Health inspection·February 1, 2024

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 Based on interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 119) and her Responsible Party (RP) were provided a copy of the baseline care plan (BCP). This failure had the potential for Resident 119 and her RP to be unaware of her plan of care. Findings: During a concurrent interview and record review on 2/1/24 at 1:58 p.m. with Medical Records (MR) staff, Resident 119's BCP, dated 1/4/24 was reviewed. MR staff stated Resident 119 had an incomplete BCP because there was no indication a printed copy of the BCP was given to Resident 119 or Resident 119's RP. MR staff stated she reviewed Resident 119's clinical record and there was no documentation that a printed copy of the BCP was given. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated 2022, the P&P indicated, 1. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident.4. The resident and/or representative should be provided a written summary of the baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 2 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 interview, and record review, the facility failed to develop and implement a person-centered care plan for 1 of 50 sampled residents (Resident 18) when the facility continued to offer an oral nutrition supplement (ONS) after Resident 18 expressed dislike of the ONS. This failure had the potential to result in further significant weight loss. Findings: During a review of Resident 18's Weights and Vitals Summary (WVS), the WVS indicated the following weights: 8/1/23 - 151 pounds (lbs) 9/5/23 - 144 lbs 10/3/23 - 142 lbs 11/7/23 - 142 lbs 12/27/23 - 132 lbs 1/23/24 - 135 lbs During a review of Resident 18's WVS, the WVS indicated from 8/1/23 to 1/23/24, she had a significant weight changed of 16 lbs/10.6 %. During a review of Resident 18's Order Listing Report(OLR), dated 8/11/23, the OLR indicated, Boost Glucose Control Oral Liquid (Nutritional Supplements) Give 4 ml [milliliter-unit of volume] by mouth two times a day for supplement give after meals. During a review of Resident 18's IDT [interdisciplinary team] Significant Weight Change (IDTSWC), dated 12/29/23, the IDTSWC indicated, Boost intake % [percent] average at this time: ref [refused]. During a review of Resident 18's RD [registered dietician] weight review (RDWR), dated 1/01/24, the RDWR indicated, Wts [weights] 132 # [pounds].Per the nurse, res [resident] will drink the boost supplement at times, and she easily gets tired of it. During a review of Resident 18's IDTSWC, dated 1/12/24, the IDTSWC indicated, Boost % average intake: 7%. During a review of Resident 18's IDTSWC progress notes, dated 1/19/24, the IDTSWC progress notes, indicated, Boost intake % average at this time: 0% During a review of Resident 18's IDT weight meeting (wt mtg), notes dated 1/9/24, the IDT wt mtg notes indicated, Current weight 126 lbs, Boost % average intake: 7% .team recommends continuing with current plan of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 3 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 During an interview on 1/29/24 at 12:30 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 18 does not like Boost. During an interview on 1/30/24 at 12:05 p.m. with Resident 18 in her room, Resident 18 stated she does not like the Boost drinks. Resident 18 stated she had not been asked about her supplement preferences. Residents Affected - Few During a concurrent interview and record review on 1/30/24 at 2:17 p.m. with RD 1 and RD 2, Resident 18's RDWR, dated 1/29/24 was reviewed. The RDWR indicated, -30# (-19.2%) x 6 months.supplement: Boost Glucose Control Oral Liquid 4 oz [ounces-unit of weight] BID [twice a day] after meals.Res. usually refuses the boost supplement per eMAR [electronic medication administration record]. RD 2 stated she reviewed Resident 18's MAR for January 2024 and Resident 18 had only consumed 300 ml of Boost Glucose Control (ONS) for the month. During a review of Resident 18's Medication Administration Record (MAR), for 12/2023, the MAR indicated Resident 18 consumed 500 ml of the ONS for that month. RD 1 stated the reason why she continued to provide the Boost Glucose Control supplement even though she was aware Resident 18 did not like it was because the only other supplement the facility had available to offer was very similar to Boost, in that it was vanilla, milk based and sweet. RD 1 stated she had not asked Resident 18 what kind of ONS she would prefer because she did not have anything else to offer. RD 1 and RD 2 stated the IDT Nutrition care plan was not person-centered and did not reflect Resident 18's preferences, and dislikes. During a review of Resident 18's IDT nutrition care plan (IDTNCP), date initiated on 01/20/2020, the IDTNCP indicated, Interventions/Tasks: .Boost Glucose Control Oral Liquid 4 oz. BID after meals . During a review of Resident 18's Care Plan (CP), with a focus of right to self-direct or to refuse care dated 1/30/24, the CP indicated, Episodes of refusing meals/supplements.Interventions/Tasks.Address all concerns, allow resident to participate in care decisions. CP indicated, no documented alternative nutrition approaches to address supplement refusals. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2/18, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Reflect the resident's expressed wishes regarding care and treatment goals. During a review of the facility's P&P titled, Weight Assessment and Intervention, dated March 2022, the P&P indicated, Care Planning: 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate.Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 4 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 10) care plan was updated and revised after Resident 10's order for tube feeding (TF-a way to provide nutrition when you cannot eat or drink safely by mouth) was changed. This failure had the potential to result in further significant weight loss. Findings: During a review of Resident 10's RD [Registered Dietitian] Tube Feeding / wt [weight] (RDTF), note dated 1/27/24, the RDTF note indicated, TF order: 2 cans of Jevity 1.2 [liquid nutrition for TF) via G-Tube [a tube inserted through the belly that brings nutrition directly to the stomach] at 0600 [6:00 a.m.], 1200 [12:00 p.m.], 1800 [6:00 p.m.], and 1 can Jevity 1.2 (8 oz [ounces- unit of weight]) at 0000 [12:00 a.m.].Totals 7 cans, Res [resident] was reviewed d/t [due to] wt [weight] loss of.-13# [pounds] (-7.7%) [of body weight] x 3 m [months], likely d/t inadequate intake of TF. Recommend adding 1 can Jevity 1.2 (8 oz) at 0900 [9:00 a.m.]. During an interview on 2/1/24 at 11:19 a.m. with Assistant Director of Nursing (ADON), ADON stated she obtained a telephone order on 1/29/24 to add a can of Jevity 1.2 at 9:00 a.m. for Resident 10. During a review of Resident 10's Order Summary Report (OSR), dated 2/1/24, the OSR indicated, Order Date: 02/01/2024.Start Date 02/02/2024.Give 2 cans (16 oz.) of Jevity 1.2 via G-Tube at 0600 [6:00 a.m.], 1200 [12:00 p.m.], 1800 [6:00 p.m.], and 1 can Jevity 1.2 (8 oz) at 0000 [12:00 a.m.] and 0900 [9:00 a.m. During a concurrent interview and record review on 2/1/24 at 10:37 a.m. with Consultant 1, Resident 10's CP's were reviewed. The CP's indicated, there were no revisions to resident 10's CP to reflect the current order for TF. Consultant 1 stated, she could not find any updates regarding TF order change. During a concurrent interview and record review on 2/1/24 at 11:19 a.m. with ADON, Resident 10's CP's, were reviewed. The CP's indicated, there were no revisions to resident 10's CP to reflect the current order for TF. ADON stated, it was her responsibility to have updated and revised the CP to reflect the change to the TF order, and had not. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2/18, the P&P indicated, The comprehensive, person-centered care plan will.b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition. During a review of the facility's P&P titled, Weight Change Protocol, dated 2023, the P&P indicated, A care plan is to be developed stating the problems, the goal, and the approaches, interventions to accomplish the goal. The PES [nutrition diagnosis to include problem, etiology (cause), signs/symptoms] statement should be in the care plan as in the assessment. The care plan must be revised as goals and interventions change. The goals, interventions in the care plan should match the latest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 5 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0657 assessment. 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: 055568 If continuation sheet Page 6 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure nail care was provided for two of 50 sampled residents (Resident 42 and Resident 10). This failure had the potential to result in skin injuries, infections, and pain. Residents Affected - Few Findings: During a concurrent observation and interview on 1/29/24 at 9:12 a.m. with Resident 42 outside of Resident 42's room, Resident 42's nails were long, thick and brown in color. Resident 42 stated she would love to get some help cutting them and thought she might need a specialist because of how long and thick they were. Resident 42 stated they were painful anytime they got caught on something. During an interview on 2/1/24 at 9:57 a.m. with Registered Nurse (RN) 1, RN 1 stated she thinks Resident 42 had fungus under her nails and Resident 42's nails would not have been so difficult to cut if it had been taken care of sooner. RN 1 stated she did not notify the doctor of the suspected fungal infection because the social services department had already been working on a referral to a specialist. During an interview on 2/1/24 at 9:59 a.m. with Resident 42, Resident 42 stated she has had this issue with her nails for a while, even before she was admitted over a year ago. During an interview on 2/1/24 at 11:13 a.m. with Social Services Director (SSD), SSD stated she was not made aware of issue with Resident 42's nails prior to Monday 1/29/24 and had not made any referrals for nail care. SSD stated the nursing staff should have addressed the possible nail fungus with the physician to obtain an order to refer Resident 42 to a specialist. During a review of Resident 42's admission Record (AR), dated 1/31/24, the AR indicated, NEED FOR ASSISSTANCE WITH PERSONAL CARE as a current diagnosis with an onset of 10/24/22. During a concurrent observation and interview on 1/29/24 at 2:55 p.m. with Administrator and Infection Preventionist (IP), outside of Resident 10's room, Resident 10's nails were long and jagged. Administrator stated Resident 10's nails were too long and needed to be taken care of. Administrator asked IP to cut Resident 10's nails. IP stated Resident 10's nail length could cause him to get scratched, and could contribute to infection. During a review of Resident 10's AR, dated 1/31/24, the AR indicated, NEED FOR ASSISSTANCE WITH PERSONAL CARE as a current diagnosis with an onset of 3/23/23. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated February 2019, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed.Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 7 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 18) bowel (the tubes in your body through which digested food passes from your stomach to your anus) management protocol was followed. This failure resulted in Resident 18 not having bowel movement for four days and had the potential to result in worsening of his health condition. Residents Affected - Few Findings: During a concurrent interview and record review on 1/31/24 at 3:41 p.m. with Director of Nursing (DON), Resident 18's Task: Bowel Continence (BC), dated 1/18/24 through 1/27/24 was reviewed. The BC indicated, Resident 18 did not have a bowel movement (BM) from 1/22/24 through 1/25/24 (four days) as indicated by a check mark in the column labeled as No Bowel Movement. DON stated the facility's bowel protocol was not followed when Resident 18 did not receive treatment in a timely manner, after having no bowel movement for four (4) consecutive days, as treatment should have been provided after three (3) days of no BM. During a concurrent interview and record review on 1/31/24 at 3:43 p.m. with DON, Resident 18's Medication Administration Record (MAR), dated 1/2024 was reviewed. The MAR indicated, Milk of Magnesia (MOM). give.as needed for constipation if no BM for 3 consecutive day ordered on 7/24/2023 PRN (as needed). DON stated the MAR indicated on 1/26/24 at 8:40 a.m. administration time, MOM was provided after 4 days of no BM. DON verified Resident 18 did not receive treatment for constipation until the 5th consecutive day of no bowel movement. During a concurrent interview and record review on 1/31/24 at 3:44 p.m with DON, Resident 18's Nursing Progress Notes (NPNs), dated 1/22/24 through 1/25/24, were reviewed. The NPN indicated, Resident 18 did not refuse bowl management protocol treatments. DON stated there was no documentation in the NPNs from 1/22/2024 through 1/25/2024, to indicate the nurses were aware of Resident 18 not having a bowel movement for four days, nor that Resident 18 was offered treatment and refused. During a review of the facility's policy and procedure (P&P) titled, Bowel Management Protocol, dated 2/15/15, the P&P indicated, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. Definition: Normal bowel pattern is once every day up to once every three (3) days. Constipation results from factors such as immobility, decreased activity, and as a side effect of numerous medications.Procedure: 1. Medicate with daily stool softeners and/or bulk formers as per physician order.3. Encourage fluid intake as allowed and tolerated. Prune juice may be given daily.5. The 3-11 [3 pm to 11 pm shift] House Supervisor [HS] (or charge nurse in the event of no HS) will review the resident flow record daily and compose a list of those residents not having had a BM in three (3) days and record it on the appropriate bowel care list. 6. The 3-11 nurse will provide medication as ordered by the physician or obtain a physician's order, to residents on the bowel care list. The medication given should be recorded on the MAR and the bowel care list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 8 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) was accurately assess for risk of elopement (leaving an area without supervision or permission). This failure had the potential for Resident 10 to get out of the facility without supervision and compromise his safety. Findings: During a concurrent observation and interview on 1/29/24 at 12:15 p.m. in Resident 10's room with Licensed Vocational Nurse (LVN) 7, Resident 10 was wearing a code alert bracelet on his right wrist. LVN 7 stated Resident 10 used to get sad and would try to leave. During an interview on 2/1/24 at 11:27 a.m. with Assistant Director of Nursing (ADON), ADON stated Resident 10 tries to leave the facility at times. During a concurrent interview and record review on 2/1/24 at 11:37 a.m. with Administrator, Resident 10's Elopement Risk Observation/Assessment (EROA), dated 12/2/23 was reviewed. The EROA indicated, Elopement Risk Score 8. If the total score is 10 or greater, the Resident would be considered to be At Risk for Elopement. Administrator stated Resident 10's EROA completed on 12/2/23 was not completed correctly because Resident 10 takes the medication Keppra (medication used to treat and prevent uncontrolled movements called seizures or convulsions). Administrator stated if the assessment had been completed correctly, Resident 10 would have scored At Risk for Elopement on the EROA. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated March 2019, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 9 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of four sampled resident's (Resident 54) Foley Catheter (FC - flexible tube inserted into the bladder to drain urine) was monitored. This failure had the potential to result in FC dislodgement. Findings: During a concurrent observation and interview on 1/31/24 at 7 a.m. with Minimum Data Set Coordinator (MDSC) in front of nurses' station 2, Resident 54 was sitting in his wheelchair with the tubing for his Foley catheter on the floor, laying directly behind the front wheel of the wheelchair. MDSC stated the tubing could have been pulled out and caused pain. MDSC stated the tubing being on the floor could have also caused infection. MDSC stated the Foley catheter tubing should have been positioned off the ground. During a review of Resident 54's Physician's Order (PO), dated 4/21/23, the PO indicated, Monitor Foley Catheter induced laceration [cut] to Penis for signs of worsening and infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated August 2022, the P&P indicated, Be sure the catheter tubing and drainage bag are kept off of the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 10 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to ensure timeliness of Registered Dietitian (RD) nutrition assessment after a significant weight loss for one of four sampled residents (Resident 10) who received nutrition via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach). This failure resulted in delayed nutrition interventions. Residents Affected - Few Findings: During a review of Resident 10's Weights and Vitals Summary (WVS), the WVS indicated, the following weights: 7/25/23 - 174 pounds (lbs) 8/29/23 - 168 lbs 9/26/23 - 167 lbs 10/10/23 - 168 lbs 11/14/23 - 164 lbs 12/12/23 - 161 lbs 1/16/24 - 155 lbs 1/23/24 - 152 lbs During a concurrent interview and record review on 1/31/24 at 1:59 p.m. with RD 1, Resident 10's IDT [interdisciplinary] Significant Weight Change (IDTSWC), dated 1/19/24 was reviewed. The IDTSWC indicated, Resident 10 had a significant weight change as of 1/16/24 of - 6 lb x 1 month 3.7% [loss of body weight], -13 lb x 3 month 7.7%, -18 lb x 6 month 10.4%, Current weight: 155# [pounds].Current Diet: GTube Feeding Jevity 1.2 [a nutrition liquid formula delivered via a tube].IDT recommends: Unintentional weight loss. Tolerating well with a couple refusals. Team recommends weekly weights and continuing with current plan of care. Continue to monitor weight changes .IDT members present 1/19/2024: DON [Director of Nursing], ADON [Assistant Director of Nursing], DOR [Director of Rehabilitation], DSD [Director of Staff Development], IP [Infection Preventionist], SSD [Social Services Director], RD. RD 1 stated there was no documented root cause analysis to help determine the reason for the significant unplanned weight loss, and no new nutrition interventions developed that would add calories and/or protein to address the weight loss noted. RD stated, there was no RD present for the IDT and she was not involved in the IDT for Resident 10 even though an RD is listed as having been present. During a review of Resident 10's RD Tube Feeding [a way to provide nutrition when you cannot eat or drink safely by mouth]/wt [weight] (RDTF), note dated 1/27/24, the RDTF note indicated, TF [tube feeding] order: 2 cans of Jevity 1.2 [liquid nutrition for TF) via G-Tube [a tube inserted through the belly that brings nutrition directly to the stomach] at 0600 [6:00 a.m.], 1200 [12:00 p.m.], 1800 [6:00 p.m.], and 1 can Jevity 1.2 (8 oz) at 0000 [12:00 a.m.].Totals 7 cans, Res [resident] was reviewed d/t [due to] wt loss of.-13# (pounds) (-7.7%) x 3 m [months], likely d/t inadequate intake of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 11 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0692 TF.Recommend adding 1 can Jevity 1.2 (8 oz [ounces]) at 0900 [9:00 a.m.]. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/27/24 at 2:05 p.m. with RD 1, RD 1 stated the RDTF, dated 1/27/24 was the first RD evaluation and nutrition recommendations to address Resident 10's significant unplanned weight loss since it occurred on 1/16/24, 10 days later. RD 1 stated she evaluated one of the root cause for the unplanned weight loss was resident's numerous refusals of his scheduled midnight bolus tube feeding. RD 1 stated she recommended a nutrition intervention to add one can of Jevity 1.2 at 9 a.m. to increase the likelihood the nutrition would be delivered to Resident 10's stomach via G-tube. RD 1 stated a 10 day delay in an RD assessment and RD nutrition recommendations to address significant weight loss was not timely. RD 1 stated Resident 10 could have benefited from the implementation of nutrition intervention to add calories and protein 10 days earlier to help prevent or minimize further weight loss. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol, dated 2023, the P&P indicated, Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 12 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 103, Resident 281, and Resident 49) dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) assessments were completed. This failure had the potential for dialysis related complications to occur/worsening of residents health condition. Residents Affected - Some Findings: During a concurrent observation and interview on 1/29/24 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 103's room, Resident 103 was not in his room. LVN 1 stated Resident 103 was at dialysis. During a concurrent observation and interview on 1/30/24 at 10:07 a.m. with Resident 103, in Resident 103's room, Resident 103 stated he goes for dialysis on Mondays, Wednesdays, and Fridays. Resident 103 pointed to an area on his upper right arm where an AV fistula (connection made between an artery and a vein for dialysis access) could be seen. During a concurrent interview and record review on 2/1/24 at 9:54 a.m. with Minimum Data Set Coordinator (MDSC), Resident 103's medical record was reviewed. The following were noted: Dialysis Assessment Record (DAR) dated 1/15/24 indicated the Pre-Dialysis Assessment (PDA) was to be completed by [facility] nurse was missing the time, vital signs, and a nurse's signature. The section of the form To be completed at the dialysis center was blank. DAR dated 1/17/24 indicated the section of the form To be completed at the dialysis center was blank. DAR dated 1/19/24 indicated the section of the form To be completed at the dialysis center was blank. MDSC was unable to find a Dialysis Assessment Record for 1/22/24. DAR dated 1/24/24 indicated the section of the form To be completed at the dialysis center was blank. MDSC was unable to find a Dialysis Assessment Record for 1/26/24. DAR dated 1/29/24 indicated the section of the form To be completed at the dialysis center was blank. MDSC was unable to find any documentation for Resident 103 from the dialysis center for 1/15/24, 1/17/24, 1/19/24, 1/22/24, 1/24/24, 1/26/24, or 1/29/24. During an interview on 2/1/24 at 10:34 a.m. with Administrator, Administrator stated the missing information is important and We need to fix that system [how facility and dialysis center exchange resident information]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 13 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/30/24 at 11:20 a.m. with Resident 281, Resident 281 stated she receives dialysis every Monday, Wednesday, and Friday. Resident 281 stated vital signs are only checked when the nurses make their rounds. Resident 281 stated she is not assessed, and her vitals are not taken before or after dialysis. During a concurrent interview and record review on 2/1/24 at 11:45 a.m. with Registered Nurse (RN) 2, Resident 281's clinical record (CR) was reviewed. The CR indicated, on 1/24/24 and 1/26/24 there were assessments completed before or after Resident 281's dialysis treatments. RN 2 stated there should have been an assessment done prior to and after Resident 281's dialysis treatment. During a review of Resident 281's Order Summary Report (OSR), dated 1/22/24, the OSR indicated, VITAL SIGNS PRE [before] AND POST [after] DIALYSIS. During an interview on 2/1/24 at 12:17 p.m. with LVN 7, LVN 7 stated the Certified Nursing Assistant (CNA) does the vitals when the patient comes back from dialysis. LVN 7 stated she only takes Resident 49's blood pressure after dialysis if he needs medication. During a concurrent interview and record review at 12:18 p.m. with LVN 7, Resident 49's CR was reviewed. LVN 7 stated she was unable to locate documentation for assessments completed before and after dialysis treatment on 1/30/24. During a review of the facility's policy and procedure (IP&IP) titled, Charting and Documentation, dated 2022, the P&P indicated, The services provided to the resident progress toward the care plan goals. [sic] Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record. 7) Documentation of procedures and treatments should include care-specific details, including items such as: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable. D. Whether the resident refused the procedure/treatment; e. Notification of family, physician, or other staff, if indicated; and f. The signature and title of the individual documenting. During a review of the facility's P&P titled, End-Stage Renal Disease, Care of a Resident with, dated 2010, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.1. Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of the residents. 2. Education and training of staff includes.a. The nature and clinical management.b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. 4. Agreements between this facility and the contracted ESRD facility [dialysis center] include all aspects of how the resident's care will be managed, including. How information will be exchanged between the facilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 14 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review the facility failed to develop a system to demonstrate nursing competencies for licensed nursing staff. This failure had the potential to result in nursing staff not being competently skilled to meet the care needs of the facility's residents. Findings: During a concurrent interview and record review of personnel files on 2/1/24 at 3:47 p.m. with Staff Development Designee (SDD) and Consultant 1, Licensed Nurse Skills Inventory lists were reviewed, and the following were noted: Licensed Vocational Nurse (LVN) 6's skills inventory was signed off as completed by the Director of Nursing (DON) on 1/17/24. LVN 1's skills inventory was signed off as completed by the DON on 1/28/24. LVN 7's skills inventory was signed off and completed by the DON on 3/31/21. The skills lists did not indicate if competency was shown by a return demonstration, or by pre- or post-testing. SDD stated the skills lists are done on hire and annually. The Licensed Nurse Skills Inventory indicated Prepare, administer and record medications and treatments- see separate MED [medication] PASS skills checklist. The facility did not provide completed MED PASS skills checklist[s] for LVN 1 or LVN 7. No other form of proven competency (lecture with return demonstration, pre- and post-test, or demonstrated ability) for licensed nursing staff was provided. SDD acknowledged the findings. During a concurrent interview and record review on 2/1/24 with Consultant 1, Resident 282's Treatment Administration Record (TAR), dated January 2024 was reviewed. The TAR indicated, Registered Nurse (RN) 3 provided Peripherally Inserted Central Catheter (PICC - tube inserted into a vein in the arm, leg or neck for long-term antibiotics, nutrition, medications, and blood draws) line care on 1/27/24 and 1/28/24. Consultant 1 stated there was no competency for PICC line care for RN 3. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated August 2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 15 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Medication Administration for one of six sampled residents (Resident 93) when nursing staff did not administer the correct medication and dose ordered by the physician. This failure had the potential to adversely affect Resident 93's health condition. Findings: During an observation on 1/31/24 at 7:40 a.m. outside of Resident 93's room, Licensed Vocational Nurse (LVN) 1 prepared and administered 2 tablets of Oyster Shell Calcium (calcium supplement) 500 milligrams (mg-metric unit of weight). During a review of the Order Summary Report (OSR), dated 1/31/24, the OSR indicated, Oyster Calcium + D Oral Tablet 250-3.125 MG-MCG [microgram-unit of weight] (Calcium Carbonate [calcium supplement]-Vitamin D [supplement essential in the absorption of calcium]) Give 2 tablet by mouth one time a day for supplement. During an interview on 1/31/24 at 11:58 a.m. with LVN 1, LVN 1 stated she gave Resident 93 the wrong oyster shell calcium. During a review of the facility's P&P titled, Medication Administration, dated 2023, the P&P indicated, Medications are administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 16 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Obtain a physician's order for one of four sampled residents (Resident 95) to discontinue Seroquel (medication used to treat mental disorders that affect a person's ability to think, feel, and behave clearly) after the physician had agreed to the recommendation of the pharmacy consultant. 2. Follow-up/obtain physician's order for one of four sampled residents (Resident 42) to include parameter/recommendation by pharmacy consultant in administering Percocet (Oxycodone-Acetaminophen - pain medication used to treat moderate to severe pain, known to cause drowsiness and respiratory distress or even death when taken in high doses or combined with other substances). These failures had the potential for Resident 95 and Resident 42 to received unnecessary medications for prolonged period of time. Findings: 1. During a review of Resident 95's Consultant Pharmacist's Recommendation To Inter-Disciplinary Team (CPRIDT), dated [DATE], the CPRIDT indicated, This resident is currently administered Seroquel 25mg [milligram-metric unit of weight] qhs [every evening] . since [DATE]. Since last review, behaviors have declined quite a bit. Her anxiety [feelings of worry] behaviors have also decreased. I defer it to your opinion if we may . D/C [Discontinue] Seroquel (dose at 25mg is more sedative [causing sleep] than anything else). Resident 95's physician circled the recommendation to d/c seroquel. The physician signed and dated the pharmacy recommendation on [DATE]. During a concurrent interview and record review on [DATE] at 12:40 p.m. with Minimum Data Set Coordinator (MDSC), Resident 95's Order Summary Report (OSR), dated [DATE], and the pharmacy recommendation signed by Resident 95's physician were reviewed. The OSR indicated, Seroquel Tablet 25 MG . Give 1 tablet by mouth in the evening. Order Status Active. Start Date [DATE]. Reviewed Pharmacy recommendation indicating physician agreed to discontinue seroquel. MDSC stated Seroquel was not discontinued and should have been. 2. During a review of Director of Nursing Summary Report (DNSR), dated [DATE], the DNSR indicated, Pharmacy Consultant MMR [Medication Regimen Review] Date: [DATE] Please hold routine Percocet for O2 sat <90 [oxygen saturation less than 90 percent-indicating low oxygen levels in the blood], RR <12 [respiratory rate less than 12 breaths per minute], and overt sedation [decreased awareness or responsiveness] for Resident 42. During a concurrent interview and record review on [DATE] at 2:03 p.m. with MDSC, Resident 42's OSR, dated [DATE] was reviewed. The OSR indicated, (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth two times a day. There were no parameters to hold the medication included in the order. MDSC stated she looked through the previous orders and could not find any evidence the recommendation from the pharmacy consultant on [DATE] was carried out. MDSC stated it should have been. During a review of the facility's policy and procedure (P&P) titled, MEDICATION MONITORING AND MANAGEMENT, dated 2023, the P&P indicated, In order to optimize the therapeutic benefit of medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 17 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0756 Level of Harm - Minimal harm or potential for actual harm therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 18 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) pain level was properly assess prior to administering narcotic (highly addictive controlled medication used to relieve pain) pain medication. This failure had the potential for Resident 15's pain to not appropriately treated and worsening of her health condition. Residents Affected - Few Finding: During a review of Resident's 15 Medication Administration Note (MAN), dated 1/8/24, the MAN indicated, Percocet [narcotic pain medication] Tablet 5-325 MG [milligram -a unit of measure] Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe Pain (4-10) [0 no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain]. During an interview on 2/1/24 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 15 is only able to verbalize two words, mama and yes. During a concurrent interview and record review on 2/1/24 at 3:24 p.m. with Minimum Data Set Coordinator (MDSC), Resident's 15's Medication Administration Record (MAR), dated October 2023, November 2023, December 2023 and January 2024 were reviewed. The MAR indicated the following: 10/1/23 at 12:27 a.m. Percocet given for pain level 3; 10/2/23 at 12:47 a.m. Percocet given for pain level 3; 12/9/23 at 12:34 a.m. Percocet given for pain level 3; 12/12/23 at 1:31 a.m. Percocet given for pain level 3; 12/14/23 at 12:22 a.m. Percocent given for pain level 3; 12/18/23 at 2:26 a.m. Percocet given for pain level 3; 12/19/23 at 12:23 a.m. Percocet given for pain level 3; 12/20/23 at 12:11 a.m. Percocet given for pain level 3; 1/10/24 at 6:05 p.m. Percocet given for pain level 3; 1/26/24 at 11:29 p.m. Percocet given for pain level at 0; 1/28/24 at 1:00 a.m. Percocet given for pain level 3. MDSC stated licensed nurses should give medication within the parameters of the physicians orders. MDSC stated nurses should call physician for clarification of orders as needed. During an interview on 2/1/2024 at 4:52 p.m. with LVN 6, LVN 6 stated if a resident is not able to verbally say they are in pain, staff should look for facial cues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 19 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 2023, the P&P indicated, Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. 2)Medications are administered in accordance with written orders of the attending physician. 3) If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Event ID: Facility ID: 055568 If continuation sheet Page 20 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discontinue Seroquel (a psychotropic medication used to treat mental disorders that affect a person's ability to think, feel, and behave clearly) for one of four sampled residents (Resident 95) when the physician agreed with the pharmacist's recommendation to discontinue the medication. This failure resulted in Resident 95 receiving a mind-altering medication unnecessarily for 89 days. Findings: During a review of Resident 95's Consultant Pharmacist's Recommendation To Inter-Disciplinary Team (CPRIDT), dated [DATE], the CPRIDT indicated, This resident is currently administered Seroquel 25 mg [milligram-metric unit of weight] qhs [every evening] . since [DATE]. Since last review, behaviors have declined quite a bit. Her anxiety [feelings of worry] behaviors have also decreased. I defer it to your opinion if we may . D/C [Discontinue] Seroquel (dose at 25mg is more sedative [causing sleep] than anything else). Resident 95's physician circled the recommendation to d/c seroquel. The physician signed and dated the pharmacy recommendation on [DATE]. During a concurrent interview and record review on [DATE] at 12:40 p.m. with Minimum Data Set Coordinator (MDSC), Resident 95's Order Summary Report (OSR), dated [DATE], and the pharmacy recommendation signed by Resident 95's physician were reviewed. The OSR indicated, SEROquel Tablet 25 MG. Give 1 tablet by mouth in the evening. Order Status Active. Start Date [DATE]. Pharmacy recommendation dated [DATE] indicated physician agreed to discontinue Seroquel. MDSC stated Seroquel was not discontinued and should have been discontinued on [DATE] when the physician signed and agreed with the pharmacy recommendation. During a review of Resident 95's Medication Administration Record (MAR), dated [DATE], the MAR indicated, Resident 95 received Seroquel every evening in [DATE]. During a review of Resident 95's MAR, dated [DATE], the MAR indicated, Resident 95 received Seroquel every evening in [DATE]. During a review of Resident 95's MAR, dated [DATE], the MAR indicated, Resident 95 received Seroquel every evening in [DATE]. During a review of the facility's policy and procedure (P&P) titled, MEDICATION MONITORING AND MANAGEMENT, dated 2023, the P&P indicated, In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. During a review of the facility's P&P titled, Medication Administration, dated 2023, the P&P indicated, Medications are administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 21 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview, and record review, the facility failed to utilize the Registered Dietitian(s) (RD) expertise and skills sets to carry out the functions of the food and nutrition services when: Residents Affected - Some 1. The RD documented imposed limitations of allowed hours the RD had at the facility impeded the following: timely weight reviews for residents, timely admission nutrition assessments for residents (Resident 18 and Resident 23), and inconsistent ability to conduct a monthly kitchen inspection to provide oversight over food safety, sanitation, evaluation of menus and therapeutic diets and lack of nutritional products/resources to offer choices to residents, when needed. 2. The RD was not incorporated into the IDT (interdisciplinary) weight review (care planning for weight change), in a timely manner, to address Resident's 10 significant weight loss. 3. The facility did not ensure the RD's skills sets were sufficiently incorporated into the facility's quality assurance and performance improvement (QAPI) by the facility not requiring the participation of the RD during the QAPI meetings. These failures resulted in the facility failing to utilize the RDs expertise in the development of resident care related to purchasing of supplies to have choices available for residents to ensure resident(s) nutritional needs were met, and to ensure the facility provides care and services in accordance with current standards of practice, that meet residents' nutritional needs in a timely manner. Findings: 1. During a concurrent interview and record review on 1/30/24 at 3 p.m. with RD 1, and RD 2, RD 1 stated she did not have adequate time to accomplish RD's duties in a complete and timely manner that affects the nutritional care provided at the facility. RD 1 stated she did not have time to provide sufficient oversight over food and nutrition services as she was unable to complete monthly kitchen inspections as expected. RD 2 stated she agreed with RD 1 about not having adequate time to accomplish RD duties. RD 1 and RD 2 stated they have completed their RD Nutrition Consultant Reports as required per their contract with the facility which includes communication to Administration of their concerns due to lack of contracted RD hours. RD 1 and RD 2 stated that they only have 8 hours a week to carry out RD duties to ensure residents nutritional needs were met for all resident in the facility. RD 1 and RD 2 stated the communication had not resulted in an action plan to assist the RDs to be able to carry out RD functions for food and nutrition services. A review of the RD(s) Nutrition Consultant Report (NCR), dated 11/9/23 to 1/12/24 was reviewed. Five of ten NCR's indicated, weight reviews (to identify and address unplanned weight loss or weight gain) were not being completed due to limited hours. Two of ten NCR's indicated, the monthly kitchen inspection was not done d/t [due to] limited hours. An NCR, dated 1/12/24, indicated, The facility has 7 new admissions [Residents admitted to the facility who would require a comprehensive nutrition assessment to be completed by an RD to meet resident's clinical nutrition needs] and 5 readmissions [5 residents returned to residing at the facility and were required to have a comprehensive nutrition assessment to meet their clinical nutrition needs] this week, but only finish 8 of them. Did not update or review the monthly weight d/t limited hours [ability to identify significant weight changes to plan nutrition interventions to prevent or minimize nutritional and/or medical complications]. RD 1 and RD 2 stated the NCR reports go to the facility's Administrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 22 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 1/30/24 at 2:17 p.m. with RD 1 and RD 2, Resident 18's RD weight review (RDWR), dated 1/29/24, was reviewed. The RDWR indicated, -30#[pounds] (-19.2%) x 6 months.supplement: Boost Glucose [oral nutrition supplement used to add calories and protein] Control Oral Liquid [ONS] 4 oz [unit of weight] BID [twice a day] after meals.Res [resident] usually refuses the boost supplement per eMAR [electronic medication administration record]. RD 2 stated she reviewed the eMAR for January 2024 and Resident 18 had only consumed 300 ml total consumption of ONS for the month. During a review of Resident 18's eMAR for December 2023, the eMAR indicated Resident 18 consumed 500 ml of the ONS for that month. RD 1 stated the reason why she continued to provide the Boost Glucose Control supplement even though she was aware the resident did not like it was because the only other supplement the facility had available to offer was very similar to the Boost, in that it was vanilla, milk based and sweet. RD 1 stated she had not asked Resident 18 what kind of oral nutrition supplement she would prefer because she did not have anything else to offer. RD 1 and RD 2 stated the IDT Nutrition care plan was not person-centered and did not reflect Resident 18's preferences, and dislikes, when Boost Glucose Control ONS continued to be provided two times a day after facility staff was aware Resident 18 did not like it. RD 1 stated she had communicated her concern of lack of nutritional products to offer residents to provide choices in order to honor food preferences, but the concern went unmet by administration. During a review of the facility's job description titled Registered Dietician (JDRD), the JDRD indicated, Complete nutritional initial, quarterly, annual and significant change reviews on residents according to federal and state guidelines. Assist in coordination of nutrition care services with Dietary Supervisor. Complete nutritional reviews monthly on high risk residents (significant weight loss/gain, pressure ulcer, hemodialysis, and tube fed). Essential Duties.Attends and participates in morning meetings/stand up to facilitate communications with the team. Assess nutritional needs, diet restrictions and current health plans in order to develop and implement dietary care plans and provides nutritional counseling as needed. Monitor food services operations to ensure conformance to nutritional, safety, and sanitation and quality standards, as well as state and federal regulations. Monitor.preparation methods.in order to ensure that food is prepared and presented in an acceptable manner. Inspect diet trays for conformance to physician's diet orders prior to delivery. During a review of the facility's Agreement to Provide Consultant Services (RD Contract), dated 10/1/18, the RD Contract indicated, Purpose: The purpose of this agreement is to provide a qualified RDN Consultant. The RDN's sole responsibility shall be guidance and council to the Nutrition Services Department.Responsibilities of the consultant.Provides consultation to administration regarding planning, policy development, and priority-setting, based on initial and ongoing evaluations of the food service needs.Maintains a summary of consultation activities by the consultant.Assess resident's nutritional needs. Documents nutritional information in accordance with the policies of the facility and accepted professional practice. This function is performed by the RDN (Registered Dietitian Nutritionist; interchangeable with RD) for all Initial Assessments, Annuals, and Change of Condition. Participates in care planning meetings.Reviews sanitation [of food service operations] in accordance with current regulatory standards.Maintains and provides written reports of each visit to the facility. This will include any audits performed, summary of performance, goals and recommendations to the facility. 2. During a concurrent interview and record review on 1/31/24 at 1:59 p.m. with RD 1, Resident 10's IDT [interdisciplinary] Significant Weight Change (IDTSWC), dated 1/19/24 was reviewed. The IDTSWC indicated, Resident 10 had a significant weight change as of 1/16/2024 of - 6 lb x 1 month 3.7% [loss of body weight], -13 lb x 3 month 7.7%, -18 lb x 6 month 10.4%, Current weight: 155# [lbs].Current Diet: GTube Feeding Jevity 1.2 [a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 23 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nutrition liquid formula delivered via a tube].IDT recommends: Unintentional weight loss. Tolerating well with a couple refusals. Team recommends weekly weights and continuing with current plan of care. Continue to monitor weight changes.IDT members present 1/19/2024: DON [Director of Nursing], ADON [Assistant Director of Nursing], DOR [Director of Rehabilitation], DSD [Director of Staff Development], IP [Infection Preventionist], SSD [Social Services Director], RD. RD 1 stated there was no documented root cause analysis to help determine the reason for the significant unplanned weight loss, and no new nutrition interventions developed that would add calories and/or protein to address the weight loss noted, at that time. RD stated there was no RD present for the IDT and she was not involved in the IDT for Resident 10 even though an RD is listed as having been present. During an interview on 1/27/24 at 02:05 p.m. with RD 1, RD 1 stated the RDTF, dated 1/27/24, was the first RD evaluation and nutrition recommendations to address Resident 10's significant unplanned weight loss since it occurred on 1/16/24, 10 days later. During a review of the facility's RD Contract, dated 10/1/18, the RD Contract indicated, Participates in care planning meetings. 3. During an interview on 1/30/24 at 2:17 p.m. with RD 1 and RD 2, RD 1 and RD 2 stated they were contracted consultant RD's, and did not work for the company of the skilled nursing facility. RD 1 stated Resident 23's admission nutrition assessment, dated 1/28/24 did not include Resident 23's usual body weight (UBW), which was nutrition care standards of practice for a comprehensive nutrition assessment. RD 1 stated the nutrition assessment form located in the electronic healthcare record (EHR) used to have a spot for UBW but one day it was no longer there. RD 1 and RD 2 stated they had not brought their concern to QAPI (quality assurance performance improvement- a committee that oversees the identification and handling of quality issues) because they do not attend the QAPI meetings. RD 1 and RD 2 stated the Dietary Services Supervisor (DSS) attends QAPI and they have only been asked to provide the DSS with the resident's weights for the DSS to report during QAPI meetings. RD 1 and RD 2 stated a DSS does not have clinical nutrition care scope of practice and therefore the Food and Nutrition Services (FANS) department was not fully represented during QAPI. During a concurrent interview and record review on 1/30/24 at 2:17 p.m. with RD 1 and RD 2, Resident 18's RDWR, dated 1/29/24 was reviewed. The RDWR included, -30# (-19.2%) x 6 months.supplement: Boost Glucose Control Oral Liquid 4 oz BID after meals.Res [resident] usually refuses the boost supplement per eMAR RD 2 stated she reviewed the eMAR for 1/2024 and Resident 18 had only consumed 300 ml total consumption of ONS for the month. During a review of Resident 18's eMAR for December 2023, the eMAR indicated Resident 18 consumed 500 ml of the ONS for that month. RD 1 stated the reason why she continued to provide the Boost Glucose Control supplement even though she was aware Resident 18 did not like it was because the only other supplement the facility had available to offer was very similar to the Boost, in that it was vanilla, milk based and sweet. RD 1 stated she had not asked Resident 18 what kind of ONS she would prefer because she did not have anything else to offer. RD 1 and RD 2 stated the CP was not person-centered and did not reflect Resident 18's preferences, and dislikes, when ONS continued to be provided two times a day after facility staff were aware Resident 18 did not like it. RD 1 and RD 2 stated they had communicated the lack of nutrition products/resources available to them to offer choices to residents for those who needed extra support to meet their nutritional needs. RD 1 and RD 2 stated they had not brought the issue to QAPI in order to discuss the need for performance improvement and advocate for the residents. RD 1 and RD 2 stated that administration had not asked RDs to participate in the facility's QAPI meetings. During a review of the facility's QAA Committee Information (QAACI - Name of Contact, Names of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 24 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Members and Frequency of Meetings), the QAACI indicated, Name of Meetings: Quality Assurance monthly, Infection Control; Pharmacy - Quarterly, Patient Care, Patient Safety - Annually; Attendees: Activities Director, Administrator, Admissions Director, Business Office Manager, Dietary Supervisor, Director of Rehab [Rehabilitation], DON [Director of Nursing], DONAC [Assistant Director of Nursing], DSD [Director of Staff Development], Environmental Services Director, Infection Control Preventionist, MDS [Minimum Data Set] Coordinator, Medical Director, Medical Records Supervisor, Pharmacist, Social Services Director. During a review of the facility's policy and procedure (P&P) titled Quality Assessment and Assurance Committee, dated August 2006, the P&P indicated, Policy Statement: This facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues. Policy Interpretation and Implementation: 1. The Administrator shall delegate the necessary authority for actions and processes to the Quality Assessment and Assurance Committee. 2. The committee shall be a standing committee of the facility, and shall provide reports to the Administrator and governing board (body). Goals of the Committee: The primary goals of the Quality Assessment and Assurance Committee are.To oversee facility systems and processes related to improving quality of care and services.To help identify negative outcomes relative to resident care and resolve them appropriately; To help departments, consultants and ancillary services implement plans to correct identified issues in quality of care; To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals; To help departments, consultants and ancillary services establish effective accountability for care quality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 25 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure one of one sampled Dietary Aide (DA)1 demonstrated the correct technique for testing the sanitation of dishes after running dishes through the low temperature dish machine. This failure had the potential to cause foodborne illness (illness caused by contaminated food). Findings: During a concurrent observation and interview on 1/29/24 at 9:15 a.m. with DA 1, in the facility's kitchen, DA 1 obtained a chlorine (chemical element) chemistry strip (strip used to check concentration of sanitizer) and inserted it into the low temperature dish machine's water tank. DA 1 compared the chemistry strip to the color-coded graph on the chlorine vial. DA 1 stated it was 100 PPM [parts per million]. During an interview on 1/29/24 at 9:17 a.m. with Dietary Services Supervisor (DSS), DSS stated DA 1 should have checked the sanitizer concentration at the plate level to ensure the dishes were properly sanitized. DSS stated DA 1 did not demonstrate the correct way to test the sanitizer concentration to ensure the dishes were properly sanitized. During a review of the facility's policy and procedure (P&P) titled, Dishwashing, (undated), the P&P indicated, Low-temperature machine.The chlorine should read 50-100 ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing the dishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 26 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 2. During a concurrent observation and interview on 1/29/24 at 12 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 85's room, LVN 1 stated Resident 85's finger stick blood sugar was 276 mg (milligram-unit of measurement of weight)/dL (deciliter - a unit of measurement of volume). During a concurrent observation and interview on 1/29/24 at 12:07 p.m. with CNA 2, in Resident 85's room, Resident 85 was in her room with her lunch tray on the overbed table. Resident 85 stated she did not like the chilli and requested an alternative. Resident 85 was served two large tamales as an entrée alternative to the planned menu item of 3 (three) bean chili onto her lunch meal tray, in addition to other items on her tray with the CCHO planned menu. During a concurrent observation and interview on 1/29/24 at 12:32 p.m. with DSS in the hallway adjacent to the kitchen, the Alternative Menu (Alt. Menu) was posted on a bulletin board. DSS stated, the Alt. Menu was available for those residents who requested an alternative entrée. DSS stated he had developed the Alt. Menu based on food preferences and did not take theraputic diets into consideration. During a concurrent interview and record review on 1/29/24 at 3:13 p.m. with RD 1, RD 1 stated the facility had not developed an Alt. Menu for therapeutic diets to include direction to dietary staff on what food to serve and quantity to be in accordance with therapeutic diet orders, including CCHO diet. RD 1 stated, she verified with DSS that Resident 85 was served two large tamales, along with other carbohydrate (CHO) foods that were on the planned CCHO menu, to include cornbread, milk, and dessert with whipped topping. RD 1 stated Resident 85 was provided 85 grams (unit of weight measurement) of CHO for lunch on 1/29/24. RD 1 stated the facility's Diet Manual for CCHO was planned for 55-65 grams of CHO for lunch meals. RD 1 stated, Resident 85's CCHO diet was not followed as listed in the Diet Manual. RD 1 stated it was the RD's responsibility to evaluate menus, to include alternate menus, for nutritional adequacy for regular and therapeutic diets, and that had not been done. During a review of Resident 85's Physician's Orders (PO), dated 11/15/23, the PO indicated, CCHO diet. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2023, the P&P indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders.Menus are to be approved by the Facility Registered Dietitian. Procedures: 1. The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. During a review of the facility's Diet Manual (DM), dated 2023, the DM indicated, Description: A controlled carbohydrate diet, (CCHO), is a meal plan without specific calorie levels typically used for diabetic residents and those with other metabolic concerns. Instead of counting calories, the carbohydrates are evenly, systematically, and consistently distributed through three meals and H.S. [bedtime] snack in an effort to maintain stable blood sugar level throughout the day.The carbohydrates are controlled through portion control and avoiding some concentrated sweets.Carbohydrates: Regular [regular portion] Lunch - 55 - 65 gms. During a review of the facility's P&P titled, Food Substitutions For Residents Who Refuse The Meal, dated 2023, the P&P indicated, Policy: Residents will be provided a suitable nourishing alternate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 27 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal after the planned, served meal has been refused. Procedure: Nursing personnel will ask any resident who does not eat his meal or food item as to why he is not eating and offer a food substitution in accordance with the resident's diet order. Based on observation, interview, and record review, the facility failed to follow the menu and/or facility's diet manual as planned for two of eight sampled residents (Resident 23 and Resident 85) when: 1. Lettuce in the tossed green salad and whole, sliced tomatoes were served that were larger than 1/2 (inch) pieces for Resident 23's mechanical soft (diet designed for people that have trouble chewing and swallowing) diet order. 2. Entree alternates were not nutritionally evaluated by a registered dietitian (RD) for Resident 85's CCHO (controlled carbohydrate diet for diabetes) diet. This failure had the potential for Resident 23 to choke and Resident 85 to have elevated blood sugars. Findings: 1. During a concurrent observation and interview on 1/29/24 at 11:56 a.m. with Resident 23 in Station 3 Dining Room, Resident 23 ate all the food that was on her tray except for most of the salad. Resident 23 stated she would have eaten all of her salad if it was cut up smaller. During a concurrent observation and interview on 1/29/24 at 12:08 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 23's tray only had the salad left. CNA 1 stated the lettuce in the salad was cut to about an inch in length and width. During a concurrent observation and interview on 1/29/24, at 12:24 p.m. with Dietary Services Supervisor (DSS), in front of Station 3 Dining Room, Resident 23's lunch meal tray was on the dirty meal delivery cart. DSS stated the pieces of lettuce were too large for a mechanical soft diet. DSS went into the kitchen and pointed to the planned menu for the therapeutic mechanical soft diet that indicated 1/2 or less for the tossed green salad. DSS stated the planned menu for the therapeutic mechanical soft diet was not followed. During an observation on 1/30/24 at 11 a.m. in the kitchen, the Dietary [NAME] (DC) placed two tomato slices on Resident 23's lunch meal tray. During an observation on 1/30/24 at 11:18 a.m. in the kitchen, Resident 23's lunch meal tray was placed on the meal delivery cart with two slices of tomato with the skin on. During a concurrent observation and interview on 01/30/24, at 11:19 a.m. with Registered Dietitian (RD) 1, RD 1 removed Resident 23's meal tray from the meal delivery cart to check it for accuracy. RD 1 stated, The tomatoes should be smaller, chopped. During a review of Resident 23's meal tray ticket (MTT), dated 1/30/24, the MTT indicated, Diet Order: Mechanical Soft, *Regular, -Thin Liquids. During a review of Resident 23's admission Record (AR), dated January 2024, the AR indicated, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 28 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0803 Level of Harm - Minimal harm or potential for actual harm diagnosis of Dysphagia [difficulty swallowing food or liquid], oropharyngeal phase [moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat]. During a review of Resident 23's Nutrition Care Plan (NTC), dated 1/21/19, the NTC indicated, Provide diet as ordered. Residents Affected - Few During a review of the facility's Diet Manual (DM), the DM indicated, Regular Mechanical Soft Diet.Avoid any raw vegetables unless chopped 1/2 or smaller and Whole tomatoes. Must be chopped 1/2 or smaller. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 29 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 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 ensure safe food handling and sanitation when: Residents Affected - Few 1. A Time Temperature Control for Safety (TCS- food that requires time-temperature control to prevent the growth of bacteria) food was not cooled down according to facility's policy. 2. One of one sampled dietary aide (DA 2) washed her hands after handling dirty dishes and prior to handling clean dishes. These failures had the potential to result in the development of foodborne (caused by contaminated food) illness. Findings: 1. During a concurrent interview and record review on 1/30/24 at 9:08 a.m. with Dietary Services Supervisor (DSS), the facility's Cooling/Chilling Temperature Control Log (CTCL), dated October 2023 to January 2024 were reviewed. The CTCL indicated, on 11/14/23, roast beef was documented at a starting cooling temperature (temp) of 179 degrees (°) Fahrenheit (F- unit of temperature measurement) at 1 p.m. The next temperature noted in the log was documented at 3:30 p.m. 2 1/2 (two and half hours) after the start of the initial cool down. The DSS stated the cook should have checked the temperature no later than 2 hours after the start of the initial cool down for food safety. DSS stated one out of three dietary staff who documented on the cooling log needed to be re-trained on safe cooling of TCS foods. The CTCL had directions on the log that indicated, Cooling Temperature: 135°F -> [to] 70° F in 2 hours, then 70° F to 41° F in 4 additional hours. During a review of the FDA Food Code (FFC), dated 2022, the FFC indicated, Cooked time/temperature control for safety food shall be cooled within 2 hours from 135° F to 70° F and within a total of 6 hours from 135° F to 41° F or less.Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41° F to 135° F too long. During a review of the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous [dangerous] or Time/Temperature Control for Safety Food, dated 2023, the P&P indicated, Cool cooked food from 140° F to 70° F within two hours. Then cool from 70° F to 41° F or less in an additional four hours for a total cooling time of six hours. 2. During an observation on 1/30/24 at 11:26 a.m. in the kitchen, DA 2 used hand sanitizer [a product used to reduce or eliminate germs] from a dispenser that was affixed to the wall after handling dirty utensils/dishes. DA 2 proceeded to handle clean dishes that came out of the low temperature dish machine before placing them on a shelf, without washing her hands at the hand washing sink. During an interview on 1/30/24 at 11:35 a.m. with DA 2, DA 2 stated she used hand sanitizer after handling dirty utensils/dishes and then handled clean dishes, without washing her hands. DA 2 stated the hand sanitizer was there to be used for touching the door knob for going in and out of the kitchen, and during dish washing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 30 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 - Few During an interview on 1/30/24 at 11:38 a.m. with DSS, DSS stated he trained dietary staff that hand sanitizer could be used as a hand wash alternative since it was a food grade hand sanitizer. During review of the FFC, dated 2022, the FFC indicated, if a facility chooses to use hand antiseptic (EPA approved for food contact] shall be applied only to hands that are cleaned by handwashing with soap; rub together vigorously, to create friction, for at least 10 to 15 seconds. (2-301.16, 2-301.12). During a concurrent interview and record on 1/31/24 at 10:17 a.m. with DSS, the facility's P&P titled, Hand Washing Procedure, dated 2023 was reviewed. The P&P indicated, When hands need to be washed. 2. After handling soiled dishes and utensils. DSS stated, the kitchen staff need to be hand washing in the kitchen after handling dirty dishes and not using the hand sanitizer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 31 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Based on interview, and record review, the facility failed to ensure the contract for Registered Dietitian (RD) services included clear guidelines for the development of action plans, prompt implementation and monitoring of the Registered Dietitian's recommendations to address the nutritional needs of the residents. This failure resulted in an untimely RD assessment for Resident 10, and had the potential for delay in identifying and addressing other residents' nutritional needs in a timely manner. Findings: During a concurrent interview and record review on 2/1/24 at 12:24 p.m. with Administrator and Corporate Consultant (CC), RD's Nutrition Consultant Report (NCR), dated 11/9/23 to 1/12/24 were reviewed. The NCR's indicated, concerns with insufficient time to work on QAPI (quality assurance performance improvement-committee that addresses quality concerns), monthly kitchen inspections being missed, incomplete reviews of monthly weights, and not an adequate amount of time to meet the required comprehensive admission nutrition assessments in a timely manner for residents. Administrator stated he was aware RD's completed NCR reports every time they worked at the building and had not reviewed the NCR consultation reports. Administrator stated the NCR reports go to the dietary services supervisor (DSS) and possibly to the DON [Director of Nursing]. Administrator stated he should have been receiving and reviewing the NCR's in order to develop action plans to address the concerns communicated and had not. During an interview on 1/27/24 at 2:05 p.m. with RD 1, RD 1 stated Resident 10 had a nutrition evaluation with nutrition recommendations provided, 10 days after Resident 10 had a significant weight loss. RD 1 stated that an IDT (interdisciplinary) weight review was conducted 10 days earlier for Resident 10 without the presence of an RD to provide recommendations for a nutrition intervention. RD 1 stated the majority of IDT weight reviews were conducted at the facility without an RD present. RD 1 stated she was limited to eight hours a week to conduct RD related duties to meet the nutritional needs of approximately 122 residents. RD 1 stated eight hours a week was insufficient to meet the nutritional needs of the residents in a timely manner, and to provide frequently scheduled consultation to the DSS. RD 1 stated the facility had not communicated what the expectations were for timeliness of the RD nutrition assessments. RD stated she was unaware if there was a policy and procedure (P&P) on timeliness of RD assessments. During a concurrent interview and record review on 2/1/24 at 9:28 a.m. with DSS, the facility's P&P titled Weight Change Protocol, dated 2023, the P&P indicated, Residents who experience significant changes in weight or insidious weight loss will be assessed by the Facility RD. DSS stated there are no other policy's that address timeliness of RD assessments. During a review of the facility's Agreement to Provide Consultant Services (RD Contract), dated 10/1/18, the RD Contract lacked specifications that the facility assumes responsibility for the timeliness of the services. The RD Contract indicated, Contracted hours for the facility will be 32 - 48 hrs per month and additional hours as negotiated with [name of contracted company] and administrator. The number of hours shall be determined by the needs of the facility. Hours will be based on the average census, acuity rate of the facility and qualifications of the Director of Food and Nutrition Services [DSS]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 32 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm During a review of RD's Nutrition Consultant Report(NCR), dated 11/9/23 to 1/12/24 the following were noted: The NCR dated 11/16/23 indicated, tasks the RD had completed during that visit and noted, Will take 45 mins [minutes] off next time, no overtime for facility. Residents Affected - Some The NCR dated 11/24/23 indicated, Worked 8 hr [hours] 45 mins last week, will take off 45 mins next time. The NCR dated 12/15/23 indicated, Worked 8 hr 45 mins on 11/10, will take off 45 mins next time. The NCR dated 12/29/23 indicated, Worked 8 hr 45 mins on 11/10, so worked 7 hr 15 mins this week (no overtime). During interview on 2/1/24 at 12:46 p.m. with Administrator and CC, Administrator and CC stated it was not acceptable for a facility to take ten days to ensure a resident's nutritional needs are evaluated and addressed after a significant change of condition. Administrator and CC stated timeliness expectation had not been communicated in writing via RD contracted services, P&P or in person to the RDs. Administrator and CC stated without written, clear expectations of what timeliness meant in terms of RD contracted services meeting the nutritional needs of residents it was difficult to evaluate the effectiveness of RD contracted services. Administrator and CC stated that timeliness of facility's outside RD Contracted Services should have been formalized, and was not. During an interview on 1/30/24 at 2:17 p.m. with RD 1 and RD 2, RD 1 and RD 2 stated they were contracted consultant RDs and did not work for the company of the skilled nursing facility. RD 1 and RD 2 stated they had not been asked to attend QAPI meetings for the facility. RD 1 and RD 2 stated they had only been asked to provide the DSS with the resident's weights for the DSS to report during QAPI meetings. RD 1 and RD 2 stated the DSS does not have clinical nutrition care scope of practice and therefore, the Food and Nutrition Services (FANS) department was not fully represented during QAPI in order to provide quality assurance and performance improvement in clinical nutritional care to meet the nutritional needs of the residents. During an interview on 2/1/24 at 1 p.m. with Administrator and CC, Administrator stated the facility did not require RD's to attend QAPI and RD's have not attended. Administrator stated the DSS attends QAPI. During a review of the facility's Agreement to Provide Consultant Services (RD Contract), dated 10/1/18, the RD Contract indicated, Purpose: The purpose of this agreement is to provide a qualified RDN Consultant. The RDN's sole responsibility shall be guidance and council to the Nutrition Services Department.Responsibilities of the consultant.Provides consultation to administration regarding planning, policy development, and priority-setting, based on initial and ongoing evaluations of the food service needs.Maintains a summary of consultation activities by the consultant.Assess resident's nutritional needs. Documents nutritional information in accordance with the policies of the facility and accepted professional practice. This function is performed by the RDN (Registered Dietitian Nutritionist; interchangeable with RD) for all Initial Assessments, Annuals, and Change of Condition. Participates in care planning meetings.Reviews sanitation [of foodservice operations] in accordance with current regulatory standards.Maintains and provides written reports of each visit to the facility. This will include any audits performed, summary of performance, goals and recommendations to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 33 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's job description titled Registered Dietician (JDRD), the JDRD indicated, Complete nutritional initial, quarterly, annual and significant change reviews on residents according to federal and state guidelines. Assist in coordination of nutrition care services with Dietary Supervisor. Complete nutritional reviews monthly on high risk residents (significant weight loss/gain, pressure ulcer, hemodialysis [a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately] and tube fed). Essential Duties.Attends and participates in morning meetings/stand up to facilitate communications with the team. Assess nutritional needs, diet restrictions and current health plans in order to develop and implement dietary care plans and provides nutritional counseling as needed. Monitor food services operations to ensure conformance to nutritional, safety, and sanitation and quality standards, as well as state and federal regulations. Monitor.preparation methods.in order to ensure that food is prepared and presented in an acceptable manner. Inspect diet trays for conformance to physician's diet orders prior to delivery. Event ID: Facility ID: 055568 If continuation sheet Page 34 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, and record review, the facility failed to: 1. Ensure an accurate and complete clinical record (CR) for one of one sampled resident (Resident 10). This failure resulted in weight loss interventions not carried out in a timely manner. 2. Follow its policy and procedure (P&P) titled, Resident Participation - Assessment/Care Plans for one of six sampled residents (Resident 52). This failure had the potential for Resident 52 to not have the opportunity to participate in, be aware of and develop care goals and outcomes, and incorporate his personal and cultural preferences. Findings: 1. During a concurrent interview and record review on 1/31/24 at 1:59 p.m. with RD 1, Resident 10's IDT [interdisciplinary] Significant Weight Change (IDTSWC), dated 1/19/24 was reviewed. The IDTSWC indicated, Resident 10 had a significant weight change as of 1/16/24 of - 6 lb x 1 month 3.7% [loss of body weight], -13 lb x 3 month 7.7%, -18 lb x 6 month 10.4%, Current weight: 155# [pounds].Current Diet: GTube Feeding Jevity 1.2 [a nutrition liquid formula delivered via a tube].IDT recommends: Unintentional weight loss. Tolerating well with a couple refusals. Team recommends weekly weights and continuing with current plan of care. Continue to monitor weight changes .IDT members present 1/19/2024: DON [Director of Nursing], ADON [Assistant Director of Nursing], DOR [Director of Rehabilitation], DSD [Director of Staff Development], IP [Infection Preventionist], SSD [Social Services Director], RD. RD 1 stated there was no documented root cause analysis to help determine the reason for the significant unplanned weight loss, and no new nutrition interventions developed that would add calories and/or protein to address the weight loss noted. RD stated, there was no RD present for the IDT and she was not involved in the IDT for Resident 10 even though an RD is listed as having been present. During an interview on 2/1/24 at 12:20 p.m. with Administrator and facility corporate consultant (CC), Administrator and CC stated the clinical record needs to be accurate and complete. During a review of the facility's policy and procedure (P&P) titled, Health Information/Record Manual, revised 12/27/20, the P&P indicated, Policy: Clinical records, paper or electronic, shall be kept for each resident admitted for care. Content shall be in compliance with licensing and certifying governmental agency requirements and professional standards.The clinical record provides for.Communicating effectively. Records shall be reviewed periodically for currency and completion, while the resident is in the facility. 2. During an interview on 1/29/24 at 11:15 a.m. with Resident 52, Resident 52 stated he had not been asked to participate in his care planning conferences. During a concurrent interview and record review on 2/1/24 at 9:57 a.m. with MDSC and Social Services Director (SSD), Resident 52's Care Plan Conference Reports (CPCR), dated 1/18/23, 2/15/23, and 5/2/23 were reviewed. The following were noted: Care Plan Conference Report dated 1/18/23 indicated, Care Plan Participation. Did Resident/RP [Responsible Party]/Legal Representative Attend Yes? No ? If no, state reason. Was Family/RP Notified of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 35 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Care Plan Conference? Yes ? Date Notified: 1/16/23 By: SSD ? In Person. List of family members that need to be involved with resident's care: SELF. Neither Yes or No were checked for resident attendance and the reason for not attending was blank. Care Plan Conference Report dated 2/15/23 indicated, Care Plan Participation. Did Resident/RP [Responsible Party]/Legal Representative Attend Yes? No ? If no, state reason. Was Family/RP Notified of Care Plan Conference? Yes ? Date Notified: 2/13/23 By: SSD ? In Person. List of family members that need to be involved with resident's care: SELF. Neither Yes or No were checked for resident attendance and the reason for not attending was blank. Care Plan Conference Report dated 5/2/23 indicated, Care Plan Participation. Did Resident/RP [Responsible Party]/Legal Representative Attend Yes? No ? If no, state reason. Was Family/RP Notified of Care Plan Conference? Yes ? Date Notified: 5/1/23 By: SSD ? In Person. List of family members that need to be involved with resident's care: SELF. Neither Yes or No were checked for resident attendance and the reason for not attending was blank. SSD stated the lack of documentation does not clarify who attended the care conference sessions. SSD stated care conferences are conducted quarterly and as needed. Requested Care Plan Conference Report from 5/2/23 to 2/1/24. Facility was unable to find documentation for care conferences for the period of 5/2/23 to 2/1/24. During a review of the facility's P&P titled, Resident Participation - Assessment/Care Plans dated 2/21, the P&P indicated, The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.3. The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to: a. participate in the planning process; b. identify individuals to be included in the planning process; c. request meetings; d. request revisions to the plan of care; e. participate in establishing his or her goals and expected outcomes of care; f. participate in the type, amount, frequency and duration of care; g. receive the services and/or items included in the care plan; h. be informed, in advance, of changes to the plan of care; i. refuse, request changes to and/or discontinue care or treatment offered or proposed; j. be informed, in advance (by the physician, practitioner or professional), of the risks and benefits of the care or treatment proposed; k. have access to and review the care plan; and l. review and sign care plan after any significant changes are made. 4. The care planning process: a. facilitates the inclusion of the resident and/or representative; b. includes an assessment of the resident's strengths and his or her needs; and c. incorporates the resident's personal and cultural preferences in establishing goals of care. 5. Facility staff supports and encourages resident/representative participation in the care planning process by: a. ensuring that residents, representatives and families understand the care planning process; b. holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best; c. providing sufficient notice in advance of the meeting; and d. planning for enough time for exchange of information and decision making.8. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. 9. The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: a. the date, time and location of the conference; b. the name of each person contacted and the date he or she was contacted; c. the method of contact (e.g., mail, telephone, email, etc.); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 36 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0842 d. input from the resident or representative if they are not able to attend; e. refusal of participation, if applicable; and f. the date and signature of the individual making the contact. 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: 055568 If continuation sheet Page 37 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 follow its policy and procedure (P&P) titled, Handwashing/Hand Hygiene when a Licensed Vocational Nurse (LVN) 1 did not change gloves or perform hand hygiene after checking the blood sugar for one of two sampled residents (Resident 126). This failure had the potential to result in the spread of bloodborne pathogens (germs that are carried in the blood and can cause disease in people). Residents Affected - Few Findings: During an observation on 1/31/24 11:12 a.m. in Resident 126's room, LVN 1 applied gloves and tested the blood sugar for Resident 126. There was an error with test strip. LVN 1 grabbed a new test strip from the vial of test strips on the medication cart but did not change her gloves or wash her hands. During an interview on 1/31/24 at 11:16 a.m. with LVN 1, LVN 1 stated she did not wash hands or change gloves after she checked Resident 126's blood sugar. LVN 1 stated she should have changed her gloves before grabbing a new strip and taking the Resident 126's blood sugar a second time. During an interview on 2/1/24 at 5:03 p.m. with Infection Preventionist (IP), IP stated nurses should change their gloves if a new test strip is needed to check a blood sugar. IP stated LVN 1 should not have gone back to get a new test strip without changing her gloves and washing her hands. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 11/22/19, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap. and water for the following situations. Before and after direct contact with the residents. Before and after handling an invasive device. After removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 38 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow its policy and procedure titled Consent to Treat for three of 50 sampled residents (Resident 10, Resident 280, and Resident 282 when: Residents Affected - Few 1. Resident 10 was given Flu (contagious respiratory illness) vaccine without obtaining a consent. 2. Resident 280 and Resident 282 were not assessed and offered Flu vaccines on admission. These failures had the potential to spread miss information and infectious diseases. Finding: 1. During an interview on 2/1/24 at 1:22 p.m. with Administrator, Administrator stated he could not find a consent for Flu vaccine for Resident 10 and he should have a consent. During a review of Resident 10's Infection Note (IN), dated 9/26/23, the IN indicated, To receive season influenza vaccine administer 0.5 ml IM (intramuscular- muscle to absorbing administered medication) one time. Administer per facility protocol. Orders carried out as planned no signs and symptoms of adverse reaction. 2. During a concurrent interview and record review on 1/31/24 at 1:42 p.m. with Infection Preventionist (IP), Resident 282's vaccines records were reviewed. IP stated honestly, I didn't recheck with the resident. IP stated our policy is to offer vaccines on admission. During a concurrent interview and record review on 1/31/24 at 1: 48 p.m. with IP, Resident 280's vaccines records were reviewed. IP stated, I haven't gone back, and I usually go back in a week to offer vaccines. During a review of the facility's policy and procedure (P&P) titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated May 2011, the p & p indicated, . (e)Patients' rights policies and procedures established under this section concerning consent, informed consent and refusal of treatments or procedures shall include, but not limited to the following: . (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies and procedures which include these rights and shall make a copy of these policies available to the patient and any representative of the patient . (4) To consent to or to refuse any treatment or procedure or participation in experimental research. During a review of the facility policy and procedure (P &P) titled, Consent to Treat, undated, the p &p indicated, The resident acknowledges that he/she is under the medical treatment and care of an Attending Physician, and that the facility renders services to the resident under the general specific instructions of said physician. The resident and/or authorized representative hereby consents to the facility providing such routine nursing care as maybe directed by said Attending Physician. I have been personally advised and have received a copy of this consent to treat statement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 39 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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, the facility failed to provide the minimum square footage as required by regulation in 20 of the facility's bedrooms. This had the potential to affect the care and safety of residents. Findings: During a concurrent observation and interview on 2/1/24 at 5:21 p.m. with Maintenance Supervisor (MS) and the Administrator, the facility's multiple occupancy rooms were observed, measured and the facility floor plan was reviewed. MS stated, the residents' rooms square footage is the same as what is on the floor plan. The floor plan indicated the following rooms did not provide the minimum square footage (sq. ft.) as required by regulation (80 sq. ft. per resident for multi-occupation rooms): room [ROOM NUMBER] - 220.4 square feet- 3 residents. room [ROOM NUMBER]- 220.4 square feet- 3 residents. room [ROOM NUMBER] - 217.3 square feet- 3 residents. room [ROOM NUMBER]- 217 square feet- 3 residents. room [ROOM NUMBER] - 218 square feet- 3 residents. room [ROOM NUMBER] - 219 square feet- 3 residents. room [ROOM NUMBER] - 218 square feet- 3 residents. room [ROOM NUMBER] - 221 square feet- 3 residents. room [ROOM NUMBER] - 214 square feet- 3 residents. room [ROOM NUMBER] - 217 square feet- 3 residents. room [ROOM NUMBER] - 217 square feet- 3 residents. room [ROOM NUMBER]- 217 square feet- 3 residents. room [ROOM NUMBER] - 218 square feet- 3 residents. room [ROOM NUMBER]- 301 square feet- 4 residents. room [ROOM NUMBER]- 217 square feet- 3 residents. room [ROOM NUMBER] - 219 square feet- 3 residents. room [ROOM NUMBER] - 219 square feet- 3 residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 40 of 41 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 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 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 room [ROOM NUMBER] - 217 square feet- 3 residents. Level of Harm - Potential for minimal harm room [ROOM NUMBER] - 217 square feet- 3 residents. room [ROOM NUMBER] - 218 square feet- 3 residents. Residents Affected - Some The Administrator stated the residents' room sizes on the floorplan are correct. Administrator stated although the residents' rooms did not provide the minimum sq. ft. as required by regulation, variations were in accordance with the needs of the residents. Residents had a reasonable amount of privacy. Closets and storage were adequate. Bedside stands were available. There was sufficient space for nursing care and for residents to ambulate and/or use their wheelchairs. Toilet facilities were accessible. The health and safety of the residents will not be adversely affected by the room waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 41 of 41