careful assessment for other reasons for impaired cognitive performance. The final determination of the level of impairment should be made by the resident's physician or mental health care specialist; however, these practitioners can be provided specific BIMS results and the following guidance: The BIMS total score is highly correlated with Mini-Mental State . scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Event ID: Facility ID: 055454 If continuation sheet Page 10 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline (starting point) care plan for one of six sampled residents (Resident 188), when Resident 188 did not have a care plan for hospice (care focuses on terminally ill patient's pain and symptoms and emotional and spiritual needs at the end of life) care within 48 hours of admission. This failure had the potential to result in Resident 188's hospice needs to go unmet. Findings: During a review of Resident 188's admission Record (AR-document that gives a resident's information at a quick glance) dated 5/6/21, the AR indicated, .admission Date 05/01/2021 .Diagnosis Information .OTHER SEQUELAE (condition which is the consequence of a previous disease or injury) OF CEREBRAL INFARCTION (blockage in the brain) . During a review of Resident 188's Order Summary Report undated, the Order Summary Report indicated, .Admit to [name of company] Hospice for Dx (diagnosis): End stage Sequelae of cerebral vascular . order date: 5/2/202 . During a concurrent interview and record review on 5/12/21, at 2:51 p.m., with the Minimum Data Set (MDS- standardized clinical assessment of each resident's functional capabilities and health needs) nurse, the MDS nurse reviewed Resident 188's care plan dated 5/10/21. The MDS nurse stated the care plan was initiated on 5/10/21, the MDS nurse stated the care plan should have been initiated within 48 hours Resident 188 was admitted in the facility. The MDS nurse stated Resident 188 was admitted in the facility under hospice care on 5/1/21. The MDS nurse stated the care plan directed and guided the staff on the care necessary to take care of residents' needs. During an interview on 5/13/21, at 1:10 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated baseline care plans were completed within 24 hours of admission. LVN 4 stated Resident 188's care plan for hospice should have been initiated within 24 hours of admission because Resident 188 was already under hospice care when admitted to the facility. LVN 4 stated the care plan was a very important tool because it directed staff on the interventions necessary to take care of Resident 188's needs. During an interview on 5/18/21, at 10:11 a.m., with the Director of Nursing (DON), the DON stated baseline care plans were completed within 48 hours of admission. The DON stated Resident 188's care plan for hospice should have been initiated and completed within 48 hours of admission. The DON stated Resident 188 was admitted to the facility on [DATE] and was already on hospice. The DON stated Resident 188's hospice care plan should have been initiated within 48 hours of admission but was not. During a review of the facility's policy and procedure titled, Care Planning Process dated 12/11/17, the policy and procedure indicated, .1. Upon admission to the center, a baseline care plan will be developed within 48 hours. 2. A written summary of the baseline care plan will be presented to the patient/resident and if applicable, the resident representative, before the comprehensive care plan is completed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 11 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 187), when Resident 187's did not have a care plan to address his hard of hearing and Resident 187's care plan for activities of daily living (ADL- routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, mobility, and continence) was incomplete. This failure had the potential to result in Resident 187's hard of hearing and ADL care needs to go unmet. Findings: During a concurrent observation and interview on 5/10/21, at 8:35 a.m., with Resident 187, Resident 187 was observed leaned forward to try to hear what was said. Res 187 stated he did not hear well from both ears. Resident 187 stated he had a hearing aid prior to admission to the facility on 4/29/21. Resident 187 stated he did not use his hearing aid because it make loud noises and it made him unable to hear what people said. During a concurrent interview and record review on 5/12/21, at 9:15 a.m., with the Director of Social Services (DSS), the DSS stated Res 187 complained of hard of hearing to both ears since he was admitted to the facility. The DSS stated she did not check Res 187's hearing aid batteries to see if it worked. The DSS reviewed Resident 187's care plan and stated there was no care plan for hard of hearing. The DSS stated hard of hearing should have care planned, and it should have been individualized to the resident. The DSS stated, It was my responsibility to put together a care plan to address [Resident 187's] the hard of hearing. The DSS stated care plans were important because it guided staff on how to provide care to residents. During a concurrent interview and record review on 05/12/21, at 2:57 p.m., with the Minimum Data Set (MDS) nurse, the MDS nurse reviewed Resident 187's clinical record titled, Care plans. The MDS nurse stated she did not find a care plan for hearing to address Resident 187's hard of hearing. The MDS nurse stated there should have been a care plan for hard of hearing. The MDS nurse reviewed Resident 187's care plan and stated Resident 187's care plan for ADL care was incomplete. The MDS nurse stated the ADL care plan should had been completed and individualized. The MDS nurse stated care plans were important because it directed and guided staff on taking care of residents' needs. During an interview on 5/18/21 at 10:20 a.m., with the Director of Nursing (DON), the DON stated all care plans should be person-centered and individualized to residents' needs. The DON stated the nurse and/or the Interdisciplinary Team (IDT- approach involves team members from different disciplines working collaboratively, with a common purpose, to set goals, and make decisions and share sources and responsibilities) were responsible in creating a care plan, reviewing and revising the care plan as needed to fit residents' needs. During a review of facility's policy and procedure titled, Care Planning Process dated 12/11/17, the policy and procedure indicated, .3. The comprehensive care plan will be developed by the interdisciplinary team that includes the attending physician, a member of nutritional services, an RN (registered nurse) and a can (certified nursing assistant) with responsibility for the patient/resident. The patient/resident and if applicable, the resident representative will be encouraged to participate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 12 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 in development of the care plan. 4. The care plan will be person-centered and incorporate the patient/resident's goals of care and treatment . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 13 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented for two of two sampled residents (Resident 7 and Resident 20) when: Residents Affected - Few 1. Resident 7 was provided a house supplement (beverage containing protein and other performance substances as ingredients mixed with milk or water for the purposes of improved nutrition) for weight loss and did not have a physician's order for a house supplement; and 2. Resident 20 suffered a fall on 2/12/21 and the licensed nurse on duty did not complete an assessment of Resident 20. Resident 20 had an x-ray (type of radiation called electromagnetic waves, creates pictures of the inside of your body, the images show the parts of the body in different shades of black and white to checking for broken bones) completed on 2/17/21 which indicated a fracture of the long middle finger. These failures resulted in Resident 7 and Resident 20 not receiving professional care and presented with delayed treatment and care. Findings: 1. During an observation on 5/10/21, at 12:16 p.m., in the dining room, Resident 7 was observed eating lunch. Resident 7 had gelatin, a sandwich that was cut into four pieces, potatoes and green beans on her plate. Resident 7 had a cup of coffee and a cup of water. Resident 7 notified the Infection Preventionist (IP) she was done eating and was not hungry. During an observation on 5/10/21, at 12:24 p.m., in the dining room, the IP asked Resident 7 if she was done eating and Resident 7 stated Yes. The IP picked up Resident 7's plate and cups from the table. During a review of Resident 7's Tray Card (TC) dated 5/10/21, the TC indicated, [Resident 7] .Diet Order: Finger Foods, Regular . Standing Orders: 1 . House Supplement . During a concurrent interview and record review on 5/10/21, at 12:31 p.m., with the IP, Resident 7's TC dated 5/10/21 was reviewed. The IP stated she would assist in passing out meal trays in the dining room a couple of times a week. The IP stated she had worked in the facility for two years. The IP stated Resident 7 would come into the dining room every day to have lunch so staff could encourage her to eat due to weight loss. The IP stated on 5/10/21, she checked the lunch trays to ensure all items were provided to the residents in the dining before the trays were passed out to each resident. The IP stated she would check the lunch trays for consistency, correct food, and fluids. The IP stated Resident 7 did not receive the house supplement for lunch as indicated on the tray card. The IP stated she forgot to provide Resident 7 with the house supplement. The IP stated it was important for Resident 7 to have the house supplement because Resident 7 had recent weight loss. The IP stated the house supplement should have been provided to Resident 7 during lunch and Resident 7 did not eat her lunch on 5/10/21. During a concurrent interview and record review on 5/12/21, at 2:51 p.m., with the IP, Resident 7's admission Record (AR) undated and Resident 7's Order Summary Report (OSR) dated 5/12/21 were reviewed. The IP stated Resident 7 was admitted on [DATE]. The IP reviewed the OSR and stated Resident 7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 14 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not have a physician's order for the house supplement in the medical record. The IP stated the Dietary Service Manger (DSM) would generate the TC on a daily basis. The IP stated Resident 7 should have had a physician order for the house supplement. During a concurrent interview and record review on 5/12/21, at 3:24 p.m., with the DSM, Resident 7's clinical record was reviewed. The DSM stated he had worked in the facility since March 2020. The DSM stated he generated and printed the tray cards daily. The DSM stated when there was a change in the residents' diet, the nurses would send him a communication slip with any changes in diet or when nutritional supplements were added or discontinued. The DSM stated a standing order was an order he would receive through the communication slip form the nurses. The DSM stated a diet change or house supplement required a physician order. The DSM stated the house supplement required a physician's order and had to be entered in the tray card as a standing order to ensure residents received the correct diet. The DSM reviewed Resident 7's tray card dated 5/12/21 and stated Resident 7 had a standing order for a house supplement. The DSM stated he was responsible to input the information onto the tray card and Resident 7 should have received a house supplement with her lunch on 5/10/21. The DSM stated Resident 7 had recent weight loss and the facility had ordered the house supplement. The DSM stated the house supplement was not provided to Resident 7 on 5/10/21 and should have been provided to Resident 7. During an interview on 5/13/21, at 9:05 a.m. with the DSM, the DSM stated he was not able to locate Resident 7's communication slip for the house supplement. During an interview and concurrent record review on 5/15/21, at 9:25 a.m. with the Director of Nursing (DON), Resident 7's clinical record was reviewed. The DON reviewed Resident 7's Progress Notes (PN) dated 4/22/21. Resident 7's PN indicated, Resident had weight loss 1.0 [pound times one week]. On regular texture diet, able to feed self with set up assistance . [Medical Director (MD)] gave order . house supplement between meals. This writer offered house supplement, resident states, I don't like any shakes and I will throw up. [MD] informed ok to [discontinue house supplement]. Resident, nurse on duty and dietary informed. The DON stated Resident 7 had weight loss of one pound. The DON stated on 4/22/21, Resident 7 was offered the house supplement, but she refused and the house supplement was discontinued on 4/22/21. The DON reviewed Resident 7's TC and stated a standing order on the tray card required a physician's orders and the house supplement should have been discontinued from the TC. The DON stated because the TC had a standing order for house supplement, it was required to have a physician order. The DON stated Resident 7 did not have an order for the house supplement, but the tray card indicated she had a standing order for the house supplement. The DON stated she put in the order for Resident 7's house supplement on 5/12/21. The DON reviewed the facility's policy and procedure (P&P) titled, Physician Orders undated. The DON stated per the facility's P&P, a house supplement required a physician's order if it was administered to Resident 7. During a review of the facility's P&P titled, Physician Orders undated, the P&P indicated, To ensure the physician orders are obtained on admission, reviewed and transcribed, signed and filed appropriately . Physician's Orders: Obtain Physician's admission orders for the Resident's immediate care and treatment .orders . should include . diet, including nutritional supplements . During a professional reference review titled, Lippincott Manual of Nursing Practice 10th Edition, dated 2014, pages 16-17 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 15 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . Failure to adhere to facility policy or procedural guidelines . 2. During an interview on 5/11/21, at 4:19 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she worked in the facility for six months. CNA 3 stated she had worked with Resident 20 for about three months. CNA 3 stated she worked the evening shifts in the facility. CNA 3 stated Resident 20 was alert to self and able notify staff he needed to be changed or when he needed a shower. CNA 3 stated Resident 20 had suffered a fall in the shower room while she assisted Resident 20. CNA 3 was unable to recall the date Resident 20 fell in the shower room. CNA 3 stated the fall happened around 3:30 p.m. to 4 p.m. CNA 3 stated on the day of the fall, during the evening shift, Resident 20 sat on the shower chair, Resident 20 stood up, held on to the bar in the shower room and he slipped down towards wall and sat down on the floor. CNA 3 stated Resident 20 did not hit his head in the shower room. CNA 3 stated when Resident 20 fell down to the floor, she yelled for CNA 2's help. CNA 3 stated Resident 20 wanted to get up from the floor. CNA 3 stated CNA 2 assisted her (CNA 3) in helping Resident 20 to get up from the floor. CNA 2 stated Resident 20 stated he was not in pain and said, I need to get up. CNA 3 stated CNA 2 went to notify the licensed nurse on shift and the licensed nurse did not come to the shower room. CNA 3 stated she did not notify the licensed nurse Resident 20 had fallen. CNA 3 stated at the time of the fall Resident 20 did not have an injury because he did not complain of pain. CNA 3 stated three or four days later, Resident 20 had bruising to the right middle finger. CNA 3 stated when a resident suffered a fall, the CNAs had to call for help and the licensed nurse needed to assess the residents before the resident could be moved. During an interview on 5/12/21, at 5:07 p.m., with CNA 2, CNA 2 stated she worked the day Resident 20 fell in the shower room. CNA 2 stated she was working across the shower where Resident 20 fell when she heard CNA 3 calling for help. CNA 2 stated when she entered the shower room, Resident 20 was on the floor. CNA 2 stated CNA 3 and she (CNA 2) attempted to get Resident 20 up from the floor. CNA 2 stated she looked out into the hallway and the licensed nurse was by room [ROOM NUMBER] giving medications. CNA 2 stated Resident 20 was attempting to stand up on his own and was transferred from the floor to the commode by CNA 3. CNA 2 stated she went to the licensed nurse and notified her Resident 20 had fallen in the shower room and the licensed nurse replied, OK, I will be there. CNA 2 stated the licensed nurse did not come in to assess Resident 20. CNA 2 stated the licensed nurse did not work in the facility anymore. CNA 2 stated she went back to the shower room to make sure Resident 20 and CNA 3 were okay and then she continued on with her duties. CNA 2 stated she wrote a statement of what occurred on the day of the fall and signed it. CNA 2 stated when a resident suffered a fall in the facility, one CNA had to stay with the resident and one CNA had to call the licensed nurse. CNA 2 stated when a resident suffered a fall, the licensed nurses in the facility would observe the resident and ask questions about pain, check for bruising and ask if the resident was hurt. CNA 2 stated CNA 3 and she (CNA 2) should have waited for the licensed nurse to assess Resident 20. During an interview on 5/13/21, at 2:50 p.m., with the Nurse Consultant (NC), the NC stated she reviewed Resident 20's medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 16 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0658 record and verified there was no nursing or progress notes from 2/10/21 to 2/12/21. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/15/21, at 8:51 a.m. with the DON, Resident 20's clinical record was reviewed. The DON reviewed the admission Record (AR) undated, the AR indicated Resident 20 was admitted on [DATE]. The DON reviewed Resident 20's Clinical Health Status (CHS) dated 12/28/2020, the CHS indicated, . low risk for falls . The DON stated Resident 20 suffered a fall in the shower room on 2/12/2021 but Resident 20's clinical record did not have a fall documented on 2/12/2021. The DON stated on 2/15/21 around 7 a.m. one of the licensed nurses notified her (DON) that Resident 20 had a bruise on his right hand. The DON stated she assessed Resident 20 and asked Resident 20 what happened. The DON stated Resident 20 notified her he had fallen on Friday (2/12/2021). The DON stated she started her investigation and interviewed staff. The DON stated CNA 3 was giving Resident 20 a shower when Resident 20 was holding on to the shower bar and lost his balance. The DON stated CNA 3 called for help, CNA 2 went to the shower room and CNA 2 and CNA 3 assisted Resident 20 to the chair. The DON stated Resident 20 had bruising to the right middle finger. The DON stated the physician was notified on 2/15/2021 and ordered application of ice, immobilization of the right hand and an x-ray of Resident 20's right hand. The DON stated the x-rays were completed on 2/15/21 and the x-rays were questionable, and the x-rays were repeated on 2/17/21. Residents Affected - Few During an interview on 5/15/21, at 9 a.m., with the Administrator (ADM), the ADM stated CNA 3 stayed with Resident 20 during the time of the fall on 2/12/21. The ADM stated CNA 2 went to call the nurse and returned to the shower room. The ADM stated after CNA 2 and CNA 3 assisted Resident 20 back to the chair, CNA 3 took Resident 20 back to his room. The ADM stated CNA 2 informed the licensed nurse who was working the evening shift. The ADM stated when he spoke to the licensed nurse, the licensed nurse stated she did not hear CNA 2 and CNA 3 call her. The ADM stated the licensed nurse received disciplinary actions for failure to assess after a fall. During an interview on 5/15/21, at 9:05 a.m., with the DON, the DON stated she spoke to the licensed nurse and the licensed nurse stated she did not hear CNA 2 and CNA 3 calling her. During a review of the facility's documented titled, 3 Step Employee Memorandum dated 2/18/2021, the 3 Step Employee Memorandum indicated, . As per staff discoloration to Residents [right] hand reported to charge nurse on 2/14/2021 after dinner. Fall on 2/12/2021 Fail to assess Resident . During a review of Resident 20's Patient Report dated 2/17/21, the Patient Report indicated, . Right Hand . there is cortical (outer layer) irregularity about the base of the proximal phalanx (digital bones of the hand) of the long finger. Suspect nondisplaced fracture . During a review of Resident 20's Progress Notes (PN) dated, 2/15/21 at 11:42 p.m., the PN indicated, CNA notify this writer 2/15/2021 about fall, per CNA .On Friday 2/12/2021 resident lost balance while in shower, ask the resident he have any pain but the residents denies any pain and discomfort at that time, but I forgot to report the nurse on that day [Physician] notified via fax and [responsible party] notified via phone . During a concurrent interview and record review on 5/15/21, at 9:12 a.m., with the DON and the ADM, the ADM stated the interdisciplinary team (IDT- team consists of practitioners from different health professions, who have a shared patient. population and common patient care goals) met on 2/18/21. The DON reviewed Resident 20's PN dated 2/18/2021 at 4:32 p.m. The PN indicated, IDT review in attendance [DON . Infection Preventionist . ADM due to status post fall on 2/12/2021. Resident had finished with his shower in attendance of CNA, and while in shower room, CNA moved shower chair to dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 17 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few area for dressing and to transfer to his [wheelchair]. CNA remained preset and assisted resident to stand using hand rail, resident lost balance and slid to the floor. CNA ensured resident safety then called or another staff member to assist. The other CNA went to shower room to help. CNA tried to get nurses attention at the same time. Resident denied pain and began to assist himself from sitting position on the floor, CNA assisted resident to stand and then sit on commode, directly next to him, CNA then transferred Resident to his [wheelchair] safely. Staff asked resident if has in any pain. Resident said, No, I'm okay. CNA observed No skin integrity issues including no immediate swelling or bruising, resident denies pain. On 2/15/2021 [morning] staff informed Resident has a dark purple discoloration to right hand middle fingers. [Licensed Nurse] completed a head to toe observation assessment, then notified [physician], a new order for x ray right hand. [Responsible party] son was informed . The DON stated the licensed nurse should have assessed Resident 20, notified the physician, and notified the family and place Resident 20 on alert charting for delayed trauma and monitoring for 72 hours. The DON stated Resident 20 should have been assessed by the licensed nurse. The DON stated the licensed nurse did not follow the facility's policies and procedures for fall prevention. During a review of the facility's P&P titled, Fall Prevention and Fall Related Injury Management dated 4/11/17, the P&P indicated, . The care center will evaluate, treat, investigate and document fall incident investigations . Care and Documentation: 1. when a patient/resident fall occurs, the employee making the discovery immediately notifies the licensed nurse to conduct an appropriate evaluation, provide interventions and/or emergency care as needed. 2. Patient/resident fall incidents are reported to the attending physician and responsible party. Date, time and details are documented in the medical record. The licensed nurse will complete an SBAR/Change in Condition . During a professional reference review titled, Lippincott Manual of Nursing Practice 10th Edition dated 2014, pages 16-17 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . Failure to adhere to facility policy or procedural guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 18 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities of daily living did not diminish for two of twelve sampled residents (Resident 5 and Resident 29) when: Residents Affected - Few 1. Resident 5 requested a grooming services for a haircut from staff and there was not staff available to provide him with a haircut; and 2. Resident 29's Restorative Nurse Assistant (RNA-helps residents gain/improve strength and mobility) exercises and ambulation were not provided per the physician's order. These failures resulted in Resident 5 expressing and verbalizing not liking his long hair on multiple occasions and had the potential for Resident 29 to decline in her ability to carry out activities of daily living (ADL-skills required to manage one's basic physical needs including personal hygiene or grooming, dressing, toileting , transferring or ambulating, and eating), strength, and mobility. Findings: During a concurrent observation and interview on 5/10/21, at 8:10 a.m., in Resident 5's room, Resident 5's hair was uncombed. Resident 5 stated his hair was long and he needed a haircut. During an interview on 5/11/21, at 3:11 p.m., with Family Member (FM) 1, FM 1 stated they would like for Resident 5 to get a haircut. 1. During an interview on 5/12/21, at 12:18 p.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated she had worked in the facility for four and a half years. CNA 7 stated Resident 5 was admitted to the facility on [DATE]. CNA 7 stated before the COVID-19 (infection symptoms can be serious, leading to pneumonia and in some cases death) pandemic, the facility had a beautician (a person whose job is to do hair styling, manicures, and other beauty treatments). CNA 7 stated a month ago, the beautician returned to the facility and the beautician refused to do a rapid test (detects protein fragments specific to the Coronavirus) before coming into the building and was not allowed to come into the facility. CNA 7 stated Resident 5 had been asking for a haircut for about a month. CNA 7 stated Resident 5 had complained his hair was long and wanted to go to the parlor. CNA 7 stated Resident 5 constantly talked about getting a haircut because his hair was long. CNA 7 stated she notified the Director of Social Services (DSS) that Resident 5 wanted a haircut. During a concurrent interview on 5/12/21, at 4:19 p.m., with the Administrator (ADM) and Nurse Consultant (NC), the NC stated the facility did not have a policy and procedure for grooming (things that people do to keep themselves clean and make their face, hair, and skin look nice) of residents in the facility. During an interview on 5/12/21, at 4:43 p.m., with the Director of Nursing Services (DON), the DON stated the facility did not have a beautician due to the COVID-19 pandemic. The DON stated the beautician came to the facility about a month ago and she refused to get tested for COVID-19. The DON stated she would like for someone to come to the facility to provide grooming services. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 19 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few families could bring their own beauticians, but the requirements was for the beautician to be vaccinated for COVID-19. The DON stated if the DSS was aware of Resident 5 requesting a haircut, his [Resident 5's] needs should have been accommodated. The DON stated Resident 5's needs for grooming had not been communicated to her. During a concurrent observation and interview on 5/13/21, at 9:15 a.m., with Resident 5, in Resident 5's room, Resident 5 stated I never let my hair grow this long. I like it short. During an interview and record review on 5/13/21, at 11:10 a.m., with the DSS, the facility's policy and procedure (P&P) titled, Preservation of Resident Rights undated was reviewed. The DSS stated Resident 5 should not be worried about getting a haircut. The DSS stated she was not aware Resident 5 had requested a haircut. The DSS stated she would observe residents' grooming and personal care, but did not look at Resident 5's hair. The DSS stated she was aware Resident 5's hair was long, but she never removed his hat or asked him about his care. The DSS reviewed the P&P Preservation of Resident Rights and stated part of her role was to look at the residents in the facility and be involved in the personal care, address the residents' concerns, and find a solution. During an interview on 5/19/21, at 8:51 a.m., with the ADM, the ADM stated the facility had a beautician come to the facility about a month ago but the beautician was not vaccinated for COVID-19 and refused to get a COVID-19 rapid test. The ADM stated because the beautician was required to be closer than six feet to the residents, she was not allowed to come in to the facility. The ADM stated, Yes, I knew he [Resident 5] wanted a haircut . The ADM stated Resident 5's family had to take him to get a haircut. The ADM stated the facility reached out to a sister facility and had set up for the beautician to come into the facility. During a review of the facility's P&P titled, Preservation of Resident Rights undated, the P&P indicated, . The Social Services staff will promote and advocate the preservation of all resident rights The social services staff will take an active role in training employees and monitoring practice on issues regarding residents . personal care . 2. During a review of Resident 29's admission Record, dated 5/12/21, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included, . Fusion of Spine, Cervicothoracic Region (surgical procedure performed through the back of the neck, involves joining two or more damaged cervical vertebrae[neck bones]), hypertension (high blood pressure) and muscle weakness . During a review of Resident 29's clinical record titled, Functional Maintenance Program Training, dated 12/23/20, the Functional Maintenance Program Training indicated, .RNA Program 3Xweek (three times per week) for 90 days .3. Bilateral (both sides) Lower Extremities (BLE) therapy exercises active range of motion (AROM) 3X10 . 4. Gait training front wheel walker (FWW) when patient can put shoes on . During a concurrent observation and interview on 5/10/21, at 12:02 p.m., with Resident 29 in his room, resident sat at the edge of his bed. Resident 29 stated he used to be able to walk using a walker, but not anymore. Resident 29 stated during the COVID-19 pandemic, no one walked him. Resident 29 stated he wanted to get therapy to walk again. During a concurrent observation and interview on 5/13/21, at 9:17 a.m., with Resident 29 in his room, Resident 29's legs were swollen. Resident 29 stated, My legs are swollen because they are not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 20 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0676 Level of Harm - Minimal harm or potential for actual harm walking me. Resident 29 stated prior to the COVID-19 pandemic, he was able to walk to the front door without stopping and only used a walker. Resident 29 stated before the COVID-19 pandemic, the RNA used to walk him three times a week. Resident 29 stated, Certified Nurse Assistant (CNA) 10/Restorative Nurse Assistant (RNA)2 tried to find time to walk Resident 29 but she was busy all the time. Resident 29 stated he sits on his wheelchair all day. Residents Affected - Few During a concurrent interview and record review on 5/13/21, at 1:52 p.m., with CNA 10/RNA 2, CNA 10/RNA 2 stated she worked as RNA between 11 a.m., to 11:30 a.m. and 1:30 p.m., to 5 p.m. CNA 10/RNA 2 stated she worked with Resident 29 when he was first admitted in the facility. CNA 10/RNA 2 stated Resident 29 walked using a four-wheel walker with assistance. CNA 10/RNA 2 stated she did not work with Resident 29 during the COVID-19 pandemic. CNA 10/RNA 2 stated she remembered physical therapist (PT) worked with Resident 29 after Resident 29 was cleared from COVID-19 infection, but did not know how long PT worked with him. CNA 10/RNA 2 stated she remembered working with Resident 29 after PT worked with him. CNA 10/RNA 2 reviewed the RNA notes to show the minutes RNA worked with Resident 29, but unable to find documentation. CNA 10/RNA 2 stated she should have documented when she worked with Resident 29, but she did not. CNA 10/RNA 2 stated she did not remember discussing Resident 29's decline in function and mobility with the charge nurse, PT or occupational therapist (OT). CNA 10/RNA 2 stated she should have reported it to charge nurse and/or therapist. During a concurrent interview and record review on 5/14/21, at 11:47 a.m., with the Director of Rehabilitation (DOR), the DOR stated she had only been in her position for three weeks. The DOR reviewed therapy orders for Resident 29 and stated Resident 29 worked with PT for one week in 7/2020 and improved. The DOR stated Resident 29 was diagnosed with COVID-19 back in 12/2020 and was weak and declined with all his mobility and function. The DOR stated therapy should have worked with Resident 29 after he (Resident 29) was cleared from COVID-19 infection to help with the decline in function and mobility. During a concurrent interview and record review on 5/19/21, at 8:22 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 29's clinical record titled MDS section G (Functional Status) dated 10/10/20, and MDS section G dated 4/13/21. The MDSC stated there was a decline in the function and mobility of Resident 29. MDSC stated Resident 29 was COVID-19 positive on 12/27/20 and was cleared from isolation on 1/18/21. The MDSC stated he was not sure whether Resident 29 was referred for therapy after Resident 29 cleared of COVID-19 infection. During an interview on 5/19/2, at 10:21 a.m., with the DON, the DON stated, .During COVID-19 pandemic everything stopped, including RNA. The DON stated she did not know if Resident 29's decline was communicated to nursing and therapy. During an interview on 5/19/21, at 10:52 a.m., with the ADM, the ADM stated Resident 29 wanted therapy and was given therapy but did not have documentation to show Resident 29 worked with therapist. During a review of the facility's document titled, Nurse Assistant Restorative undated, the document indicated, .We provide both short-term rehabilitation and long-term care at the highest professional standards, along with comprehensive skilled nursing and progressive treatment plans promoting quality care that inspires our patients positively. An interdisciplinary care team made up of nursing staff .develop and customized plan of care that addresses the specific care needs and therapy goals necessary for the resident to reach their personal goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 21 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm During an observation, interview, and record review the facility failed to provide an ongoing activities program for three of seven sampled residents (Residents 1, 11, and 23) when the facility did not support residents in their choice of activities. Residents Affected - Some This failure had the potential to result in Resident 1, 11, and 23 being bored and verbalizing the facility did not have activities to do daily. Findings: During an interview on 5/11/21, at 2:58 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated the Activities Director (AD) was on leave. CNA 4 stated she was the Activities Assistant (AA). CNA 4 stated the AD was to come back after her leave but had not returned. CNA 4 stated she had been working in the facility since June 2019. CNA 4 stated she started doing activities in June 2020. During a concurrent observation and interview on 5/11/21, at 3:21 p.m., with CNA 4, in the hallway, a calendar dated May 2021 was reviewed. CNA 4 stated she would follow the calendar as scheduled. CNA 4 stated on 5/11/21 at 1 p.m. Aroma Therapy was scheduled. CNA 4 stated she did not do the Aroma Therapy activity because she was completing her documentation. CNA 4 stated Aroma Therapy included using different lotions on hands so the residents could have an activity to do. CNA 4 stated she worked in the facility part time and would document in the Activity Attendance Record the days she completed activities. During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the facility had an activities calendar outside of the dining room in the hallway. Resident 23 stated the facility did not have ongoing activities as scheduled on the calendar. Resident 23 stated the facility used to provide popcorn and movies. Resident 23 stated he enjoyed looking at the board, but the activities would not occur. Resident 23 stated for the month of April 2021 and May 2021 the same activities were scheduled. Resident 23 stated the facility did not have an Activities Director (AD) because she was on leave. Resident 23 stated CNA 4 would come into the facility once or twice per week to do activities and no one else in the facility would do activities. During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 5/12/21, at 10:48 a.m., with Resident 11, Resident 11 stated the facility had a calendar in the hallway with activities but the activities he would see on the calendar would not occur. Resident 11 stated he had been at the facility for four months and there had been no activities, no bingo and no popcorn. During an interview on 5/12/21, at 10:54 a.m., with Resident 1, Resident 1 stated there had not been many activities in the facility and she would like more activities during the day. During a review of Resident 1's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 5/3/21, the MDS assessment indicated, Resident 1 was moderately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 22 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitively impaired with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 5/14/21, at 11:40 a.m., with the Director of Social Services (DSS), the DSS stated the AD was on leave. The DSS stated the AD was scheduled to come back in February 2021. The DSS stated activities should have been completed per the calendar in the hallway. The DSS stated when the AA completed activities she would document in the Activity Attendance Record. The DSS stated since the facility did not have an AD, the facility was not able to schedule activities based on the monthly calendar. The DSS stated Residents 1, 11 and 23 should not have to worry about the activities in the facility. the DSS stated residents in the facility enjoyed activities and if there were no activities they could be sad. The DSS stated she was not able to validate if Resident 1, 11, and 23 attended activities. During a concurrent interview and record review, on 5/14/21, at 11:48 a.m., with the DSS, Resident 23's Activity Attendance Record (AAR) dated May 2021 was reviewed. The AAR indicated on 5/5/21 and 5/11/21, 5/12/21 and 5/13/21 were the days documented that Resident 23 participated in activities. During a concurrent interview and record review, on 5/14/21, at 11:50 a.m., with the DSS, Resident 11's AAR dated May 2021 was reviewed. The AAR indicated on 5/5/21 and 5/11/21, 5/12/21 and 5/13/21 were the days documented that Resident 11 participated in activities. During a concurrent interview and record review, on 5/14/21, at 11:53 a.m., with the DSS, Resident 1's AAR dated May 2021 was reviewed. The AAR indicated on 5/5/21 and 5/11/21, 5/12/21 and 5/13/21 were the days documented that Resident 1 participated in activities. During a concurrent interview on 5/19/21, at 9:25 a.m., with the Director of Nursing (DON) and the Administrator (ADM), the ADM stated the AD was on leave. The ADM stated the facility did not have an AD since December 2020 and CNA 4 had continued to do activities. The ADM stated the facility would do activities with residents but did not document the activities completed. The ADM stated Resident 1 would stay in her bed. The ADM stated Resident 11 had not mentioned to him he wanted to do activities. The ADM stated activities were important to residents in the facility. During a review of the facility's policy and procedure (P&P) titled, Recreation dated 6/29/2016, the P&P indicated, A program calendar will be developed that reflects planned programming based on the current assessed needs and interests of the LivingCenter population . The purpose of the calendar is to inform residents, family, staff and volunteers for the current's months recreation program . The Activities Director or designee will plan the calendar of events for the activity department each month . the activity calendar for the following moth will be reviewed and approved the facility administrator and residents group . the recreation program calendars indicate the following information, month, year, dates and days of the week, the starting and name of each program, location of each program, each activity should start at he scheduled time, a large activity calendar will be posted in a central location, in an accessible area, viewed by all, by the (date) of the proceeding months. Residents will be informed of any changes to the calendar (by verbal communication, intercom announcement, etc.) . any changes in the schedule will be maintain in a master calendar an updated in the survey readiness book . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 23 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure seven of 13 sampled residents (Residents 10, 11, 13, 25, 32, 33, and 36) received diabetic (disease in which the body's ability to produce or respond to the hormone insulin is impaired) management care in accordance with professional standards of practice when: Residents Affected - Some 1. Resident 10 did not have a baseline (starting point) hemoglobin A1C (HBA1c- test tells you your average level of blood sugar over the past two to three months; the target A1c level for people with diabetes is usually less than 7% [percent]. The higher the hemoglobin A1c, the higher the risk of having complications related to diabetes) obtained upon admission to the skilled nursing facility (SNF), licensed nurses (LNs) did not notify the physician when Resident 10 exhibited consistent elevated blood sugars, and the interdisciplinary team (IDT-approach involves team members from different disciplines working collaboratively, with a common purpose, to set goals, and make decisions and share sources and responsibilities) failed to assess Resident 10's consistent elevated blood sugars; 2. Resident 11 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 11 was on a regular diet, LNs did not notify the physician when Resident 11 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 11's consistent elevated blood sugars; 3. Resident 13 did not have a baseline HBA1c obtained upon admission to the SNF, LNs did not notify the physician when Resident 13 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 13' consistent elevated blood sugars; 4. Resident 25 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 25 was on a regular diet, LNs did not notify the physician when Resident 25 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 25's consistent elevated blood sugars; 5. Resident 32 was on a regular diet, LNs did not notify the physician when Resident 32 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 32's consistent elevated blood sugars; 6. Resident 33 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 33 was on a regular diet, LNs did not notify the physician when Resident 33 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 33's consistent elevated blood sugars; and 7. Resident 36 did not have a baseline HBA1c obtained upon admission to the SNF, LNs did not notify the physician when Resident 36 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 36's consistent elevated blood sugars. Because of the serious potential harm to Residents 10, 11, 13, 25, 32, 33, and 36 due to not following professional standards of practice with care of residents with diabetes (a disease in which your blood glucose, or blood sugar, levels are too high) in obtaining a baseline HBA1c upon admission, four of the seven residents were on a regular diet and not a consistent carbohydrate diet (the focus of the diet is eating the same amount of carbohydrates every day; this helps keep your blood sugar, or glucose, levels stable), licensed nurses did not notify the physician when residents presented with consistent elevated blood sugars and the IDT did not assess the consistent elevated blood sugars, an Immediate Jeopardy (IJ-a situation in which the provider's noncompliance with one or more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 24 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on 5/14/21 at 3:44 p.m. under Code of Federal Regulations (CFR) 483.25 Quality of Care (F684) with the Director of Operations, Administrator (ADM), Director of Nursing (DON), Director of Social Services (DSS), and the Minimum Data Set Consultant (MDSC). The IJ template was provided to the ADM. The facility submitted an acceptable IJ Plan of Removal (Version 3) on 5/17/21, at 8:55 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Immediate training to LNs, Certified Nursing Assistants (CNAs), and IDT on diabetes management. 2) Immediate training to dietary staff on consistent carbohydrate diet. 3) Obtaining baseline HBA1c levels on all 17 diabetic residents. 4) IDT review all 17 residents with diagnosis of diabetes and evaluated the therapeutic diet (meal plan that controls the intake of certain foods or nutrients). 5) IDT including physician evaluate residents with diagnosis with diabetes with persistent hyperglycemia (too much sugar in the blood) and evaluate treatment plan. 5) Create a system for the IDT to review and manage diabetic residents' blood sugar levels and HBA1c and follow up as required. The components of the IJ Plan of Removal was validated through observations, interviews, and record review. The IJ was removed on 5/18/21 at 3:54 p.m. with the Director of Operations, ADM, DON, and the Nurse Consultant. These failures resulted in Resident 11 to experience headache and dizziness and had the potential for Residents 10, 11, 13, 25, 32, 33, and 36 to continue to have elevated blood sugars not assessed and had the potential for life-threatening complications/conditions. Findings: 1. During a review of Resident 10's admission Record (AR-document that gives a resident's information at a quick glance) undated, the AR indicated, .admission Date 10/28/2020 .Diagnosis Information .Type 2 Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal breakdown of carbohydrates and elevated levels of sugar in the blood and urine) with Diabetic Chronic Kidney Disease (serious kidney related complication of diabetes) . During a review of Resident 10's Laboratory Report dated 3/3/21, the Laboratory Report indicated .GLYCOHGB (A1c) .Abnormal Summary .7.3 H [high] . During a review of Resident 10's Medication Administration Record (MAR) dated March 2021, the MAR indicted the blood sugar results from 6:30 a.m. ranged from 107 mg/dl (milligrams per deciliter - units of measurement) to 191 mg/dl (the ideal goal for adults with diabetes is to achieve glucose levels between 70 and 130 mg/dl). The blood sugar results from 11:30 a.m. ranged from 118 mg/dl to 195 mg/dl. The blood sugar results 4:30 p.m. ranged from 110 mg/dl to 255 mg/dl. During a review of Resident 10's MAR dated April 2021, the MAR indicted the blood sugar results from 6:30 a.m. ranged from 108 mg/dl to 188 mg/dl. The blood sugar results from 11:30 a.m. ranged from 116 mg/dl to 207 mg/dl. The blood sugar results from 4:30 p.m. ranged from 111 mg/dl to 245 mg/dl. During a review of Resident 10's MAR dated May 2021, the MAR indicted the blood sugar results from 6:30 a.m. ranged from 79 mg/dl to 184 mg/dl. The blood sugar results from 11:30 a.m. ranged from 130 mg/dl to 188 mg/dl. The blood sugar results 4:30 p.m. ranged from 147 mg/dl to 279 mg/dl. During a review of Resident 10's Order Summary Report dated 2/11/21, the Order Summary indicted, .Carbohydrate Controlled diet . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 25 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 5/10/21, at 8:04 a.m., with Resident 10, Resident 10 stated he was on a diabetic diet and he was not getting the correct foods. Resident 10 stated no one from the facility had discussed his diet with him. During a concurrent interview and record review with the Dietary Service Manager (DSM) on 5/11/21 at 12:20 p.m. the facility's document titled, Spring Cycle Menus dated 5/10/21 was reviewed. The facility Menu indicated, .Regular .Oatmeal 4 oz (ounces- units of measurement) .Pancakes 1 (quantity) .Oven Roasted Potatoes 1/4 cup .Pasta bean soup 4 oz .Egg salad sandwich 1 .CCHO (controlled carbohydrate diet) .Oatmeal 4 oz .Pancakes 1 .Oven Roasted Potatoes 1/4 cup .Pasta Bean Soup 4 oz .Egg salad sandwich 1. The DSM stated the cooks followed the menu's portion sizes. The DSM validated the portion sizes of the regular and controlled carbohydrate diet were the same. During an interview on 5/13/21 at 3:12 p.m., with the DSM, the DSM stated his expectation was for the nursing staff to inform him when residents had consistent elevated blood sugars so he could work with residents on their diet. The DSM stated he had no training on diabetes or blood sugar control. The DSM stated Registered Dietitian (RD) 1, should have been onsite at the facility when she evaluated residents. The DSM stated he would have expected RD 1 to assist him in planning meals for diabetic residents with consistent elevated blood sugars. During an interview on 5/13/21 at 3:52 p.m., with the DON, the DON stated her expectation was for the LNs to notify her [DON] when residents had consistent elevated blood sugars. The DON stated the expectation was for the LNs to call the physician when the blood sugar was over 400 mg/dl. The DON stated the physician would give an order for a HBA1c when the blood sugars were elevated. The DON stated the DSM should have been involved when the residents' blood sugars were elevated. The DON stated she aware the residents' blood sugars were an issue. The DON stated she should have followed up with the residents' diets. The DON stated the RD was not called or was informed of the elevated blood sugars. The DON was unable to verbalize and explain the role of the RD and the oversight the RD provided to the facility. During a telephone interview on 5/14/21, at 3:21 p.m., with the Medical Director (MD), the MD validated he was the primary physician for Residents 10, 11, 13, 25, 32, 33, and 36. The MD stated he conducted facility visits once a month and he expected the LNs to notify him when the blood sugars were high, if the LNs had questions, and to discuss the care of diabetes management. The MD stated his expectation was for the LNs to provide him a list of the residents along with their elevated blood sugars to determine what the next steps were. Resident 10, 11, 13, 25, 32, 33, and 36's blood sugars readings for March, April and May 2021 were shared with the MD. The information of the residents' blood sugars readings was consistently over 150 mg/dl. The MD stated when an individual reviewed the residents' blood sugars, it looked like they are high and they were definitely high. The MD stated he was not aware diabetic residents had asked for a change from regular diet to controlled carbohydrate diet, the MD stated nursing staff did not bring this to his attention. The MD stated the facility should have made an effort to help get the residents' diet changed. The MD stated physicians are not physically present in the facility during the residents' admission, so he depended on what the nurses informed him. The MD stated he wrote the residents' diet orders based on the information he received from the nursing staff. The MD stated residents can experience acute (new) and chronic (long term) changes in their blood sugars. The facility should have considered a referral to an endocrinologist (a medical practitioner qualified to diagnosis and treat disorders like diabetes) for the chronic elevated blood sugars. The MD stated if residents were in the facility for long term care, a baseline HBA1c should have been ordered upon admission. The MD stated the registered dietitian should have been engaged in residents' diabetic management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 26 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 5/16/21, at 12:20 pm, with Resident 10, Resident 10 stated .I get carbs and too much salt . During an interview on 5/17/21, at 4:20 p.m., with Registered Dietitian (RD) 2, RD 2 stated it was her first day in this facility. RD 2 stated the facility had called her on Friday (5/14/21) and she was made aware of the IJ situation at the facility because diabetic residents had uncontrolled blood sugars, and the RD, physician, and IDT had not assessed the elevated glucose (sugar) levels. RD 2 stated the facility asked her why diabetic residents were not on a controlled carbohydrate diet. RD 2 stated residents needed nursing intervention and communication to the DON and physician. RD 2 stated her expectation was for the facility to notify her if the residents' blood sugars were consistently high. RD 2 stated her expectation of the facility staff was to be informed if they the HBA1c and blood sugars were elevated. RD 2 stated, I definitely need to be in the loop. RD 2 stated the facility should have reviewed the residents' charts to see if anything changed with their meal percentages (intake of food), infection, changes, and review the HBA1c to review trends. RD 2 stated she talked to the ADM and informed him there was no communication system between the facility and the RD [RD 2]. RD 2 stated communication system needed to be improved. RD 2 stated she followed the American Diabetes Association (ADA) standards. During an interview on 5/19/21, at 9:47 a.m., with the Social Worker (SW), the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have. During a concurrent interview and record review on 5/19/21 at 10:21 a.m., with the DON, Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars dated March, April and May 2021 were reviewed. The DON stated the facility system that was in place (communication of blood sugars) was not working. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars and validated the blood sugars were consistently elevated and should have been communicated to the physician. The DON stated LNs had not communicated to her [DON], the CNAs, DSM, RD or the physician regarding the consistent elevated blood sugars. The DON stated the physician was not notified by the LNs of the consistent elevated blood sugars and the physician should have been notified. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's medical records and validated there were no IDT notes to address the residents' blood sugars. The DON stated the RD should have educated diabetic residents on the consistent carbohydrate diet and explained the differences between a regular diet and a consistent carbohydrate diet. During a review of the facility's policy and procedure (P&P) titled, Diabetes Management Guideline revised December 2015, the P&P indicated, Guidelines statement: All residents will have appropriate treatment and services to manage their Diabetes .admission Assessments .Residents with diabetes are at very high risk for skin breakdown. Risks include vascular wounds (When there's reduced blood flow, skin and tissues in the affected areas are deprived of oxygen and nutrients, these areas will become irritated and form an open wound), pressure ulcers, infection and delayed healing .Recent lab values- A1C .Daily Observation by all staff should include: nutritional intake, glucose control .The American Diabetes Association states that the ideal goal for adults with diabetes is to achieve glucose levels between 70 and 130 mg/dl before meals, and less than 180 two hours after starting a meal, with a glycated hemoglobin (A1C) level less than 7 percent . Hyperglycemia: is common cause of illness and is the cause of secondary complications of the disease. Common signs and symptoms: .More frequent urination, incontinence, increased fatigue, unexplained weight loss, new vision problems, decreased mental function, confusion .Advanced Signs and Complications: .Poorly healing wounds, incisions, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 27 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some tingling, burning, numbness, persistent infections, dehydration, vomiting, renal dysfunction, cardiac symptoms .Nutrition .Maintaining health and promoting quality of life are two goals of nutritional care of the resident with Diabetes. The registered dietitian will complete a nutritional assessment upon admission and make changes as needed to food plans. The food plan and nutritional goals focus on the daily intake of carbohydrates, fats, protein and soluble fiber for those with diabetes. The Consistent Carbohydrate diet (Con CHO) is designed for individuals with a stable diabetes condition. A liberalized diet can enhance both the quality of life and nutritional status (relaxing the original diet prescriptions meant to control disease states like diabetes) .In caring for an individual with diabetes .b. Regularly review the meal plans and medication list of your residents .Monitoring/Compliance: The following elements are in place for the center to demonstrate satisfactory compliance with the guide: MD notification parameters in place .Hyperglycemia . Review patterns of blood glucose levels and communicate to physician .Communicate with physician if: Blood Glucose > (greater) 300 [mg/dl] . During a professional reference review of the American Diabetes Association retrieved from https://care.diabetesjournals.org/content/39/2/308 on 5/26/21, titled, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association dated February 2016, the professional reference indicated, Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost . Several organizations have developed diabetes guidelines for patients living in LTC settings. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to LTC staff who may be operating without the presence of a practitioner for prolonged periods .Hyperglycemia . persistent hyperglycemia increases the risk of dehydration, electrolyte abnormalities (imbalance of minerals in the body), urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome (occurs when a person's blood sugar levels are too high for a long period, leading to severe dehydration and confusion) .Improving Nutrition Health . a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes (is a chronic condition in which the pancreas produces little or no insulin) or type 2 diabetes on mealtime insulin .Diabetes Management During Transitions of Care . At the time of admission to a facility, transitional care documentation should include the current meal plan, activity levels, prior treatment regimen, prior self-care education, laboratory tests (including A1C, lipids [family of organic compounds, composed of fats and oils], and renal function), hydration status, and previous episodes of hypoglycemia (low blood sugar) (including symptoms and patient's ability to recognize and self-treat) .Integration of Diabetes Management Into LTC Facilities .Recommendation . Patients admitted to LTC facilities are not seen daily by a practitioner. Because of this reality, successful diabetes care needs to include a dedicated interprofessional team. This team may be composed of practitioners (physicians, nurse practitioners, and physician assistants), registered nurses, licensed practical/vocational nurses, certified nursing assistants, diabetes educators, dietitians, food service managers, consultant pharmacists, physical therapists, and/or social workers . In order to assess and improve facility-wide management of diabetes directed by multiple practitioners, the facility leadership (e.g., the director of nursing, nurse managers, medical director, and consultant pharmacist) should collect data and trends and plan strategies to improve selected process or outcome indicators relevant to diabetes management. These could include sharing data with managerial staff, providing staff education, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 28 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some planning a performance improvement project. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. Nursing leadership training programs for nurses working in LTC facilities that include skills in diabetes management can also help to improve quality of care offered to patients in these facilities .Figures & Tables .Table 6 - specific situations needing attention in patients with diabetes in LTC setting .glucose meter readings >300 mg/dl during all or part of 2 consecutive day .Confirm high glucose value by laboratory test .Evaluate nutritional intake . 2. During a review of Resident 11's AR undated, the AR indicated, .admission Date 2/9/21 .Diagnosis Information .Type 2 Diabetes Mellitus with Diabetic Neuropathy ( type of nerve damage that can occur if you have diabetes) .Hyperglycemia .Long Term (Current) Use of Insulin . Resident 11 was admitted on [DATE] from a general acute care hospital. During a review of Resident 11's Laboratory Report from the acute care hospital dated 8/28/2020 (prior to admission to the skilled nursing facility), the Laboratory Report indicated .HGBA1c .6.3 . [goal is less than 7 for diabetics] . During a review of Resident 11's Laboratory Report dated 5/5/21, the Laboratory Report indicated .GLYCOHGB (A1c) .Abnormal Summary .10.5 H [high] . During a review of Resident's 11's MAR dated May 2021, the MAR indicated Resident 11's blood sugar obtained on 5/10/21 at 11 a.m. was 370 mg/dl. During a concurrent observation and interview, on 5/10/21, at 11:45 a.m., in Resident 11's room, Resident 11 was observed in bed with his eyes closed and his left hand pressed against the left side of his head. Resident 11 stated he was diabetic, and he got too much pasta. Resident 11 stated his blood sugar was high, sometimes it was over 400 mg/dl. Resident 11 stated he experienced a headache and was dizzy. Resident 11 stated he requested a diabetic diet from nursing staff but continued to receive a regular diet. During a concurrent observation and interview, on 5/10/21, at 12:35 p.m., in Resident 11's room, Resident 11 sat on the side of bed eating lunch. Resident 11's lunch tray included: rice, pasta, green beans and pinto beans. Resident 11 stated he ate the green beans and pinto beans but did not want the rice and pasta. Resident 11 stated his blood sugar was 371 before lunch. During a concurrent observation and interview, on 5/10/21, at 4:09 p.m., in Resident 11's room, Resident 11 stated when he was in the hospital (prior to admission to the SNF), .They [hospital] gave me a diabetic diet and my blood sugars were not high. During an interview on 5/12/21 at 8:55 a.m., with the DSM, the DSM stated Resident 11 was on a regular diet. During a review of Resident 11's Order Summary Report dated 2/11/21, the Order Summary indicted, .Regular Diet . During an interview on 5/11/21, at 11:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had just assisted Resident 11 in ambulating with a walker from his room to the dining room for lunch. CNA 1 stated Resident 11 did Really good, but he was dizzy. CNA 1 stated Resident 11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 29 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 complained of being dizzy when he walked to the dining room. Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 11's MAR dated 5/11/21, the MAR indicated Resident 11's blood sugar was 361 mg/dl at 11:57 a.m. Residents Affected - Some During an interview on 5/11/21, at 1:10 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the physician was notified when blood sugars were over 400 mg/dl. LVN 3 stated she did not notify the physician when the blood sugars were over 300 mg/dl, two or more consecutive days. LVN 3 stated RD 1 did not receive notification of Resident 11's blood sugars that were over 300 mg/dl two or more consecutive days. During a concurrent observation and interview on 5/12/21 at 12:30 p.m. with LVN 4 during the noon medication pass, Resident 11 was observed. LVN 4 obtained Resident 11's blood sugar, the result was 325 mg/dl. Resident 11 stated he needed help from the surveyors to assist with his blood sugars and diet. Resident 11 stated he told the facility to stop feeding him carbs like pasta, corn and bread. Resident 11 stated his blood sugar reading in the morning was 400 mg/dl. LVN 4 did not respond to Resident 11's comments. When LVN 4 was asked if she was going to intervene with Resident 11's blood sugar, LVN 4 stated because it was under 400 mg/dl, she did not need to call the physician. LVN 4 stated, .His blood sugar is hard to control, he is always eating the wrong food . During a telephone interview on 5/12/21, at 2:55 p.m., with RD 1, RD 1 stated Resident 11 was on a regular diet and she had not received any notification Resident 11 had requested a controlled carbohydrate diet. RD 1 stated she was unaware Resident 11's blood sugars were consistently over 300 mg/dl. RD 1 stated, Thanks for letting me know. During an interview on 5/13/21 at 1:10 p.m., with the DSM, the DSM stated, No one ever mentioned his [Resident 11] blood sugars . During an interview on 5/13/21 at 3:12 p.m., with the DSM, the DSM stated his expectation was for the nursing staff to inform him when residents had consistent elevated blood sugars so he could work with residents on their diet. The DSM stated he had no training on diabetes or blood sugar control. The DSM stated RD 1, should have been onsite at the facility when she evaluated residents. The DSM stated he would have expected RD 1 to assist him in planning meals for diabetic residents with consistent elevated blood sugars. During an interview on 5/13/21 at 3:52 p.m., with the DON, the DON stated her expectation was for the LNs to notify her [DON] when residents had consistent elevated blood sugars. The DON stated the expectation was for the LNs to call the physician when the blood sugar was over 400 mg/dl. The DON stated the MD would give an order for a HBA1c when the blood sugars were elevated. The DON stated she was unaware of 11's request for a diet change from a regular diet to a consistent carbohydrate diet. The DON stated the DSM should have been involved when the residents' blood sugars were elevated. The DON stated she aware the residents' blood sugars were an issue. The DON stated she should have followed up with the residents' diets. The DON stated the RD was not called or was informed of the elevated blood sugars. The DON was unable to verbalize and explain the role of the RD and the oversight the RD provided to the facility. During a telephone interview on 5/14/21, at 3:21 p.m., with the MD, the MD validated he was the primary physician for Residents 10, 11, 13, 25, 32, 33, and 36. The MD stated he conducted facility visits once a month and he expected the LNs to notify him when the blood sugars were high, if the LNs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 30 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some had questions, and to discuss the care of diabetes management. The MD stated his expectation was for the LNs to provide him a list of the residents along with their elevated blood sugars to determine what the next steps were. Resident 10, 11, 13, 25, 32, 33, and 36's blood sugars readings for March, April and May 2021 were shared with the MD. The information of the residents' blood sugars readings was consistently over 150 mg/dl. The MD stated when an individual reviewed the residents' blood sugars, it looked like they are high and they were definitely high. The MD stated he was not aware diabetic residents had asked for a change from regular diet to controlled carbohydrate diet, the MD stated nursing staff did not bring this to his attention. The MD stated the facility should have made an effort to help get the residents' diet changed. The MD stated physicians are not physically present in the facility during the residents' admission, so he depended on what the nurses informed him. The MD stated he wrote the residents' diet orders based on the information he received from the nursing staff. The MD stated residents can experience acute and chronic changes in their blood sugars. The facility should have considered a referral to an endocrinologist for the chronic elevated blood sugars. The MD stated if residents were in the facility for long term care, a baseline HBA1c should have been ordered upon admission. The MD stated the registered dietitian should have been engaged in residents' diabetic management. During an interview on 5/17/21, at 4:20 p.m., with RD 2, RD 2 stated it was her first day in this facility. RD 2 stated the facility had called her on Friday (5/14/21) and she was made aware of the IJ situation at the facility because diabetic residents had uncontrolled blood sugars, and the RD, physician, and IDT had not assessed the elevated glucose levels. RD 2 stated the facility asked her why diabetic residents were not on a controlled carbohydrate diet. RD 2 stated residents needed nursing intervention and communication to the DON and physician. RD 2 stated her expectation was for the facility to notify her if the residents' blood sugars were consistently high. RD 2 stated her expectation of the facility staff was to be informed if they the HBA1c and blood sugars were elevated. RD 2 stated, I definitely need to be in the loop. RD 2 stated the facility should have reviewed the residents' charts to see if anything changed with their meal percentages (intake of food), infection, changes, and review the HBA1c to review trends. RD 2 stated she talked to the ADM and informed him there was no communication system between the facility and the RD [RD 2]. RD 2 stated communication system needed to be improved. RD 2 stated she followed the American Diabetes Association (ADA) standards. During an interview on 5/19/21, at 9:47 a.m., with the SW, the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have. During a concurrent interview and record review on 5/19/21 at 10:21 a.m., with the DON, Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars dated March, April and May 2021 were reviewed. The DON stated the facility system that was in place (communication of blood sugars) was not working. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars and validated the blood sugars were consistently elevated and should have been communicated to the physician. The DON stated LNs had not communicated to her [DON], the CNAs, DSM, RD or the physician regarding the consistent elevated blood sugars. The DON stated the physician was not notified by the LNs of the consistent elevated blood sugars and the physician should have been notified. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's medical records and validated there were no IDT notes to address the residents' blood sugars. The DON stated the RD should have educated diabetic residents on the consistent carbohydrate diet and explained the differences between a regular diet and a consistent carbohydrate diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 31 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0684 Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 11's Order Summary Report dated 2/9/21, the Order Summary Report indicated, Insulin [brand name] Solution 100 UNIT/ML, inject as per sliding scale, (sliding scale refers to the progressive increase of the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). Give subcutaneously (into the skin) before meals and at bedtime: 150 - [TRUNCATED] Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 32 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review, the facility failed to ensure food served met the daily nutritional needs for 21 of 37 residents (Residents 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190) when residents on regular and large portion diets were served more than the required portion size of the main dish [meatballs]. This failure had the potential to result in Resident 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190 to receive more than the recommended daily calorie intake based on residents nutritional dietary needs. Findings: During a review of facility document titled, Order Listing Report, dated 5/11/21, the order listing report indicated, .Status: Current, Order Category: Diet, Order Status: Current. Resident Name: Resident 31, Order Summary: Controlled Carbohydrate diet Regular texture .Resident 13, Renal Diet, Regular Texture .Resident 29, Regular Large Portion diet Regular texture .Resident 3, Regular diet Regular texture .Resident 16, Regular diet Regular texture .Resident 20, Regular diet Regular texture .Resident 189, Regular diet Regular texture .Resident 22, Regular diet Regular texture .Resident 23, Regular diet Regular texture .Resident 190, Regular diet Regular texture .Resident 33, Regular diet Regular texture .Resident 15, Regular diet Regular texture .Resident 10, Controlled Carbohydrate diet Regular texture .Resident 34, Regular diet Regular texture .Resident 19, Regular diet Regular texture .Resident 187, Regular diet Regular texture .Resident 28, Regular diet Regular texture .Resident 21, Regular diet Regular texture .Resident 7, Regular diet Finger foods texture .Resident 12, Regular diet Regular texture .Resident 1, Regular diet Regular texture . During a concurrent observation, interview, and record review on 5/11/21, at 11:45 a.m., during tray line, the dietary cook (DC) served three pieces of the main dish [meatballs] to residents with regular diets .The DC served four pieces of the main dish [meatballs] to residents with large portion diet. The DC weighed three pieces of the main dish [meatballs] and the weight was four ounces. The DC weighed four pieces of main dish [meatballs] and the weight was five ounces. The DC reviewed the facility document titled, RECIPE: MEATBALLS AND GRAVY undated, the recipe indicated, .Portion size: 2 meatballs (3 ounces protein). The DC reviewed facility document titled, Spring Cycle Menus, dated 5/11/21, the spring cycle menus indicated, .under Regular Column: Meatballs with Gravy .under Regular column: 2 (1-2 oz) Large Column: 2 (1-2 oz) .under CCHO (Controlled Carbohydrate) diet: Meatballs with Gravy .under Regular column: 2 . The DC stated the residents who were on regular diet should have been served 2 pieces of the main dish [meatballs] instead of three pieces. The DC stated the residents on a large portion diet should have been served two pieces of the main dish [meatballs] instead of four pieces. The DC stated the menu portion size should have been followed. During a concurrent interview, and record review on 5/11/21, at 12:20 p.m., with the Dietary Service Manager (DSM), the DSM reviewed the facility documents titled, RECIPE: MEATBALLS AND GRAVY, undated and Spring Cycle Menus, dated 5/11/21. The DSM stated the DC did not follow the menu portion size. The DSM stated, She (DC) gave more than the recommended amount/portion of food. The DSM stated DC should have given two pieces of the main dish to residents on regular and large portion diets. During a phone interview on 5/19/21, at 9:52 a.m., with the Registered Dietitian (RD) 2, RD 2 stated the DC should have followed the menu. RD 2 stated DC should have checked the menu portions prior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 33 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete to serving food. RD 2 stated the residents with regular and large portion diets were served more than what was indicated on the menu. RD 2 stated the residents received more than the recommended calorie intake, which could lead to weight gain. During a review of the facility's policy and procedure (P&P) titled, Food Service Distribution, dated 2011, the P&P indicated, .The director of dining services or designee is responsible for seeing that all meal service .Meets the therapeutic and consistency requirements of prescribed diets and personal preferences .Diets should be offered as ordered by a Physician .Serve proper portions according to the menus. Use portion-control utensils and scales as noted on menu and meal tickets . Event ID: Facility ID: 055454 If continuation sheet Page 34 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview, and record review the facility failed to provide suitable, nourishing snacks for four of seven sampled residents (Residents 1, 11, 23, and 29) when facility staff did not provide a variety of snacks for residents in the facility. This failure resulted in Resident 1, 11, 23, and 29 verbalizing and requesting different types of snacks from staff and staff did not notify the Dietary Service Manager (DSM). Findings: During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the facility staff did not pass out evening snacks. During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 5/12/21, at 10:30 a.m., with Resident 29, Resident 29 stated the facility staff did not pass out evening snacks. Resident 29 stated on 5/11/21 snacks were not passed out. Resident 29 stated the facility used to have peanut butter crackers and they did not provide them anymore during the evening shift snacks. During a review of Resident 29's MDS assessment, dated 4/13/21, the MDS assessment indicated, Resident 29 was cognitively intact with a BIMS score of 15. During an interview on 5/12/21, at 10:48 a.m., with Resident 11, Resident 11 stated the facility staff did not pass out evening snacks. Resident 11 stated he would like a peanut butter and jelly sandwich as an evening snack. During an interview on 5/12/21, at 10:54 a.m. with Resident 1, Resident 1 stated the facility staff did not pass out evening snacks. Resident 1 stated staff would notify the residents, the kitchen was closed and there were no snacks available. Resident 1 stated she would like peanut butter crackers. During an interview on 5/12/21, at 3:42 p.m., with the Dietary Service Manager (DSM), the DSM stated residents in the facility would be provided snacks at 10 a.m. 2 p.m. and 7 p.m. The DSM stated the dietary aids would make the snack carts and the activity department would pass out the 10 a.m. and 2 p.m. snacks. The DSM stated CNA's would pass out the evening snacks. The DSM stated the evening shift cook would prepare the snack cart that would go out to the residents in the facility. The DSM stated the snack cart included cereal with milk, cookies, pureed and thickened liquids, danishes, coffee and fruit. The DSM stated he was not aware there were not enough snacks in the evening time. The DSM stated the kitchen would close at 7:30 p.m. and if a resident requested a snack at 8 p.m. the CNA would have to check the snack to cart to see if there were any snacks left in the cart because the kitchen was closed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 35 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/12/21, at 4:57 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had been working in the facility since July 2020. CNA 2 stated residents would complain about wanting different types of snacks. CNA 2 stated Resident 11 was diabetic and the snack cart did not have an evening snack for him because he was diabetic. CNA 2 stated Resident 11 had notified the nurses he wanted an evening snack. CNA 2 stated on the evening of 5/11/2021, the snack tray had peanut butter and jelly sandwich, cookies, yogurt, mixed fruits, bananas and strawberries. CNA 2 stated there were no options for residents on a diabetic diet, but they were still offered a snack. CNA 2 stated two trays of snacks would be provided by the kitchen staff. CNA 2 stated there were times when no snacks were provided to some residents because there was not enough, and the dietary staff had left home. CNA 2 stated snacks were documented if they were offered. CNA 2 stated Resident 23 would give up his snacks to other residents if there were no snacks available. CNA 2 stated about three or four weeks ago there were no snacks available. During an interview on 5/17/21, at 4:20 p.m., with Registered Dietitian (RD) 2, RD 2 stated 5/17/21 was her first day in this facility. RD 2 stated the facility should pass out snacks in between meals. RD 2 stated she did not know what type of snacks the facility provided to residents in the facility. RD 2 stated snacks were provided to residents based on their diet order. RD 2 stated snacks had to be available for residents with diabetes (disease in which your blood glucose, or blood sugar, levels are too high). RD 2 stated residents with diabetes should be provided fresh fruit, fifteen milligram (mg-(unit of measurement) peanut butter crackers and a variety of snacks which all residents in the facility could eat. RD 2 stated if the facility had 40 residents then 40 snacks would have to be available to the residents. RD 2 stated she was not able to verbalize the system the facility had in place to pass out snacks and would have to talk to the DSM. RD 2 stated the facility should provide a variety of snacks to the residents in the facility. During an interview on 5/19/21, at 9:47 a.m., with the Social Worker (SW), the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have. During a review of the facility's document titled, Continental Breakfast Cart undated, indicated, . 6 PM Snack Cart Fresh Fruit- 4 of each . Assorted Cookies and Crackers-20 packages . yogurt/pudding- 6 swirl cups . ice cream- 6 individual cups . juice or punch- 1 pitcher . ½ sandwiches- 6 as needed . HS nourishments . During a review of the facility's policy and procedure (P&P) titled Dining Services dated 7/20/16, the P&P indicated, Snacks will be available through the day in accordance with residents preferences and plan of care . snacks are food or beverages in addition to the menu not sued for nutritional intervention When providing snacks, determine quantities to be distributed to each nursing station, based on the diet census and usage history . a variety of snacks will be offered based on residents' preferences . when residents request a specific snack, it will be individually prepared and distributed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 36 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when the Dietary [NAME] (DC) did not document the temperatures of the food served on 5/10/21 and 5/11/21. This failure had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages) in 37 of 39 residents who consumed food prepared the kitchen. Findings: During a review of the facility document titled, Spring Cycle Menus, dated 5/10/21, the spring cycle menus indicated, . Temp [blank] Grape juice .Temp [blank] breakfast meat . Temp [blank] Broccoli salad .Temp [blank] egg salad sandwich . During a review of the fancily document titled, Spring Cycle Menus, dated 5/11/21, the spring cycle menus indicated, .Temp [blank] Apple Juice .Temp [blank] Toasted Oats .Temp [blank] Ham and Egg Scrambles .Temp [blank] Bran Muffin .Temp [blank] Milk . During a review of the facility's document titled, Order Listing Report, dated 5/11/21, the order listing indicated, .Status: Current, Order Category: Diet, Order Status: Active . The Order Listing Report, indicated 37 residents are served food prepared in the kitchen. During a concurrent observation interview and record review on 5/11/21, at 9:25 a.m., with Dietary [NAME] (DC), in the kitchen, the DC reviewed facility document titled, Spring Cycle Menus, dated 5/10/21, the DC stated there are missing food temperatures in the temperature section of spring cycle menus dated 5/10/21 and 5/11/21. The DC stated she took the temperatures but did not document. The DC stated she should have documented the temperatures as soon as she took the temperatures. The DC stated the practice was to take temperatures of all the foods served to residents and document. The DC stated, It is important to take the temperature and document to make sure residents are served foods that are the right temperature, serving foods that are not the right temperature to residents may make residents sick. During a concurrent interview and record review on 5/11/21, at 9:45 with Dietary Service Supervisor (DSS), the DSS reviewed the facility document titled, Spring Cycle Menus, dated 5/10/21 and 5/11/21. The DSS stated the Spring Cycle Menus dated 5/10/21 and 5/11/21 had missing temperatures. The DSS stated food temperatures needed to be checked and recorded for all meals. The DSS stated, Temperatures are taken and recorded to make sure residents are served safe foods. During a phone interview on 5/19/21, at 9:52 a.m., with Registered Dietitian (RD), the RD stated the practice is to record food temperatures for each meal to make sure foods are at the right temperatures for food safety and palatability. The RD stated the cook should have recorded the temperatures as soon as she took the food temperatures. During a review of the facility's policy and procedure titled, Food Temperatures dated 2011, the policy and procedure indicated, .Meal services may consist of a combination of foods that require different temperatures - the director of dining or designee is responsible for ensuring that all food is at the proper serving temperature(s) before meal service starts .Heat food to the proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 37 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 temperature by direct heat (using a stove, oven, steamer, etc) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 38 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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, and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program for the prevention of Corona Virus (COVID-19- a contagious serious respiratory infection transmitted from person to person) transmission when one of one sampled Licensed Vocational Nurses (LVN 4) did not follow the use of a fit tested (a fit test determines if a tight-fitting respirator can be worn without having any leaks) N95 respirator (protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) when caring residents identified as PUI (person under investigation- someone on observation for symptoms of COVID-19 [a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]) COVID-19. Residents Affected - Few This practice potentially placed the residents and staff at risk for the spread and transmission of COVID-19, complications from COVID -19 and death. Findings: During a concurrent observation and interview, on 5/15/21, at 7:08 a.m., with Licensed Vocational Nurse (LVN) 4, during a medication pass observation in the PUI zone, LVN 4 was observed wearing a surgical mask under an N95 respirator. LVN 4 stated she had been fit tested for an N95 respirator. LVN 4 stated she wore a surgical mask underneath the N95 respirator because she would remove the N95 respirator in the resident's room and she would have a surgical mask on. LVN 4 stated she would continue to wear same surgical mask when she stepped outside the room. During an interview on 5/15/21, at 10:02 a.m., with the Infection Preventionist (IP), the IP stated she did not conduct fit testing in the facility. The IP stated the previous IP conducted the fit testing of N95 respirators. During a concurrent interview and record review on 5/15/21, at 10:08 a.m., with the IP, the [Skilled Nursing Facility] ALL STAFF In-Service dated 4/28/21 was reviewed. The IP stated she conducted an in-service on the topic, Yellow zone observation, donning (putting on) doffing (taking off) Personal Protective Equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries), Hand washing, [no return demonstration]. The IP stated she educated the staff how to don and doff PPE. The IP stated staff should don PPE by performing hand washing, putting on a gown, putting on an N95 respirator, goggles and gloves outside the room. The IP stated staff should doff PPE by removing the gloves, then the gown, then goggles, the N95 respirator, perform hand hygiene and put on a surgical mask. The IP stated she provided the staff education on removing the surgical mask prior to donning an N95 respirator. The IP stated staff should not be going into the room with two masks and it was not okay to have a surgical mask under an N-95 respirator. The IP stated she did not have staff do a return demonstration to validate for competency. During a review of the facility's document titled, Using Personal Protective Equipment (PPE) dated 4/23/21, indicated, Who Needs PPE .Healthcare personnel should adhere to Standard and Transmission-based Precautions when caring for patients with SARS-cov-2 infection . 1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training) 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 39 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator. Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. 5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 6. Put on gloves. Gloves should cover the cuff (wrist) of gown. 7. Healthcare personnel may now enter patient room During a professional reference review retrieved from https://www.cdc.gov/niosh/docs/2010-133/pdfs/2010-133.pdf titled How to Properly Put on and Take off a Disposable Respirator undated, indicated, WASH YOUR HANDS THOROUGHLY BEFORE PUTTING ON AND TAKING OFF THE RESPIRATOR. If you have used a respirator before that fit you, use the same make, model and size. Inspect the respirator for damage. If your respirator appears damaged, DO NOT USE IT. Replace it with a new one. Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. Follow the instructions that come with your respirator . Employers must comply with the OSHA Respiratory Protection Standard, 29 CFR 1910.134 if respirators are used by employees performing work-related duties FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 40 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the survey period from 5/10/21 through 5/19/21, the facility failed to ensure each bedroom accommodated no more than four residents (rooms [ROOM NUMBERS]). This failure had the potential to adversely effect care provided to residents in room [ROOM NUMBER] and 14. Findings: During an observation on 4/10/21 through 4/19/21, in room [ROOM NUMBER] and 14, the two resident bedrooms had more than four residents. Each room met the required needs of the residents, as well as the square footage. Closet and storage space were adequate. Bedside stands were available. There were sufficient room for nursing care to be provided to the residents. Wheelchair and toilet facilities were accessible. The health and safety of residents would not be adversely affected by the continuance of this waiver. Room Number Number of Beds Square footage 4 8 677.16 14 8 681.49 Recommend waiver continue in effect. ________________________________________________________________ Health Facilities Evaluator Supervisor Signature Date Request waiver continue in effect. ________________________________________________________________ Facility Administrator Signature Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 41 of 42 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 055454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625 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 - Potential for minimal 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 record review during the survey period of 5/10/2021 to 5/19/2021, the facility failed to provide the minimum of at least 80 square feet per resident in multiple rooms (Rooms 1, 2, 6, 8, 10, 11 and 16). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered. Findings: During a concurrent observation and interview on 5/13/21, at 8:40 a.m., with the Maintenance Supervisor (MS), an environmental tour was conducted. The MS measured six rooms and stated the rooms did not meet the minimum square footage of 80 square feet per resident. These rooms were as follows: Room Number: Square Feet: Number of Residents room [ROOM NUMBER] 150.29 2 beds room [ROOM NUMBER] 239.56 3 beds room [ROOM NUMBER] 301.32 4 beds room [ROOM NUMBER] 160.8 2 beds room [ROOM NUMBER] 149.34 2 beds room [ROOM NUMBER] 148.03 2 beds room [ROOM NUMBER] 302.4 4 beds During the observations made on 5/10/2021 to 5/19/2021, the residents had reasonable amount of privacy. Closets and storage space were adequate, bedside stands were available. There was sufficient room for nursing to provide care and for residents to ambulate. Toilet facilities and wheelchairs were accessible. The waiver will not adversely affect the health and safety of residents. Recommend waiver continue in effect. ________________________________________________________ Health Facilities Evaluator Supervisor Signature Date Request waiver continue in effect. _________________________________________________________ Administrator Signature Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055454 If continuation sheet Page 42 of 42